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19612461-DS-14
| 19,612,461 | 21,380,829 |
DS
| 14 |
2159-09-04 00:00:00
|
2159-09-04 22:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___
- Reopening of recent laparotomy and closure of gastrostomy
___ ___
History of Present Illness:
Ms. ___ is a ___ woman with a history of active EtOH use
disorder c/b cirrhosis with ascites, HE, SBP, obesity s/p RYGB
c/b anastamotic stricture w/ chronic daily emesis and recent SBO
s/p surgical repair and multiple hospitalizations at ___ for
ascites, fatigue, hyponatremia, w/ repeat admissions for
esophageal stricture including recently (discharged ___ for
abdominal pain and dry heaving thought to be due to stricture
s/p dilation who now presents for fever and vomiting.
During her last admission, also had a VRE UTI treated with
fosfomycin who presents again with fever and vomiting. Patient
describes getting home the evening of ___ (day of discharge)
and experienced nausea and vomiting as soon as she started her
tube feeds. This continued all night. Reportedly patient was
confused on the morning of ___ after awakening (noted by her
___ also reported patient had temp of 100.4F via a paper
thermometer strip but noted that patient also felt warmer.
Patient also reported increased ascites and right-sided
abdominal pain.
For these complaints, patient presented to ___/OSH before
transfer to ___ ED with patient reportedly given dilaudid 1mg
x2, Zofran 4mg x1, and ceftriaxone 2gm. Patient reports that she
was febrile to 101.4F at OSH.
In the ED initial vitals: 98.4, 93, 100/64, 15, 95% RA
CXR at OSH was reported as atelectasis vs pneumonia. Abd XR
showed mildly distened loops of bowel. ___ Dx para: WBC: 55, RBC
___. Repeat diagnostic tap at ___ was unrevealing for SBP.
Patient was given Ceftriaxone, Phytonadione 10 mg, and pain
meds.
Vitals prior to transfer were 98.1 74 109/56 18 98% RA.
REVIEW OF SYSTEMS: per HPI, denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO
- alcohol cirrhosis, diagnosed last year; complicated by
ascites, HE, SBP
- numerous hospitalizations for abdominal pain, requiring
paracentesis.
- esophageal stricturing, last dilation ___.
- depression
- anxiety
- obese BMI 30
- GERD
- hx of Cdif
- IBS
- thrombocytopenia
- left ankle fusion
- SBO
- gastric surgery
- Chronic fatigue syndrome
- Depressive disorder
- Hypertriglyceridemia
- Hyponatremia
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
====================================
VS: T 98.1 | BP 106/65 |HR 81 | RR 18 | O2 94% RA
GENERAL: Adult female in NAD. Some discomfort due to pain. A+O
x3. Able to say ___ backwards. No asterixis.
HEENT: Mildly icteric appearing. Face symmetric. PERRL. EOMI
with some end-gaze nystagmus. MMM.
NECK: Supple. No JVD.
CARDIAC: RRR, S1+S2 with ___ systolic murmur. No rubs or
gallops.
PULMONARY: Coarse crackles as bases L>R, reduced after cough.
ABDOMEN: Distended, soft. Diffusely tender but markedly tender
on right side, especially RUQ. Voluntary guarding. No rebound.
BACK: R CVAT
GENITOURINARY: No foley.
EXTREMITIES: WWP. Trace pitting edema of b/L legs. DP 1+ b/L.
SKIN: Warm, dry.
NEUROLOGIC: CN ___ intact.
PSYCHIATRIC: Mildly depressed affect but clear, linear, and
logical.
DISCHARGE PHYSICAL EXAM:
====================================
VITALS: 98.6 84 108/69 16 94RA
GEN: AOx3, no acute distress, jaundice
HEENT: mild sclera icterus, PERRLA, EMOI
NECK: supple
CARDIAC: RRR, s1/s2
PULM: CTAB/L
ABD: mildly distended, 4cm upper midline incision slow to heal
with evidence of granulation tissue, soft, nontender, J-tube
inplace and secured
EXT: warm, well perfused, trace edema, no active ulcerations
Pertinent Results:
ADMISSION LABS:
=======================================
___ 10:00PM BLOOD WBC-11.4*# RBC-2.37* Hgb-8.4* Hct-26.2*
MCV-111* MCH-35.4* MCHC-32.1 RDW-20.5* RDWSD-82.2* Plt Ct-89*
___ 10:00PM BLOOD Neuts-81.4* Lymphs-11.0* Monos-7.0
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.26*# AbsLymp-1.25
AbsMono-0.80 AbsEos-0.01* AbsBaso-0.01
___ 05:38AM BLOOD ___ PTT-37.9* ___
___ 10:00PM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-137
K-4.1 Cl-104 HCO3-21* AnGap-16
___ 10:00PM BLOOD ALT-15 AST-50* AlkPhos-72 TotBili-3.6*
___ 10:00PM BLOOD Lipase-70*
___ 10:00PM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8 Mg-1.6
IMAGING & STUDIES
=======================================
ECG ___ (my read)
Sinus rhythm, normal axis, no ST-T changes, QTc 463/503
RUQ U/S ___:
IMPRESSION:
1. Patent hepatic vasculature.
2. CBD measuring 7 mm, larger than expected for the patient's
age. Comparison with CT is difficult given differences modality,
but this may be slightly dilated compared to the prior study
from ___.
3. Moderate ascites.
4. Splenomegaly.
RECOMMENDATION(S): Mild CBD enlargement can be further evaluated
with MRCP.
Wrist XR ___
IMPRESSION:
No acute fracture or dislocation. No radiographic evidence for
osteomyelitis.
CXR ___
FINDINGS:
Enteric tube tip well below diaphragm, tip out of view. Shallow
inspiration. Normal heart size, decreased pulmonary vascularity
since prior. No pulmonary edema. Minimal basilar opacities,
likely atelectasis, improved since prior. No consolidation. No
pleural effusion. No pneumothorax.
IMPRESSION:
Interval decrease in pulmonary vascularity. Minimal basilar
opacities, likely atelectasis.
CXR ___:
IMPRESSION:
Large volume free peritoneal air
Left basilar opacity, likely atelectasis, consider aspiration or
pneumonia if appropriate.
EGD ___:
Findings:
Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Lumen: Evidence of a previous gastric bypass was seen with a
stricture was seen at the site of Gastro-Jejunal anastomosis. An
NJ tube is seen coursing through the stomach past the GJ
anastomosis - the scope was not able to traverse this stricture.
A 15mm balloon was introduced for dilation and the diameter was
progressively increased to 18 mm successfully.
Duodenum:
Other The small bowel was not seen given stricture.
Impression: Normal mucosa in the esophagus. Previous gastric
bypass of the stomach (dilation). The small bowel was not seen
given stricture.
Otherwise normal EGD to gastric pouch.
CT Abd/Pelvis with contrast ___
1. Patient is status post takedown of gastric bypass.
2. Small volume ascites with peritoneal enhancement, concerning
for peritonitis. No drainable fluid collection.
3. Limited assessment for anastomotic leak given lack of oral
contrast
administration.
4. Interval placement of a percutaneous jejunostomy tube.
5. Multiple prominent peritoneal and retroperitoneal lymph
nodes, likely
reactive.
6. Cirrhosis with evidence of portal hypertension demonstrated
by splenomegaly and varices.
7. Anasarca.
8. Ground-glass opacities within the visualized lung bases may
represent pneumonia. Small bilateral pleural effusions.
9. Cholelithiasis.
UGI with SBFT ___
1. No evidence of leak.
2. Severely delayed small bowel transit, with oral contrast not
reaching the ileum after 3.5 hours.
Abdominal ultrasound ___
Small volume ascites collecting primarily within the left upper
and lower
quadrants.
Mammogram ___
Two indeterminate masses in the right breast for which
ultrasound-guided core biopsy should be considered at this time.
Borderline right axillary lymph node, the management of which
will depend on the biopsy results of the right breast mass.
Findings reviewed with the patient at the completion of the
study. The patient underwent right breast ultrasound-guided
core biopsy which was performed following completion of the
diagnostic evaluation after discussion with Dr. ___
inpatient care team given the elevated INR.
BI-RADS: 4B Suspicious - moderate suspicion for malignancy.
CT Abd/Pelvis ___
1. Mildly dilated loops of jejunum proximal to the patient's
jejunal anastomosis, without evidence for complete obstruction.
Contrast passes into more distal loops of jejunum.
2. No evidence for leak or intra-abdominal collection.
3. Stigmata of cirrhosis and portal hypertension, with small to
moderate volume simple ascites.
4. Left pleural effusion and diffuse subcutaneous stranding,
likely related to anasarca.
5. Prominent retroperitoneal and periportal nodes, likely
reactive.
J-tube check ___
1. Successful replacement of a surgically placed J tube with a
16 ___ MIC jejunal tube. Contrast injection confirmed
appropriate positioning.
CT Abd/Pelvis ___
1. Prominent loops of fluid-filled small bowel measuring up to
4.8 cm, likely reflective of ileus or partial small bowel
obstruction. No transition point is identified and enteric
contrast is noted throughout the colon. No intraperitoneal free
air, pneumatosis intestinalis or portal venous gas.
2. Post takedown Roux-en-Y gastrojejunostomy with gastrostomy
and J-tube placement as described above.
3. Cirrhosis, with findings of portal hypertension including
moderate volume intraperitoneal ascites and splenomegaly.
4. Large left pleural effusion with overlying compressive
atelectasis.
5. Patchy and confluent opacities in the left upper lobe may
represent pneumonia in the appropriate clinical setting.
6. Evaluation for organized fluid collections is limited given
the lack of
intravenous contrast.
CT Chest ___
1. Prominent loops of fluid-filled small bowel measuring up to
4.8 cm, likely reflective of ileus or partial small bowel
obstruction. No transition point is identified and enteric
contrast is noted throughout the colon. No intraperitoneal free
air, pneumatosis intestinalis or portal venous gas.
2. Post takedown Roux-en-Y gastrojejunostomy with gastrostomy
and J-tube placement as described above.
3. Cirrhosis, with findings of portal hypertension including
moderate volume intraperitoneal ascites and splenomegaly.
4. Large left pleural effusion with overlying compressive
atelectasis.
5. Patchy and confluent opacities in the left upper lobe may
represent
pneumonia in the appropriate clinical setting.
6. Evaluation for organized fluid collections is limited given
the lack of
intravenous contrast.
Abdominal ultrasound ___
Trace perisplenic and left lower quadrant ascites decreased in
amount compared to the previous ultrasound and CT examinations.
UGI with SBFT ___
Images were obtained after the administration of contrast at 25
minutes, 55 minutes, 165 minutes, 4 hours and 45 minutes, and 7
hours and 45 minutes. Study demonstrates contrast passing
through the stomach into dilated loops of small bowel, and
passing into the cecum at 07:00 and 45 minutes.
RUQ Ultrasound ___
1. Of note, this is an extremely limited exam due to patient
discomfort and recent postoperative status with abdominal
dressings. Within these
limitations, the gallbladder appears sludge filled. Correlate
findings to
LFTs.
2. Mildly coarsened liver echotexture without obvious focal
hepatic lesion.
3. The main portal vein is patent.
4. Mild splenomegaly, measuring up to 13.8 cm.
5. Small left pleural effusion
CT Head ___
No acute intracranial process.
CT Abd/Pelvis ___
1. Multiple dilated small bowel loops measuring up to 5.4 cm are
mildly more distended since CT abdomen and pelvis ___., Previously measuring up to 4.6 cm, without a discrete
transition point likely representing an ileus. Contrast is noted
in the colon and rectum which are unremarkable.
2. Post takedown Roux-en-Y gastrojejunostomy with GJ-tube
unchanged in
position from ___.
3. placement as described above.
4. Cirrhosis with moderate volume ascites and splenomegaly.
Abdominal US ___
1. Trace, complex ascites, without a pocket large enough for
safe paracentesis.
2. Stigmata of cirrhosis and portal hypertension.
MICROBIOLOGY
=======================================
___ 9:48 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
13:10.
___ ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE
GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 8:05 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 3:15 pm BLOOD CULTURE
Source: Venipuncture 2 OF 2 LEFT ARM.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PEDIOCOCCUS SPECIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
___ with EtOH cirrhosis c/b ascites/SBP/HE/HRS (Child C, MELD
___), RYGB c/b anastomotic stricture s/p multiple EGD dilations,
recently discharged after uncomplicated stricture dilation and
therapeutic paracentesis, who was readmitted for abdominal pain
and report of fever and leukocytosis. There was a low suspicion
for infection given that she remained afebrile and HDS off abx.
Cultures did not reveal any source of infection. Of note, she
had a positive UTI on the previous admission with cultures
growing VRE and therefore Linezolid had been started on ___.
For her abdominal pain and nausea/vomiting, she underwent
another EGD with dilation on ___. After the procedure, she
returned to the hepatology floor and developed worsening
abdominal pain and distension. A CXR revealed a large amount of
free air in the peritoneum concerning for a perforation.
Transplant surgery was consulted for further management.
On ___, the patient was taken to the operating room for
management of the perforated gastrojejunostomy. An exploratory
laparotomy, takedown old gastrojejunostomy, and creation of a
gastrogastrostomy was performed (___). A feeding jejunostomy
was additionally placed. After the abdomen was closed and the
patient was extubated, it was recalled that a remaining hole in
the stomach was not closed. She was therefore re-intubated, the
abdomen was reopened and the previous gastrostomy site from the
gastrojejunostomy was repaired. The abdomen was then closed
without difficulty and the patient was extubated and transferred
to the PACU in stable condition. Patient's postoperative course
was complicated by persistent nausea/vomiting, inability to
tolerate POs, and readmissions to the ICU. Please see below for
a summary of her hospital course by systems.
#ICU admissions
___
#Neuro
Postoperatively, the patient returned to her baseline mental
status shortly after extubation. Escitalopram was continued for
depression/anxiety. Throughout her initial hospital course, she
had intermittent episodes of severe anxiety requiring PRN
Ativan. On ___, patient was transferred to the SICU after an
acute change in her mental status and decreased responsiveness.
Ammonia levels were normal at 53. She had continued bowel
movement throughout hospital course with lactulose so hepatic
encephalopathy not likely. Regardless, lactulose was titrated to
maintain frequent bowel movements while in the ICU. CT
noncontrast head showed no acute intracranial process. EEG
revealed encephalopathy with spikes and frequent epileptiform
discharges. Neruology was consulted and felt that her frequent
epileptiform discharges on EEG placed her at significant risk
for seizure at this time and Keppra 1000 BID was started with
improvement in epileptiform discharges. Plan to continue Keppra
until outpatient follow-up with neurology. Cipro (ppx) was
switched to Bactrim given concern for lowering seizure
threshold. Over the 3 days in the ICU, her mental status
improved and she returned to her baseline. Upon transfer to the
floor and on discharge, she was fully alert, interactive, and
AOx3.
#Cardiovascular
Midodrine was started on ___ at 2.5mg TID for soft blood
pressures following the operation. On ___, her hypotension
persisted despite increase of Midodrine from 2.5 q4->q6. She
became hypotensive to SBP ___ and was transferred to the SICU
for further care. She was placed on levophed for blood pressure
support. Blood pressure improved a few days later and she was
restarted on Midodrine 5TID and transferred to the floor on ___.
#Pulmonary
Patient was extubated after her index operation. Patient
developed a worsening left pleural effusion and shortness of
breath during her admission. On ___, a CT chest was obtained
which showed a large left pleural effusion with overlying
compressive atelectasis. Interventional pulmonology was
consulted and a thoracentesis was performed on ___ with a
pigtail left in place. The pigtail was discontinued on ___.
Fluid cultures were negative although drainage was exudative
based on Light's criteria.
#Breast
Patient was found to have a right breast mass during this
hospitalization. A mammogram was performed on ___ which
revealed two indeterminate masses in the right breast, BIRADS
4B. An ultrasound guided core biopsy was performed on ___.
Pathology report showed fibroadipose tissue with blood, fibrin,
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications. Breast surgery was
consulted and it was deemed that not no need further work up in
hospital and patient will f/u with Dr. ___ in breast
clinic.
#FENGI:
Given acute abdomen secondary to perforated gastrojejunostomy,
the patient underwent an exploratory laparotomy, takedown old
gastrojejunostomy, gastrogastrostomy, and J-tube placement. Her
hospital course was complicated by refractory nausea/vomiting
and PO intolerance. Trickle TFs via NGT were started on POD2 but
where shortly dc'ed after worsening abdominal distention and
abdominal pain. An abdominal/pelvic CT was performed on ___ for
her continued GI symptoms, however no significant fluid
collections were identified. Surgical JP drain was removed on
___ and the incision was stitched to prevent drainage of
ascites. Trickle tube feeds were started on ___ and she was
transferred back to the surgical floor. TPN was also started
until tube feeds were advanced further on in her hospital course
to goal of 60cc/hr. An upper GI with SBF was performed on ___
which showed severely delayed small bowel transit, with oral
contrast not reaching the ileum after 3.5 hours. Unfortunately,
the contrast in her abdomen was suctioned out before a delayed
follow-through evaluation could be performed. Over the next few
weeks, she continued to have high NGT output with multiple
failed NGT clamp trials secondary to nausea/vomiting. A CT
abd/pel was performed on ___ which showed mildly dilated loops
of jejunum proximal to the J-J anastomosis without evidence of
complete obstruction. However, contrast was found passing into
more distal loops from the anastomosis. The surgical J-tube was
slightly dislodaged and replaced successfully by ___ with a ___
MIC jejunal tube on ___. EGD was attempted on ___, however she
had emesis during the procedure when the upper third of the
esophagus was reached, so the procedure was aborted. EGD was
small bowel push enteroscopy was later performed on ___ which
showed erythema and congestion of the stomach and normal small
bowel enteroscopy to the jejunum to 100cm. CT abd/pel was
repeated on ___ showing prominent loops of fluid-filled small
bowel measuring up to 4.8cm. She continued to tolerate TFs but
had nausea/vomiting with PO trial on ___. An NGT was replaced
on ___ with >800cc emesis. UGI with SBFT was repeated on ___
showing slow transit of fluid through the intestinal system,
with contrast seen in the cecum after 7 hours and 45 minutes.
Octreotide was started without much benefit, later discontinued.
Additionally, she was trialed on erythromycin to improve
motility, however this resulted in worsened nausea. She was
transferred to the ICU on ___ for AMS. A repeat CT Abd/Pelvis
was obtained which showed multiple dilated small bowel loops
measuring up to 5.4 cm are mildly more distended since CT
abdomen and pelvis ___, without a discrete transition
point likely representing an ileus. Contrast from the prior UGI
was noted to reach the colon and rectum. On arrival to the ICU,
she was made NPO with NGT to LWS and J-tube to gravity. An
abdominal ultrasound was performed on ___ which revealed no
drainable fluid collection. Once her mental status improved, she
was restarted back on TFs on ___ and tolerated advancement ot
goal. Her diet was slowly advanced from ___ and by
discharge, she was tolerating a regular diet.
#Cirrhosis/Liver Transplant Work-up
Transplant w/u ensued during her hospitalization. On ___, TTE
revealed LVEF 60-65%, PASP unable to calc. TTE was repeated on
___ TTE PASP was 27 mmHg. A papsmear was done as her last
was in ___ with finding of atypical squamous cells. Transplant
workup was stopped given her delayed recovery from surgery and
gastrointestinal motility issues.
#Renal
Patient developed hepatorenal syndrome during her hospital
course with peak Cr level 6.3 on ___. Throughout her course, she
was taken off lasix and spironolactone. On discharge, the lasix
was titrated to 20mg daily and the spironolactone remained held.
#HEME:
Post-operatively, she required multiple blood and FFP
transfusions for resuscitation. Throughout her hospital course
she received 18 uPRBC, ___ FFP, 1 Plts.
#ID: Linezolid was continued 24 hours after her operation. Fluid
from the JP was sent for cell count which was consistent with
peritonitis. Zosyn was started. On ___, yeast was isolated for
JP fluid culture ___. Fluc was started on ___. Linezolid was
discontinued on ___. JP drain output continued to be high
with worsening renal function. On ___, JP fluid was sent for
cell count that was consistent with SBP (wbc 2376/poly 62=1473).
Zosyn was switched to Ceftriaxone. A PICC line was placed for
antibiotics on ___ with tip at cavoatrial junction. ID was
consulted on ___ with Vanco and Flagyl added. Antibiotics were
further changed to Dapto/Zosyn (___). Rare growth of ___
___ was isolated. Fluconazole was started. Serum WBC on
___ increased from 14.7 to 15.4 ua/ucx/bc sent (UA+), Zosyn was
switched back to ceftriaxone and flagyl. Urine culture was
negative as were blood cultures from ___ and ___.
Ceftriaxone/Flagyl was switched to Zosyn on ___.
Dapto/Zosyn/Flu were discontinued on ___ and patient was started
on prophylactic SBP prophylaxis with ciprofloxacin. On ___
patient was switched from ciprofloxacin to Bactrim for SBP
prophylaxis given risk of decreasing seizure threshold with
cipro. PICC line was removed and tip culture was negative. On
___, she was febrile to 102.3. Blood culture results revealed
GPCs (___), eventually growing Pediococcus species. She was
started on Linezolid and treated from ___ per ID
recommendations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
3. DICYCLOMine ___ mg PO TID W/MEALS
4. Escitalopram Oxalate 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Midodrine 15 mg PO TID
8. Spironolactone 100 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. TraMADol 50 mg PO QHS:PRN Pain - Moderate
11. Ciprofloxacin HCl 500 mg PO Q24H
12. Lactulose 30 mL PO TID
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
2. Pantoprazole 40 mg PO Q12H
3. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
4. Furosemide 20 mg PO DAILY
5. Lactulose 30 mL PO Q6H
6. Midodrine 5 mg PO TID
7. Escitalopram Oxalate 20 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
11. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until Dr ___ you
___ to restart
12.Tube Feeding
Continuous tubefeeding over 24 hours: Osmolite 1.5 Cal (or
equivalent); Full strength. Tube Type: Jejunostomy (JT);
Placement confirmed. Rate by 60 ml/hr (goal rate)Residual Check:
Not indicated for tube type Flush w/ 30 mL water Q6H. DX:take
down GJ/ gastrogastrostomy/malnutrition. Duration: 2 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
E0TOH Cirrhosis
Perforated gastrojejunostomy
Perforated hollow viscus
decompensated liver failure
___
Malnutrition
R breast nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ office at ___ for fever
of 101 or higher, chills, nausea, vomiting, diarrhea,
constipation, increased abdominal pain, malfunctioning feeding
tube, pain not controlled by your pain medication, swelling of
the abdomen or ankles, yellowing of the skin or eyes, inability
to tolerate food, fluids or medications, the incision sites have
redness, drainage or bleeding, or any other concerning symptoms.
You may shower, but no tub baths
No straining or heavy lifting (nothing heavier than 10 pounds)
No driving if taking narcotic pain medication
Do not drink alcohol
Continue tube feeds via the J tube. You may eat as you are able.
Keep your diet low sodium, and limit all fluids to 1 liter
daily. You are receiving complete nutrition via the J tube
feeds, eating and drinking is for comfort only
Followup Instructions:
___
|
19612461-DS-17
| 19,612,461 | 20,501,979 |
DS
| 17 |
2159-10-31 00:00:00
|
2159-10-31 21:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain, Nausea/vomiting, PO intolerance
Major Surgical or Invasive Procedure:
G-tube exchange and upsizing, ___
G-tube exchange and replacement ___
___ line ___
History of Present Illness:
Ms. ___ is a ___ year old woman, with past history of Child's
Class C-ETOH Cirrhosis c/b ascites, HE, SBP, and HRS, Roux-en-Y
Gastric Bypass c/b recurrent anastamotic stricutres requiring
multiple endoscopic dilations, prior history of GJ anastamotic
performation in setting of endoscopic GJ stricture dilation
requiring ex-lap, GJ take down, G-G anastaomosis. Patient was
previously discharged 3 days ago, for acute encephalopathy,
nausea/vomiting s/p venting G-tube placement, fevers,
hyponatremia, and now being re-admitted for inability to
tolerate PO intake.
Patient was recently hospitalized from ___ to ___.
Patient was initially admitted for worsening encephalopathy and
nausea/vomiting. Patient was initially found to have repetitive
movements of non-responsiveness and thought to be ___ to
seizures and encephalopathy. EEG done did not show frank seizure
activity, and patient restarted on levitraectam and home
lactulose and rifaxamin. Patient also was educated on venting
her G-tube, with inability to drainage at home. Patient has
intermittent nausea/vomiting despite G-tube drainage. Patient
had scheduled G-tube flushes, and was given dronabinol. Patient
did have a fever thought to be ___ to aspiration pneumonitis,
and was given ceftazidime/fagyl for 48 hours. Patient also found
to have acute anemia, and was given 1 unit PRBC, and maintained
on pantoprazole BID. Also found to have hyponatremia, which
improved with 50 gram albumin. and worsened with Lasix. Patient
was continued on spirionolactone, furosemide, and Bactrim daily
for SBP prophylaxis, and midodrine 5 mg TID, and thiamine,
folate, multivitamin.
She then went home, and patient reports that she continued to
have intermittent nausea/vomiting. She then re-presented to the
ED on ___ after presenting to an OSH on ___ with CT scan, and
found to have a clogged J-tube and ? SBO/ileus. Patient then
underwent replacement of the tube with a new ___. Patient was
then found to have some surrounding erythema round the site.
Patient states that her last bowel movement was on ___, and is
passing flatus. She states that the J-tube has been working, and
because of worsening nausea/vomiting, she has stopped
administering tube feeds, and has emesis that is tube feed
related. She has been applying some anti-fungal cream to the
surrounding site around the tube. No fevers. In the ED, ___ was
consulted, and patient had her J-tube disc tightened and sutured
to prevent slipping, and new dressings applied.
Notably, patient was recently hospitalized for several times
over the past few months and has been dealing with significant
GI motility issues. Patient was hospitalized from
___ for nausea/vomiting, and low grade fevers,
at the time thought to be ___ to GJ anastamotic stricture, and
underwent EGD with balloon dilation. Patient then was diagnosed
with perforated gastrojejnuostomy, for which she went for
ex-lap, GJ take down, and gastrogastrostomy on ___.
Post-operatively, she has been dealing with refractory
nausea/vomiting, with UGI series showing slowed transit through
system. Patient had malpositioned J-tube replaced on ___,
and EGD with small bowl eneteroscopy showing erythema and
congestion of the stomach and small bowel enteroscopy. Patient
was trialed on octreotide for pro motility without signficnat
effect, erythrmocycin and ultimately improved and was tolerating
TF through perc GJ.
In the ED, initial vitals were 0 98.6 111 106/57 18 100% RA
Labs were notable for WBC 12.4, Hgb 8.3, Hct 24.8, Platelet 125
(MCV 108), PMN 87%. Sodium 128, K 4.4, Cl 92, Bicarb 21, BUN 18,
Cr 0.8. Glucose 114.
ALT 13, AST 14, AP 94, Lipase 23, T-bili 5.7, Albumin 3.2.
Serum Tox: Negative.
Urine Tox: Positive for Opiates.
Imaging was notable for ileus. Minimally changed dilation of
both large and small bowel loops without discrete transition
point, consistent with ileus.
Patient was given:
___ 16:40 IV Ondansetron 4 mg
Transfer vitals were: 0 97.3 107 107/59 22 95% RA
Upon arrival to the floor, patient reports nausea.
ROS:
(+)
(-) Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy (___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy (___ ___
- ETOH cirrhosis complicated by ascites, HE, SBP
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- thrombocytopenia
- left ankle fusion
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION EXAM:
===============
Weight: 200.8 lbs.
General: Fatigued appearing, weak voice. No acute distress.
HEENT: NC/AT. Scleral icterus, pale. PERRL. EOMI. OP clear.
Neck: Supple, no cervical lymphadenopathy appreciated.
Lungs: Diminished at the bases, no adventitial sounds.
Cardiac: RRR, S1, S2. No extra sounds heard.
Abdomen: Mildly distendended, surgical scars. Dressing fresh,
with minimal erythema. Tube with bilious drainage.
Extremities: Warm well, perfused.
Neurologic: AAOx3. Mild asterixis. Able to follow commands
grossly. Strength ___ throughout.
DISCHARGE EXAM:
===============
Weight: 214.2 lbs.
VS: 98.3 104/62 84 16 94 Ra
General: chronically ill appearing, cachectic, NAD
HEENT: MMM
Lungs: CTAB
Cardiac: RRR, III/VI systolic murmur loudest at LUSB
Abdomen: Distended, mildly tender throughout, especially in
lower quadrants, hypoactive BS, no rebounding. vertical red
wound on epigastric area. Some granulation tissue and purulence
around venting G tube insertion site, no expanding erythema or
TTP.
Extremities: WWP, no ___.
Neurologic: AOx3, no asterixis
Pertinent Results:
=============================
ADMISSION LABS
=============================
___ 12:50AM BLOOD WBC-8.5 RBC-2.25* Hgb-7.8* Hct-22.7*
MCV-101* MCH-34.7* MCHC-34.4 RDW-24.6* RDWSD-89.0* Plt ___
___ 12:50AM BLOOD Neuts-78.6* Lymphs-13.4* Monos-7.3
Eos-0.1* Baso-0.1 NRBC-0.4* Im ___ AbsNeut-6.65*#
AbsLymp-1.13* AbsMono-0.62 AbsEos-0.01* AbsBaso-0.01
___ 12:50AM BLOOD ___ PTT-48.6* ___
___ 12:50AM BLOOD Plt ___
___ 12:50AM BLOOD Glucose-70 UreaN-8 Creat-0.5 Na-126*
K-5.4* Cl-90* HCO3-24 AnGap-17
___ 12:50AM BLOOD ALT-13 AST-70* AlkPhos-68 TotBili-4.5*
___ 12:50AM BLOOD Albumin-2.9*
___ 01:16AM BLOOD Lactate-2.0 K-8.0*
==========================
DISCHARGE LABS
==========================
___ 05:15AM BLOOD WBC-5.8 RBC-2.06* Hgb-7.3* Hct-22.9*
MCV-111* MCH-35.4* MCHC-31.9* RDW-23.0* RDWSD-90.3* Plt Ct-85*
___ 05:15AM BLOOD ___ PTT-46.1* ___
___ 03:50PM BLOOD Neuts-87.0* Lymphs-6.7* Monos-5.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.75*# AbsLymp-0.83*
AbsMono-0.68 AbsEos-0.01* AbsBaso-0.02
___ 05:15AM BLOOD Glucose-82 UreaN-21* Creat-0.4 Na-136
K-3.9 Cl-101 HCO3-21* AnGap-14
___ 05:15AM BLOOD ALT-18 AST-39 AlkPhos-79 TotBili-2.5*
___ 05:15AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.8
=========================
IMAGING
=========================
CT abd/pelvis w/ contrast ___
1. Uniformly dilated small bowel loops without evidence of a
transition point are grossly unchanged in appearance as compared
to CT abdomen and pelvis ___. There is distal passage
of oral contrast into the cecum and ascending colon. There is
no evidence of a mechanical obstruction. These findings are
most compatible with an ileus.
2. Persistent moderate right-sided hydronephrosis without a
cause is unchanged as compared to CT abdomen pelvis ___.
3. No intraabdominal drainable fluid collection.
4. Splenomegaly; cholelithiasis; appropriately positioned
percutaneous
gastrostomy and jejunostomy catheters; diffuse anasarca are
additional
findings.
KUB ___:
No evidence of obstruction.
G/J TUBE CHECK ___:
Appropriately positioned and functioning gastrostomy and
jejunostomy tubes.
KUB ___:
Multiple dilated bowel loops, worrisome for small bowel
obstruction.
CT Abd/Pelvis ___: 1. Minimally changed dilation of both large
and small bowel loops without a
discrete transition point, most consistent with an ileus.
2. Small volume ascites and moderate anasarca.
3. Gallbladder sludge/cholelithiasis without acute
cholecystitis.
4. Splenomegaly.
5. Slightly decreased loculated left pleural effusion.
KUB ___: Supine and upright views of the abdomen pelvis
provided. Peg tube and gastrostomy tube again noted projecting
over the left hemiabdomen. An IUD projects over the pelvis.
There is gaseous distension of the colon with multiple air-fluid
levels noted. No free air seen below the right
hemidiaphragm. Residual contrast is noted within the left upper
abdomen
likely within the proximal stomach. Bony structures appear
grossly intact.
No free air is seen below the right hemidiaphragm.
============================
MICROBIOLOGY
============================
No growth on any cultures
___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL INPATIENT
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
Brief Hospital Course:
Key Information for Outpatient ___ yo female w/ PMHx
significant for EtOH cirrhosis c/b ascites, HE, and SBP, and
obesity s/p Roux-n-Y gastric bypass (___) c/b stricture of
gastrojejunal anastomosis & internal hernia resulting in SBO s/p
multiple endoscopic dilations. Course has been further c/b
perforation requiring takedown of old gastrojejunostomy and
gastrogastric anastomosis, s/p feeding jejunostomy (___) c/b
N/V ___ ileus, s/p venting G-tube on ___. J-tube feeding was
c/b multiple instances of intolerance despite short term bowel
rest with slow re-initiation of feeds. Abdominal imaging c/w
ileus on ___. Given suboptimal provision of enteral nutrition
and PO intolerance, TPN started ___ for 100% energy and protein
needs. TFs restarted on ___ at a very low rate (5cc/hr), which
the patient appeared to be tolerating well. Plan to continue
current nutritional plan to provide 100% nutrition via TPN and
see outpatient provider for chronic dysmotility issues.
ACUTE ISSUES:
=============
# Nausea/Vomiting/Abdominal pain
The patient was admitted to the hospital unable to tolerate TFs
due to severe nausea and vomiting, with copious output from
venting G-tube. There was a concern for obstruction vs. slow
motility. The patient had repeated studies during this
hospitalization looking for a cause of her inability to tolerate
PO. Multiple KUBs showed no obstruction but the patient
continued to have a functional ileus. A percutaneous G/J tube
check on ___ with contrast hand injection via the pre-existing
gastrostomy and jejunostomy tubes demonstrated both tubes to be
in appropriate positioning without evidence of obstruction.
After discussion with motility specialists in GI, an MRI with
small bowel follow through was ordered but could not be
accomplished due to concerns that she would not be able to
tolerate the PO contrast bolus. Also, per radiology
recommendations, that was not a good study to assess motility of
the bowels. A CT scan with contrast of her abdomen on ___ showed
uniformly dilated small bowel loops without evidence of a
transition point and no evidence of a mechanical obstruction.
These findings are most compatible with an ileus. Given that the
patient could not tolerate tube feeds, in order to offer
nutrition the last resort was to place a PICC line on ___ and
TPN was started ___. Trickle tube feeds at a rate of 5 cc/hr
were restarted. Patient was continued on standing reglan to 10
Q6.
# Nutrition - Patient was discharged on TPN and trickle tube
feeds. 100% nutrition via TPN, tube feeds Osmolite 1.5 @ 5
ml/hr. She will have folic acid, copper, zinc and thiamine
supplements in TPN.
# Cellulitis - Patient developed purulence and erythema around
the G-tube. NO fever or elevation in white count was noted.
Doxycycline 100 mg twice a day was started on ___ and she will
need to complete a course of 7 days until ___.
# EtOH CIRRHOSIS:
Childs C c/b ascites, HE, SBP, and HRS. MELD-Na score 22.
Patient at this point has minimal ascites on examination. Not
transplant candidate largely due to nutrition and complicated
post-surgical problems. The patient was continued on lactulose
and rifaximin. The diuretics were held in the setting of her ___
(which later on resolved), home furosemide 20mg qd was restarted
by time of discharge. Midodrone 5 mg TID was continued, as well
as TMP-SMX for SBP prophylaxis
# Anemia - Likely multifactorial given liver disease, poor
nutrition, and chronic illness in general. The patient has been
transfused prn with appropriate bump in H&H (5 total units
PRBCs). There was no active concern for bleeding. Hemolysis labs
were negative.
# ___ - Cr went from .8 as high as 1.7 during this
hospitalization. There is likely some effect of prerenal state
given increased output from venting G-tube, worsened iso chronic
liver disease. After decreasing to baseline, Cr has been stable.
CHRONIC ISSUES:
===============
# H/o ROUX-EN-Y: Patient receiving zinc and copper
supplementation through TPN with weekly monitoring of Cu levels.
# History of seizure: Continued levetiracetam 100 mg BID
# Depression: Continued escitalopram 20 mg daily
# History of alcohol abuse: Continued thiamine, folate,
multivitamin
TRANSITIONAL ISSUES:
====================
- Weight at discharge: 97.16kg. Patient needs to continue to
trend weights
- Cr at discharge: 0.4
- Diuretics at discharge: Furosemide 20mg PO daily
- H/H at discharge: 7.3/22.9. Patient required 5 units of blood
transfusion during her admission. The anemia will need to be
monitored on an outpatient basis, transfusions ordered prn. Last
transfusion was ___.
- Patient currently has a J-tube for feeds/meds along with a
venting G-tube, interventional radiology evaluated patient
during this admission as above.
- Patient needs to continue with nutrition recommendations of
100% nutrition via TPN, tube feeds Osmolite 1.5 @ 5 ml/hr. She
will have folic acid, copper, zinc and thiamine supplements in
TPN, has currently had weekly copper levels checked.
- Patient should have evaluation by outpatient GI motility (have
called to set-up appointment with either Dr. ___, Dr.
___ Dr. ___.
- CT abdomen and pelvis w/ contrast showed persistent moderate
right-sided hydronephrosis without a cause, unchanged as
compared to CT abdomen pelvis ___.
- Patient is very sensitive to changes in lactulose - 2 doses of
lactulose were held during this admission and the patient became
encephalopathic immediately.
- Low copper on ___ labs. ___ Cu labs were pending at time
of discharge.
- Please continue to discuss transplant status with ongoing
nutrition and GI motility issues
- Bowel regimen on discharge: Lactulose 30 mL Q6H, Senna 8.6 mg
BID, Polyethylene Glycol 17 g DAILY, Bisacodyl 10 mg PR QHS:PRN
constipation through J-tube
- QTc at discharge 479. Please continue to monitor QTc
- Code status: Full Code
- Contact info: ___ (parents) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. copper gluconate 4 mg oral Q12H
2. Dronabinol 5 mg PO BID
3. Esomeprazole 40 mg Other DAILY
4. LevETIRAcetam Oral Solution 1000 mg PO BID
5. Rifaximin 550 mg PO BID
6. Spironolactone 25 mg PO DAILY
7. Lactulose 30 mL PO TID
8. Midodrine 5 mg PO TID
9. Furosemide 40 mg PO DAILY
10. Escitalopram Oxalate 20 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
14. Thiamine 100 mg PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth Q8 Disp #*90 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*11 Capsule Refills:*0
4. Hyoscyamine 0.125 mg SL QID PRN abdominal pain
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually four
times a day Disp #*120 Tablet Refills:*0
5. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
RX *lidocaine 5 % 1 Appl BID:PRN twice a day Disp #*60 Patch
Refills:*0
6. Metoclopramide 10 mg PO Q6H
RX *metoclopramide HCl 10 mg 1 by mouth every six (6) hours Disp
#*120 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [Natural Senna Laxative] 8.6 mg 1 mg by mouth
twice a day Disp #*60 Tablet Refills:*0
10. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone [Gas Relief] 40 mg/0.6 mL 0.6 mL by mouth four
times a day Refills:*0
11. TraMADol 100 mg PO BID
RX *tramadol 50 mg 2 tablet(s) by mouth twice a day Disp #*120
Tablet Refills:*0
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Lactulose 30 mL PO Q6H
RX *lactulose 20 gram/30 mL 30 mL by mouth every six (6) hours
Disp #*1000 Milliliter Refills:*0
14. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. LevETIRAcetam Oral Solution 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
17. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
18. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
19. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
20. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Sulfatrim] 200 mg-40 mg/5 mL
20 mL by mouth daily Refills:*1
21. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Nausea/vomiting
Ileus
Anemia
___
Secondary diagnosis:
====================
Malnutrition
Alcohol cirrhosis
Seizures
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were hospitalized for a small bowel obstruction in the
setting of eating solid food at home. You were monitored and
tube feeds were slowly restarted or stopped as needed based on
what you were able to tolerate.
Initially you continued to receive tube feeds through your
J-tube, and you had your G-tube upsized with some improvement in
your symptoms. However, you required G-tube venting and suction
intermittently because of recurrent vomiting and ileus (poor
movement in the bowels). We went down on how fast the tube feeds
were going into your J-tube but you still did not tolerate them
and that caused you more nausea and vomiting, as well a copious
output from venting G-tube. So we need to stop them completely
to prevent your symptoms. In order to give you nutrition we
started TPN, which is nutrition that goes directly into your
blood. That made you feel better and improved your nausea and
vomiting.
Moving forward you will need to continue to receive TPN, and
trickle tube feeds (tube feeds at a very slow rate in order to
keep your bowels working). You need to be able to take care of
the G-tube alone at home since periodically you will need to
vent it. You were taught by our nurses how to do that. You will
also need to learn how to manage your TPN at home and follow the
lessons your were taught in the hospital by our staff.
While you were hospitalized multiple teams of doctors saw ___,
including our surgery and motility colleagues, who recommended
special studies. These studies did not show any obstruction in
your bowels. We believe that your intolerance to oral food is
due to abnormal motility of your bowels. We has contacted one of
our motility specialists for you to see as an outpatient. If
you are not called over the next several days please call
___ to schedule an appointment with either
Dr. ___, Dr. ___ Dr. ___.
Moving forward, you will continue to receive TPN nutrition,
trickle tube feeds and you will need to take care of you G-tube
and TPN nutrition at home. Also, you should not eat anything by
mouth because that will make you sick and you will most probably
come back to the hospital. All of your medications should be
administered through your feeding tube.
You developed some pus and redness around the G-tube.
Doxycycline 100mg twice a day was started on ___ to prevent any
skin infection, and you will need to complete a course of 7 days
until ___.
Please try to wean down tramadol in the future. Also, you can go
up on the tube feeds rate, but if you do this, you need to go up
very slowly and in consultation with your motility doctor since
you are very sensitive to this change and it may cause nausea
and vomiting otherwise.
Please follow up with your doctors as listed below. If you do
note hear from Dr. ___ over the next several days,
please call ___ to schedule an appointment.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19612461-DS-18
| 19,612,461 | 29,416,331 |
DS
| 18 |
2159-12-03 00:00:00
|
2159-12-03 18:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, leg swelling
Major Surgical or Invasive Procedure:
G-tube replacement (___)
PICC line placement (___)
History of Present Illness:
Ms. ___ is a ___ year old female with history of Childs C
alcoholic cirrhosis c/b ascites, HE, SBP, and HRS as well as
Roux-en-Y gastric bypass c/b recurrent anastomotic strictures
requiring multiple endoscopic dilations and abdominal surgeries
for bowel anastomosis complications who was recently admitted
from ___ for persistent obstructive symptoms and
malnutrition, found to have an ileus and discharged on TPN who
presents to the ___ with weight gain, abdominal pain, and
vomiting.
The patient reports several weeks of worsening abdominal and
lower extremity swelling. The swelling has worsened her chronic
abdominal pain and she now describes a diffuse pain that feels
like her abdomen is stretching. She also reports two episodes of
non-bloody vomiting, once last night and once today. Per
records, her weight at last admission was 212 lbs; she went down
to 173 lbs during the hospitalization, and discharge weight was
214 lbs after her diuretics were held in the setting of ___.
During a follow-up apt on ___ weight was still up, at which
time Lasix was increased from 20 mg to 40 mg and spironolactone
from 25 mg to 50 mg. She continued to have swelling and new
vomiting overnight so presented to the ED today. She otherwise
reports some mild shortness of breath and orthopnea. No cough,
chest pain, fever, chills, confusion, constipation, melena, or
blood in her stools. Last BM this morning. Also reports venting
her G/J-tube frequently without improvement of her abdominal
pain.
Of note, the patient was recently discharged on ___
following a one month admission for nausea, vomiting, and
inability to tolerated tube feeds. A percutaneous G/J tube check
showed the gastrostomy and jejunostomy tubes were in the
appropriate positions without evidence of obstruction. She was
eventually
diagnosed with an ileus and started on TPN on ___. She was
discharged on trickle tube feeds at a rate of 5 cc/hr. Her
hospital course was also complicated by cellulitis around her
G-tube, treated with doxycycline x 7 days.
In the ED, initial vitals were T97.9, HR 86, BP 96/53, RR 18,
SaO2 98% on RA
Labs were notable for:
H/H of 7.6/23.7, Plts 93, Lactate of 2.2, Tbili of 2.7, Albumin
of 2.7, proBNP 1666, ___ 22.7, PTT 42.0, INR 2.1
Imaging was notable for:
CXR: Chronic left-sided loculated effusion.
CT A/P: limited study with evidence of stable dilatation of
small bowel loops without obvious obstruction, stable moderate
hydronephrosis, pleural effusions. Bedside ultrasound indicated
no tappable fluid.
Hepatology was consulted and recommended discharge home given
lack of acute issues, with plan to follow up with the liver
clinic on ___. However, patient continued to have significant
pain, nausea, and given need for pain/nausea control and
uptitration of diuretics, decision was made to admit to ___.
Patient was given:
-IV Morphine Sulfate 4 mg x2
-Midodrine 5 mg x2
-Lactulose 30 mL
-Rifaximin 550 mg x2
-NS 50 mL/hr
-IV Ondansetron 4 mg
-Lactulose 30 mL
-Polyethylene Glycol 17 g
-Senna 8.6 mg
-Bisacodyl 10 mg
-FoLIC Acid 1 mg
-LevETIRAcetam 1000 mg
-PO Pantoprazole 40 mg
-Thiamine 100 mg
-IV LORazepam .25 mg
Transfer vitals were: 97.9F BP 117/69 HR 92 RR 20 95% on Ra
Upon arrival to the floor, patient reports she continues to have
diffuse abdominal pain. No recent vomiting. She also describes
significant swelling over her lower extremities.
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy (___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy (___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 97.9F BP 117/69 HR 92 RR 20 95% on Ra
Weight: 245.6 lbs
GENERAL: NAD. Cachetic appearing. Lying comfortably in bed.
HEENT: NC/AT. No conjunctival pallor or scleral icterus, pupils
equal and round, EOMI.
NECK: Supple, JVD to mandible.
HEART: RRR with normal S1 and S2. II/VI SEM heard throughout,
best over the left sternal border. No rubs or gallops.
LUNGS: Normal respiratory effort. CTAB over anterior chest
without wheezes, rales or rhonchi. Decreased BS over lateral
fields bilaterally. Pt unwilling to accommodate examination of
back.
ABDOMEN: Soft, obese. Mildly distended. Diffuse TTP to light
palpation. Voluntary guarding. Normoactive BS. G/J tube site
without drainage or surrounding erythema.
EXTREMITIES: Warm. ___ pitting BLE edema up to mid thigh.
SKIN: No rashes.
NEUROLOGIC: A&Ox3. Moves all extremities. No asterixis.
DISCHARGE PHYSICAL EXAM:
=========================
VS: T97.8, BP 108/61, P82, RR18, Po296% RA
GENERAL: NAD. Cachetic. Lying comfortably in bed.
HEENT: No conjunctival pallor or scleral icterus.
HEART: RRR, S1+S2. III/VI SEM heard throughout, best over the
LLSB. No rubs or gallops.
LUNGS: CTAB, no W/R/C
ABDOMEN: moderately distended, firm, irregular topography. Mild
TTP diffusely. G/J site with clean bandage, mild drainage, no
erythema
EXTREMITIES: Warm. 1+ pitting BLE edema up to mid shins. No
erythema.
SKIN: No rashes.
NEUROLOGIC: A&Ox3. Moves all extremities. No asterixis.
Pertinent Results:
ADMISSION LABS:
================
___ 06:25PM BLOOD WBC-7.2 RBC-2.10* Hgb-7.6* Hct-23.7*
MCV-113* MCH-36.2* MCHC-32.1 RDW-21.6* RDWSD-86.7* Plt Ct-93*
___ 06:25PM BLOOD Neuts-74.7* Lymphs-13.4* Monos-10.7
Eos-0.7* Baso-0.1 Im ___ AbsNeut-5.40 AbsLymp-0.97*
AbsMono-0.77 AbsEos-0.05 AbsBaso-0.01
___ 06:25PM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-140
K-3.8 Cl-98 HCO3-30 AnGap-12
___ 06:25PM BLOOD ALT-13 AST-39 AlkPhos-92 TotBili-2.7*
___ 06:25PM BLOOD Lipase-25
___ 06:25PM BLOOD proBNP-1666*
___ 06:25PM BLOOD Albumin-2.7* Calcium-8.6 Phos-3.9 Mg-2.0
___ 06:36PM BLOOD Lactate-2.2*
PERTINENT LABS:
======================
___ 06:25PM BLOOD Lipase-25
___ 06:25PM BLOOD proBNP-1666*
___ 06:36PM BLOOD Lactate-2.2*
___ 10:09PM BLOOD Lactate-1.2
___ 04:50PM BLOOD ZINC- 31*
___ 04:50PM BLOOD COPPER (SERUM)- 75
MICRO:
=======
___ BCx: No growth
___ BCx:
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ <=0.5 S
___ Wound culture: MIXED BACTERIAL FLORA
___ Blood cultures: No growth
___ urine culture: No growth
DISCHARGE LABS:
===============
___ 05:31AM BLOOD WBC-6.9 RBC-2.00* Hgb-7.2* Hct-22.5*
MCV-113* MCH-36.0* MCHC-32.0 RDW-20.9* RDWSD-85.0* Plt Ct-74*
___ 05:31AM BLOOD ___ PTT-35.4 ___
___ 05:31AM BLOOD Glucose-138* UreaN-31* Creat-0.8 Na-135
K-4.0 Cl-97 HCO3-29 AnGap-9
___ 05:31AM BLOOD ALT-20 AST-42* AlkPhos-94 TotBili-2.0*
___ 05:31AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
PERTINENT IMAGING:
====================
___ CXR:
Left-sided PICC terminates in the low SVC without evidence of
pneumothorax.
Left lower lobe opacity corresponds to chronic loculated pleural
fluid and
atelectasis as seen on abdominal CT. Left mid lung
atelectasis/scarring is
seen. Cardiac and mediastinal silhouettes are stable.
No overt pulmonary edema.
___ CT Abd/pelvis:
1. Of note, this is a suboptimal study due to body habitus.
Within these
limitations, diffuse dilatation of multiple small bowel loops
are again noted without definite transition point.
2. Moderate hydronephrosis is again seen without definite source
of
obstruction, similar to the prior study on ___.
3. Postsurgical changes are noted following Roux-en-Y gastric
bypass.
Incidental note is made of a G-tube and a J-tube.
4. Consolidations are seen in the left lower lobe, which can be
concerning for infection in the appropriate clinical setting.
5. Small loculated left pleural effusions unchanged.
6. Splenomegaly and cholelithiasis.
7. Diffuse anasarca, unchanged.
___ TTE:
IMPRESSION: Biatrial enlargement. Mildly dilated left ventricle
with preserved biventricular systolic function. Mildly dilated
right ventricle with preserved function. Mild pulmonary artery
systolic hypertension. Ascites is present.
___ Abdominal US:
Somewhat limited evaluation secondary to poor patient tenderness
and poor
acoustic windows. No definite collection identified around the
entry sites of the J-tube or G-tube.
___ Gastrostomy tube exchange:
1. Appropriately positioned new 16 ___ MIC gastrostomy tube.
___ Abd xray:
Probable ileus, grossly unchanged. No gross free air.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of alcoholic
cirrhosis c/b ascites, HE, SBP, and HRS as well as Roux-en-Y
gastric bypass c/b recurrent anastomotic strictures requiring
multiple endoscopic dilations c/b perforation requiring multiple
abdominal surgeries. She is now s/p multiple admissions, most
recently from ___ for persistent obstructive symptoms and
malnutrition, found to have an ileus and discharged on
TPN/trickle feeds, readmitted with volume overload, found to
have likely PICC-associated enterococcus bacteremia.
#Anasarca: Patient presented with anasarca and 50 pound weight
gain in the last month. Likely due to cirrhosis and low protein
from malnutrition. Pt diuresed with high doses of torsemide and
spironolactone back to dry weight (92.53 kg/ 203.99 lb on
discharge). Discharged on 100mg spironolactone and 40mg
torsemide daily.
#Enterococcus Bacteremia: Blood cultures on admission grew
vancomycin sensitive enterococcus from PICC line. PICC was
discontinued and patient was switched from vanc -> daptomycin on
___ (given history of VRE) and narrowed back to vancomycin
(___) after return of cultures. She had a murmur on exam (old);
TTE this admission without obvious vegetation. Otherwise, HD
stable. PICC line replaced on ___. Repeat cultures were
negative following the start of antibiotics. She ultimately
completed 2 weeks of vancomycin on ___. Discharged off
antibiotics. Attempted to increase tube feeds repeatedly during
admission, with the hope of getting enough nutrition through
tube feeds that TPN and PICC line could be discontinued, but
unable to tolerate tube feeds at a high enough rate to be
sufficient as singular source of nutrition, and thus PICC
remained in place on discharge.
#Decompensated ETOH Cirrhosis: History of Childs C cirrhosis c/b
ascites, HE, SBP, and HRS. MELD-Na 18 on admission, Childs C.
Grossly overloaded. No varices on last EGD in ___. Hgb slowly
trended down, s/p 1u pRBC on ___ with appropriate response.
Stable upon discharge. No signs of active GI bleed. No signs of
SBP or HE. Etiology of chronic decompensated state likely
multifactorial, from large TPN volumes, malnutrition, and
bacteremia this admission. Continued lactulose and rifaximin
550mg BID, pantoprazole 40 mg daily, midodrine 5 mg TID, Bactrim
ppx. As per above, pt discharged on 100mg spironolactone and
40mg torsemide daily.
#Cellulitis: Noted to have erythema with purulent discharge
around G/J tube. Previously treated for cellulitis during last
hospitalization with doxycycline 100 mg BID x 7 days. Obtained
culture and started vancomycin ___, briefly on daptomycin given
history of VRE, but narrowed back to vancomycin as of ___.
Completed 2 weeks of treatment on ___ (duration of therapy
was for bacteremia, but more than adequate for cellulitis).
Wound culture grew mixed flora. Ultrasound unremarkable.
Erythema resolved and drainage improved following upsize of
G-tube and antibiotic therapy.
#Abdominal pain: Acute on chronic abdominal pain. CT abdomen
limited this admission, but showed diffuse dilation of small
bowel, similar to previous studies, and no signs of infection.
Surgery evaluated in ED and felt there was no acute change in
abdominal pain. Remained HD stable and without leukocytosis.
Likely worsened by volume overload and acutely worsened with
tube feeds at rates > 45cc/hr. Discharged with tube feeds
running at 45cc/hr. Seen by GI motility team who recommended a
trial of methylnatrexone x 3 days, which appeared to help
(slightly) with the patient's abdominal pain and motility.
Methylnatrexone 12mg subQ daily was prescribed for the patient
to continue taking as an outpatient, and she was able to
successfully inject herself prior to discharge. Otherwise,
discharged without changes to home regimen (tramadol 100 mg BID,
hyoscyamine 0.125 mg QID prn, metoclopramide 10 mg q6h,
simethicone prn). She will follow-up with the motility team as
an outpatient.
#Malnutrition: PICC initially placed ___ and TPN started ___
in the setting an ileus and poor po intake. Had also been on
trickle tube feeds Osmolite 1.5 @ 5 ml/hr at home, prior to
admission. She reported minimal po intake and presented
dependent on TPN. TPN stopped ___ after ___ pulled given
bacteremia, restarted ___ after a new PICC was placed. Tube
feeds were slowly titrated up. She did not tolerate feeds >60
cc/hr and was ultimately discharged on TPN through PICC and tube
feeds at 60 cc/hr.
#Anemia: Hgb 7.4 on admission, stable from baseline ___. Likely
multifactorial given liver disease, poor nutrition, and chronic
illness in general. Previous hemolysis labs negative. Iron
studies showed elevated ferritin, low TIBC, low transferrin, low
normal iron, overall consistent with anemia of
inflammation/chronic disease. Received 1U pRBCs during admission
with appropriate response.
CHRONIC/STABLE/RESOLVED ISSUES:
================================
#Loculated pleural effusion. Noted to have chronic loculated
pleural effusion and atelectasis on CXR and CT abd. Patient
reports mild SOB but without cough, fever, or chills. Low
concern for PNA, antibiotics were not given for this issue.
#Depression/anxiety: Continued home escitalopram 20 mg daily.
#Seizures: Continued home keppra 1000mg BID.
DISCHARGE LABS:
MELD-Na: 18
Cr: 0.8
Weight: 92.53 kg/ 203.99 lb
TRANSITIONAL ISSUES:
====================
[ ] Continue methylnaltrexone 12mg subQ daily. Will be seen by
___ motility specialist (Dr ___ as an outpatient for
ongoing management of this issue. Prior authorization was
obtained for this medication through ___
(___) on ___, good for 12 months.
[ ] Discharged on with tube feeds through G tube and TPN through
RUE ___ (failed many attempts to increase tube feeds with the
hopes of stopping TPN, but pt could not tolerate tube feeds at a
sufficient rate such that tube feeds alone would be sufficient
to meet her nutritional needs.
[ ] Discharge diuretic regimen: 100mg spironolactone and 40mg
torsemide daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Lactulose 30 mL PO Q6H
4. Midodrine 5 mg PO TID
5. Rifaximin 550 mg PO BID
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
8. TraMADol 100 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas pain
13. Metoclopramide 10 mg PO Q6H
14. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
15. Hyoscyamine 0.125 mg SL QID PRN abdominal pain
16. Bisacodyl 10 mg PO/PR DAILY
17. Thiamine 100 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. LevETIRAcetam Oral Solution 1000 mg PO BID
21. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Methylnaltrexone 12 mg Subcut DAILY
RX *methylnaltrexone [Relistor] 12 mg/0.6 mL 12 mg subQ Once a
day Disp #*21 Syringe Refills:*0
2. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg Two tablet(s) by mouth Once a day Disp #*60
Tablet Refills:*0
3. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg One tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. Bisacodyl 10 mg PO/PR DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Hyoscyamine 0.125 mg SL QID PRN abdominal pain
9. Lactulose 30 mL PO Q6H
10. LevETIRAcetam Oral Solution 1000 mg PO BID
11. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
12. Metoclopramide 10 mg PO Q6H
13. Midodrine 5 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Polyethylene Glycol 17 g PO DAILY
17. Rifaximin 550 mg PO BID
18. Senna 8.6 mg PO BID
19. Simethicone 40-80 mg PO QID:PRN gas pain
20. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
21. Thiamine 100 mg PO DAILY
22. TraMADol 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary: Decompensated cirrhosis, Enterococcus bacteremia
#Secondary: Malnutrition, Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were retaining a lot of fluid.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were treated with water pills (diuretics - specifically,
torsemide and spironolactone) to get extra fluid out of your
system.
- You were found to have bacteria growing in your blood, we
think this infection was caused by your PICC line. Your PICC
line was taken out and a new one was put in. You were treated
with antibiotics through your PICC line for 2 weeks.
- We tried to switch you from taking TPN through your PICC line
for nutrition to tube feeds through your G-tube, but had a very
difficult time managing your pain and nausea while you were on
the tube feeds. We even exchanged your G-tube for a different
G-tube to see if that would help, but it didn't.
- You were seen by our motility team, who specialize in issues
of moving food through your GI tract, and we tried a medication
called methylnatrexone to help your GI tract move and improve
your pain. It seemed to help a little, so we will continue to
have you take this medicine at home.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to have TPN through your PICC line and tube feeds
through your G-tube.
- Continue to take all of your medicines as prescribed.
- You will see your primary care doctor and gastroenterologist
in the office (see below for details).
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19612461-DS-20
| 19,612,461 | 22,789,727 |
DS
| 20 |
2160-01-28 00:00:00
|
2160-01-29 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute on chronic abdominal pain, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with EtOH cirrhosis complicated by ascites, SBP, HE, and
HRS,s/p ___ gastric bypass c/b recurrent anastomotic
strictures requiring multiple endoscopic dilations, and multiple
abdominal surgeries for bowel anastomosis complications
(including bowel perforation) who was recently admitted for
acute on chronic abdominal pain with hospital course complicated
by Klebsiella bacteremia, ___ dysfunction, ___
cellulitis and confusion. She currently ___ with
recurrent acute on chronic abdominal pain and confusion. She is
unable to describe how many days she has had worsening abdominal
pain but does endorse confusion despite adherence to her
lactulose at home. Patient denies fevers chest pain or shortness
of breath and she is A&O x3 but with difficulty formulating
sentences.
On arrival to the floor, patient corroborates the above story.
She states that there has been no leaking from her new ___
and the site where her old ___ was placed continues to leak
minimally into an overlying ostomy bag. She otherwise has no new
complaints.
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy (___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy (___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or ___ emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.2PO, 118/54, 90, 18, 94% RA
___: NAD
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclera, pink
conjunctiva, MMM with white plaques over her tongue
HEART: RRR, normal S1/S2, ___ early systolic murmur best heard
at LSB, no JVD.
LUNGS: fine bibasilar crackles, no wheezes, breathing
comfortably without use of accessory muscles
ABDOMEN: obese and firm, very tender to light palpation,
hyperactive bowel sounds, unable to appreciate
hepatosplenomegaly
EXTREMITIES: ___ pitting edema bilaterally
NEURO: A&Ox3 but confused with word finding difficulty, moving
all 4 extremities with purpose
SKIN: well healed abdominal scars, erythematous groin rash with
satellite lesions and skin breakdown in fold of groin and under
panus.
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.5 PO 105 / 63 88 18 94 RA
GEN: Pleasant ___ woman, lying down in bed, appears
comfortable, in no acute distress
HEENT: Mild scleral icterus, OP clear
CV: RRR, ___ flow murmur best heard at the RUSB, normal S1/S2,
no
rubs, gallops, or thrills
RESP: CTAB, no w/r/r, good inspiratory effort
ABD: Soft, mildly tender to palpation throughout. ___ in
place. Dressing clean and dry over old ___ site.
EXT: Warm and ___, 2+ pitting edema bilaterally to the
knees. Left ankle mobility limited due to surgical hardware. No
clubbing or cyanosis.
NEURO: A&Ox3; no asterixis, moving all 4 extremities with
purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 03:50PM BLOOD ___
___ Plt ___
___ 03:50PM BLOOD ___
___ Im ___
___
___ 03:50PM BLOOD ___ ___
___ 03:50PM BLOOD ___
___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD cTropnT-<0.01
___ 03:50PM BLOOD ___
___
___ 03:50PM BLOOD ___
___ 03:50PM BLOOD ___
___
___ 05:35PM BLOOD ___
___ Base ___
___ 04:14PM BLOOD ___
___ 05:35PM BLOOD O2 ___
INTERVAL LABS:
================
___ 03:02PM BLOOD Ret ___ Abs ___
___ 03:02PM BLOOD ___
___
___ 06:46AM BLOOD Folate->20
___ 04:53AM BLOOD ___
Test Result Reference
Range/Units
VITAMIN D, 1,25 (OH)2, TOTAL <8 L ___ pg/mL
VITAMIN D3, 1,25 (OH)2 <8 pg/mL
VITAMIN D2, 1,25 (OH)2 <8 pg/mL
Test Result Reference
Range/Units
ZINC 37 L ___ mcg/dL
Test Result Reference
Range/Units
COPPER 67 L ___ mcg/dL
Test Result Reference
Range/Units
___ 29 H ___ pg/mL
Test Result Reference
Range/Units
___ 25 ___ pg/mL
IMAGING:
==========
___ CT HEAD:
1. No acute intracranial abnormality within confines of
noncontrast head CT. Specifically no large territory infarct or
intracranial hemorrhage.
2. Given the patient's clinical history, MRI would be more
sensitive for
subtle findings of encephalopathy, if there are no
contraindications.
___ ECHO:
The left atrial volume index is severely increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal
(Quantitative (biplane) LVEF = 64 %). There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with normal free wall contractility. 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. There is mild to moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild to moderate pulmonary hypertension. Mild
biventricular cavity dilation with normal function. Increased
right atrial pressure.
___ CT Chest w Contrast
IMPRESSION:
-Several new lung nodules associated with new mediastinal
lymphadenopathy
could represent - 1. lymphoma, 2. metastatic disease or less
probably 3.
septic emboli.
-Small pleural effusions on a background of mild pulmonary
edema.
DISCHARGE LABS:
===============
___ 06:11AM BLOOD ___
___ Plt ___
___ 06:11AM BLOOD ___ ___
___ 06:11AM BLOOD ___
___
___ 06:11AM BLOOD ___
___ 06:11AM BLOOD ___
___ 06:40AM BLOOD ___ TOP
___ 06:40AM BLOOD ___
Brief Hospital Course:
Ms. ___ is a lovely ___ year old woman with EtOH cirrhosis
complicated by ascites, SBP, HE, and HRS,s/p ___ gastric
bypass with multiple complications including recurrent
anastomotic strictures, bowel perforation, s/p Klebsiella
bacteremia, who presented with abdominal pain, confusion, ___
and hypercalcemia of unknown etiology. Hypercalcemia and ___
were treated with fluids and calcitonin with improvement in
mental status. Course was complicated by hypoxemia in setting of
fluid administration for ___. Chest CT was done out of concern
for malignancy which revealed small nodules and hilar
lymphadenopathy on Chest CT. Pulmonary was consulted and
recommended repeat CT scan in ___ weeks, and felt that nodules
were likely infectious.
ACTIVE ISSUES:
==============
#Confusion: RESOLVED
The etiology of her confusion was felt to be hypercalcemia in
the setting of malabsorption and renal dysfunction from ___.
Hepatic encephalopathy was less likely given regular bowel
movements, though she continues to be at risk of hyperammonemia
given decompensated liver failure with gastric motility issues.
Her neuro exam was without focal deficits and her head CT was
negative. She was treated for hypercalcemia with calcitonin. She
received delirium precautions and frequent reorientation, as
well as Lactulose QID goal ___ BM per day.
# ___: RESOLVED
Patient was believed to be in a ___ azotemima in the
setting of poor PO intake due to confusion. Her creatinine on
admission was 1.1 from her baseline of 0.5. It improved to 0.9
with fluids and treatment of hypercalcemia. She then became
fluid overloaded and was subsequently diuresed with Lasix as
above. Her creatinine continued to downtrend back to her
baseline, and was 0.6 at discharge.
#s/p Hypercalcemia
#Hyperreflexia
#Concern for malignancy
Her hypercalcemia continued to be of undetermined etiology: most
likely malignancy vs poor PO intake and immobility. Her calcium
level was elevated to 13.2 (corrected for hypoalbuminemia) on
admission, new from prior discharge (highest level appears to be
around 10). iCal was also elevated at 1.46. She had elevated
lambda and kappa chains, but with a normal ratio, which is less
consistent with a plasma cell dyscrasia. Additionally, her blood
smear was without any evidence of malignancy. Her 1,25 vit D was
normal, and normal SPEP. Calcium downtrended to normal with
initiation of calcitonin treatment per Endocrine (Calcitonin
4u/kg for 400u BID). Her CT chest showed small nodules as above,
concerning for malignancy vs infection, which will be followed
up on CT by pulmonology in ___ weeks. She was given Vitamin D
supplementation 2000u daily in the setting of Vit D deficiency.
Her home dose of metoclopramide was decreased from 10 mg to 5mg,
as metoclopramide could cause hyperreflexia.
#Hypoxia and pulmonary edema: RESOLVED
Patient developed orthopnea and hypoxia in the setting of
receiving albumin infusion for ___ and hypercalcemia. Her CXR
showed pulmonary edema. She was briefly placed on supplemental
O2, then weaned back to RA. Tachypnea improved with IV diuresis.
Discharged on Torsemide 60mg daily.
#EtOH cirrhosis
#Coagulopathy
#Volume Overload
Childs C, ___ 22 on admission. EtOH cirrhosis c/b ascites,
HE, SBP, and HRS. No varices on last EGD in ___. No signs of
HE. Patient reports adherence to lactulose at home. At her last
hospitalization, patient was seen by palliative care and chose
to continue aggressive medical management at this time. Patient
is not a transplant candidate at this time due to complex
medical conditions. This hospitalization, she was given TPN via
PICC for nutrition. Her Midodrine 10 mg PO TID was continued.
Also continued Lactulose 30 mL PO QOD, Rifaximin 550 mg PO BID
with goal ___ BMs/day, Ciprofloxacin 500mg daily for SBP ppx,
Folic Acid 1 mg, MVM 1 TAB, Thiamine 100 mg, Vit D. She was
diuresed with IV Lasix this admission, and transitioned back to
Torsemide for maintenance. Her discharge regimen was Torsemide
60mg today and Spironolactone 50mg daily.
#Pancytopenia
#Coagulopathy
Patient is pancytopenic, likely secondary to liver disease,
alcohol marrow suppression, poor nutrition, and chronic illness.
She has no evidence of active bleed at this time. WBC was
elevated on admission relative to baseline, but her infectious
work up was negative. She received IV Vit ___ ___. She was
transfused blood on ___.
# Abdominal pain, chronic
Patient presented with acute worsening of chronic abdominal
pain, now stable. CT abd/pelv showed no evidence of acute
obstruction, showed ___ appropriately positioned, and
evidence for ileus. No evidence infection. ___ site appeared
clean and ___. She had no significant ascites for
diagnostic paracentesis. C. diff negative, UCx contaminated. BCx
NGTD. ___ remained in place, patient continued having bowel
movements. Continued methylnaltrexone 12 mg Subcut DAILY,
Metoclopramide 10 mg PO Q6H, Simethicone ___ mg PO QID:PRN for
gas pain, TraMADol 100 mg PO BID, Dilaudid 2 mg PO q6h prn,
given AMS. Her bowel regimen was continued as well: Bisacodyl 10
mg, Polyethylene Glycol, Lactulose 30 mL Q6H
# ___
# ___ site cellulitis
# Malnutrition
She is TPN dependent given inability to tolerate full PO or full
tube feed goals. She is s/p replacement and upsizing of her
___ by ___ on her last admission. ___ was removed after
discussion with consulting services on last admission, now with
minimal drainage into a gauze bandage over the site. She has a
PICC and she continued TPN with the hope of using her ___ in
the future if tolerated. Nutrition followed her during this
admission. She was discharged home with ___ for TPN.
#Hyponatremia: RESOLVED
She had hyponatremia on admission, likely secondary to liver
disease, poor PO intake, and ___. Resolved s/p fluid
resuscitation.
#Chronic illness
#Chronic pain
Patient with severe and chronic pain, poor quality of life, and
recurrent hospitalizations. Palliative Care saw patient and
discussed goals with her. She wants aggressive medical
management of her conditions to give her the best chance to
live.
#Thrush
#Intertriginous candidiasis
Continued Nystatin Oral suspension TID and miconazole cream for
groin itching.
#Depression/anxiety:
Continued home escitalopram 20 mg daily.
#Seizures:
Continued Levetiracetam 1000mg PO BID.
TRANSITIONAL ISSUES:
====================
[ ] ___ + albumin and ionized calcium in ___ days (can be
done at follow up appointment).
[ ] Follow up CT scan in ___ weeks (___).
[ ] Decreased the dose of metoclopramide in the setting of
hyperreflexia, please ___ at next appointment. If
worsening PO/mobility, can increase metoclopramide back to prior
to admission dose.
[ ] Discharge with ___ for home TPN.
DISCHARGE STATS
-Discharge Weight: 107 kg
-Discharge Creatinine: 0.6
NEW MEDS:
- Vitamin D ___ UNIT PO 1X/WEEK (MO)
CHANGED MEDS:
- Torsemide 60mg PO daily (down from 80mg)
- Spirinolactone 50 mg PO daily (down from 200mg)
- Metoclopramide 5 mg Q6H (down from 10mg)
- Tramadol 50 mg PO BID (down from 100mg)
FOLLOW UP:
- PCP
- ___
# CODE: full code, confirmed
# CONTACT: Mother/Father: ___. Boyfriend ___.
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Lactulose 30 mL PO Q6H
5. LevETIRAcetam Oral Solution 1000 mg PO BID
6. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
7. Methylnaltrexone 12 mg Subcut DAILY
8. Metoclopramide 10 mg PO Q6H
9. Polyethylene Glycol 17 g PO DAILY
10. Rifaximin 550 mg PO BID
11. Senna 8.6 mg PO BID
12. Simethicone ___ mg PO QID:PRN gas pain
13. Spironolactone 200 mg PO DAILY
14. TraMADol 100 mg PO BID
15. FoLIC Acid 1 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Thiamine 100 mg PO DAILY
18. Torsemide 80 mg PO DAILY
19. Ciprofloxacin HCl 500 mg PO DAILY
20. Midodrine 10 mg PO TID
21. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
22. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Vitamin D ___ UNIT PO 1X/WEEK (MO)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth on ___ Disp #*4 Capsule Refills:*0
2. Metoclopramide 5 mg PO Q6H
RX *metoclopramide HCl 5 mg 1 tab by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
3. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
4. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
5. TraMADol 50 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Bisacodyl 10 mg PO/PR DAILY
8. Ciprofloxacin HCl 500 mg PO DAILY
9. Escitalopram Oxalate 20 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
12. Lactulose 30 mL PO Q6H
13. LevETIRAcetam Oral Solution 1000 mg PO BID
14. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
15. Methylnaltrexone 12 mg Subcut DAILY
16. Midodrine 10 mg PO TID
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY
20. Rifaximin 550 mg PO BID
21. Senna 8.6 mg PO BID
22. Simethicone ___ mg PO QID:PRN gas pain
23. Thiamine 100 mg PO DAILY
24.Outpatient Lab Work
Diagnosis: Cirrhosis K70.30
Lab: ___ + albumin + ionized calcium
Date: ___
Fax results to Dr. ___
25.TPN
Volume(ml/d) ___, Cycle over 18 hours.
Amino Acid (g/d) 105, Dextrose(g/d) 435, Fat(g/d) 60
NaCL 300, NaAc 25, KCl 15, KPO4 55, MgS04 35, CaGluc 5. NaPO4 0,
KAc 0.
Zinc 10 mg, Copper 1 mg, multivitamins.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hypercalcemia
Toxic Metabolic Encephalopathy
SECONDARY DIAGNOSES
EtOH cirrhosis
Obesity s/p ___ bypass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for confusion, for acute injury to your
kidneys, and for high levels of calcium.
What was done for me in the hospital?
- You were given a medicine called albumin to help your kidneys
recover.
- Your confusion was felt to be due to the high level of calcium
in your body. We're not quite sure why it got so high. You were
given a medicine to lower the amount of calcium in your body,
and your confusion improved.
- You underwent testing to rule out reasons why you could be
confused.
- You developed some fluid in your lungs because of the extra
water we gave you to help your kidneys. To help correct this,
you were given oxygen and diuretics through the veins (to help
you urinate out extra water).
- You had a CT scan of your lungs to check for a cause of high
Calcium, and were found to have several nodules. Pulmonary
doctors have recommended that you have a repeat CT scan in ___
weeks to check in on these nodules and see if you need a biopsy
or any further treatment.
What should I do when I leave the hospital?
- Please attend all appointments as listed below.
- Please take all of your medicines as prescribed.
- Please try to limit the liquids you drink each day to 1.5L (50
oz). This will help keep your legs from swelling up.
When should I return to the hospital?
- Please return if your confusion comes back, if you have
difficulty breathing, if your body becomes swollen with fluids,
if you develop a fever or have chills, if you have severe
abdominal pain, or any other symptom that concerns you.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
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2160-02-23 12:15:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
G-tube exchange (___)
History of Present Illness:
___ with hx cirrhosis (MELDNa 23) c/b ascites, SBP on ppx, HE,
HRS on midodrine, s/p rou-en-Y gastric bypass c/b recurrent
anastomotic c/b strictures requiring multiple endoscopic
dilations, and multiple abdominal surgeries for bowel
anastomosis
complications (including bowel perforation) now on TPN for
nutrition who presents with 2 weeks of weight gain, edema and
generalized weakness.
She was recently admitted ___ for abdominal pain, ___ and
___ of unclear etiology. During that admission she
developed volume overload in setting of albumin administration
requiring nasal cannula briefly, and was diuresed. TTE performed
with mild-mod pulm HTN and preserved biventricular systolic
function. She was ultimately discharged on 60mg torsemide and
50mg spironolactone daily. She was discharged on TPN for
nutrition, has been taking meds by Gtube and no other dietary
intake. She reports good med compliance. Since time of discharge
she reports progressive edema diffusely throughout her body,
consistent with prior instances of volume overload. Reports
orthopnea, dyspnea with activity, and progressive generalized
fatigue. Tmax 99.9 at home, some chills. Had sore throat x3 days
now resolved. No chest pain, PND, rhinorrhea or current sore
throat, nausea vomiting, constipation, melena, hematochezia, or
confusion. Has been having ___ BMs per day and compliant with
lactulose. Has been able to ambulate including one set of stairs
yesterday, but causes excessive fatigue. Thinks could walk half
hallway before stopping to rest. Finally, she reports an episode
of near syncope yesterday when turning to her R which has since
resolved.
In the ED, initial VS were: 98.3 88 118/67 19 94% RA
Exam notable for:
- Bedside US without pocket to tap, with sig subcuatenous edema
Labs showed: INR: 2.2, Cr 0.8, Hb 7.3 and plt 56 (Baseline for
pt), lactate 1.0
Patient received:
- ___ 18:45 PO TraMADol 50 mg
Hepatology was consulted
Transfer VS were: 98.2 88 108/43 16 97% RA
On arrival to the floor, patient reports feeling fatigued. She
knows she needs IV diuresis but would rather wait until morning.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy (___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy (___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.5 PO 100 / 61 85 16 96 Ra
GENERAL: NAD, alert, oriented
HEENT: EOMI, anicteric sclera, pink conjunctiva, MMM
Neck: No JVD appreciated
HEART: Regular rate, systolic murmur loudest over LUSB
LUNGS: bibasilar crackles, CTAB, no wheezes, breathing
comfortably on room air without use of accessory muscles
ABDOMEN: nondistended, soft, mild subjective tenderness
throughout but without rebound/guarding, G tube in place without
erythema/drainage. Fistula site with green drainage with small
flecks of blood but no e/o cellulitis.
EXTREMITIES: 3+ edema bilaterally, warm
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused
LINES: LUE PICC without any erythema
DISCHARGE PHYSICAL EXAM
VS: 97.8 PO 105 / 62 80 18 94 RA
GENERAL: Pleasant middle-aged woman, in NAD, alert, oriented,
appears comfortable
HEENT: EOMI, anicteric sclera, pink conjunctiva, MMM
HEART: RRR, systolic murmur loudest over LUSB (___), normal
s1/s2, no rubs, gallops, or thrills
LUNGS: Crackles at the bases of both lungs, no wheezes or
rhonchi, breathing comfortably on RA
ABDOMEN: nondistended, soft, mild tenderness throughout but
without rebound/guarding, G tube in place without
erythema/drainage. Fistula site with small amount of frankly
bloody discharge, not actively bleeding.
EXTREMITIES: ___ lower extremity edema to the mid-shin
bilaterally (stable), warm and well perfused, no clubbing or
cyanosis
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
SKIN: No rashes or other lesions
Pertinent Results:
ADMISSION LABS
___ 11:40AM BLOOD WBC-6.4 RBC-1.96* Hgb-7.3* Hct-22.1*
MCV-113* MCH-37.2* MCHC-33.0 RDW-21.4* RDWSD-88.3* Plt Ct-56*
___ 11:40AM BLOOD Neuts-73.5* Lymphs-11.6* Monos-13.4*
Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.71 AbsLymp-0.74*
AbsMono-0.86* AbsEos-0.05 AbsBaso-0.01
___ 11:40AM BLOOD ___ PTT-43.4* ___
___ 11:40AM BLOOD Glucose-95 UreaN-43* Creat-0.8 Na-134*
K-4.3 Cl-98 HCO3-24 AnGap-12
___ 11:40AM BLOOD ALT-16 AST-47* AlkPhos-92 TotBili-3.0*
___ 11:40AM BLOOD Albumin-3.0* Calcium-8.7 Phos-4.7* Mg-1.9
___ 12:13PM BLOOD Lactate-1.0
PERTINENT LABS
___ 05:22AM BLOOD WBC-4.8 RBC-1.82* Hgb-6.8* Hct-20.1*
MCV-110* MCH-37.4* MCHC-33.8 RDW-21.4* RDWSD-87.3* Plt Ct-51*
___ 05:15AM BLOOD WBC-6.5 RBC-2.05* Hgb-7.5* Hct-22.4*
MCV-109* MCH-36.6* MCHC-33.5 RDW-22.0* RDWSD-87.7* Plt Ct-54*
___ 06:00AM BLOOD WBC-6.3 RBC-2.00* Hgb-7.4* Hct-22.1*
MCV-111* MCH-37.0* MCHC-33.5 RDW-20.9* RDWSD-83.3* Plt Ct-46*
___ 06:00AM BLOOD ___
___ 05:22AM BLOOD ALT-15 AST-44* AlkPhos-88 TotBili-3.7*
___ 05:47AM BLOOD ALT-19 AST-55* LD(LDH)-178 AlkPhos-82
TotBili-2.4*
___ 05:27AM BLOOD ALT-24 AST-65* LD(___)-164 AlkPhos-83
TotBili-2.0*
___ 05:15AM BLOOD Triglyc-40
___ 05:15AM BLOOD CRP-68.3*
DISCHARGE LABS
___ 07:10AM BLOOD WBC-8.7 RBC-2.00* Hgb-7.4* Hct-22.6*
MCV-113* MCH-37.0* MCHC-32.7 RDW-21.0* RDWSD-86.2* Plt Ct-61*
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD Glucose-106* UreaN-26* Creat-0.6 Na-134*
K-4.8 Cl-95* HCO3-28 AnGap-11
___ 07:10AM BLOOD ALT-26 AST-76* LD(LDH)-192 AlkPhos-81
TotBili-2.2*
___ 07:10AM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.4 Mg-2.0
IMAGING/STUDIES
CXR (___)- 1. Mild pulmonary vascular congestion.
2. Left retrocardiac opacity is likely due to atelectasis and a
small
effusion, although superimposed infection may be considered in
the appropriate
clinical setting.
RUQ U/S (___)- Liver cirrhosis with sequelae of portal
hypertension, including ascites and
splenomegaly. Small right pleural effusion.
CXR (___)- Compared to chest radiographs ___ through
___.
Moderate pulmonary edema which improved between ___ and
___
has worsened again. Concurrent pneumonia would be difficult to
recognize.
Mild cardiomegaly is chronic. Pleural effusions small if any.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a history of EtOH
cirrhosis (MELD 21 on admission) c/b ascites, SBP on ppx, HE,
?HRS on midodrine, s/p roux-en-Y gastric bypass c/b recurrent
anastomotic strictures requiring multiple endoscopic dilations,
and multiple abdominal surgeries for bowel anastomosis
complications (including bowel perforation), now on TPN for
nutrition, who presented with volume overload. Also found to
have possible pneumonia. Now with improvement in volume overload
and improving PO nutrition.
ACUTE ISSUES
# Dyspnea
# Anasarca: Progressive weakness and dyspnea i/s/o significant
weight gain. Volume overload appears to have been
slow/progressive per patient despite med compliance, and was
likely related to low oncotic pressure secondary to poor
nutrition and underlying cirrhosis. She had no chest pain or EKG
changes to suggest current or interval cardiac ischemia. TTE
recently done with preserved biventricular systolic function,
and no significant valvular disease. The patient was started on
high dose IV diuresis (up to 120mg Lasix BID) with good effect
and improvement in shortness of breath and anasarca. She was
then switched to increased doses of PO torsemide and
spironolactone prior to discharge.
# Pneumonia: The patient was noted to have an infiltrate on CXR
after having a new oxygen requirement and leukocytosis to 11 at
that time. Concern was for CAP. Patient remained otherwise
stable. She was started on ceftriaxone and azithromycin and
completed a course of each antibiotic (7 and 5 days,
respectively) with improvement in symptoms.
# Malnutrition: Hx of Roux-en-Y gastric bypass c/b recurrent
anastomotic strictures requiring multiple endoscopic dilations,
and multiple abdominal surgeries for bowel anastomosis
complications (including bowel perforation). Currently has
G-tube, which has been functioning through which she receives
her PO meds. G-tube was noted to be cracked and was exchanged on
___ by ___ without complications. The patient was noted to be
able to increase her PO intake, and as a result, had her TPN
volume decreased to 1600cc at the time of discharge. The patient
also has a fistulous tract, which has been putting out a small
amount of greenish output from J-tube site. This is stable.
CHRONIC ISSUES
# EtOH cirrhosis: Childs B, MELD 21 on admission. EtOH cirrhosis
c/b ascites, HE, SBP, and HRS. No varices on last EGD in ___.
Last drink ___, not a transplant candidate per recent
documentation due to co-morbidities. At this time no evidence of
acute decompensation, some ascites on ultrasound, no
encephalopathy, labs at baseline.
# Anemia: Anemic in the 7s on admission, downtrended to 6.8.
Likely related to underlying chronic disease. Transfused 1U
pRBCs on ___. Now stable in low-mid-7s.
# Chronic pain: In the past has seen palliative care for ongoing
abdominal pain. Remained at baseline.
TRANSITIONAL ISSUES
[] diuretic regimen on discharge: torsemide 80mg, spironolactone
100mg
[] if patient gaining weight, should attempt to titrate
diuretics as outpatient before being admitted - patient
counseled extensively on calling ___ clinic if any weight
gain.
[] should get ___ labs - to be faxed to PCP and Dr.
___ - ___ given. Going home with services and home ___.
[] Follow up CT scan in ___ weeks of pulmonary nodules
(___).
[] Reassess metoclopramide dose as needed
[] continue to uptitrate PO intake as tolerated; can
subsequently consider weaning down TPN
[] discharge weight: 106.6 kg (235.01 lb)
#CODE: FULL CODE (confirmed)
#CONTACT: Patient would like her boyfriend ___ to be her
emergency contact ___. Her main healthcare proxies are
her parents: ___ (mother), ___ (father)
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
6. Lactulose 30 mL PO Q6H
7. LevETIRAcetam Oral Solution 1000 mg PO BID
8. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
9. Methylnaltrexone 12 mg Subcut DAILY
10. Midodrine 10 mg PO TID
11. Rifaximin 550 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas pain
13. TraMADol 50 mg PO BID
14. Bisacodyl 10 mg PO/PR DAILY
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
19. Thiamine 100 mg PO DAILY
20. Metoclopramide 5 mg PO Q6H
21. Spironolactone 50 mg PO DAILY
22. Torsemide 60 mg PO DAILY
23. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Bisacodyl 10 mg PO/PR DAILY
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Lactulose 30 mL PO Q6H
9. LevETIRAcetam Oral Solution 1000 mg PO BID
10. Lidocaine 5% Ointment 1 Appl TP BID:PRN Pain around g tube
11. Methylnaltrexone 12 mg Subcut DAILY
12. Metoclopramide 5 mg PO Q6H
13. Midodrine 10 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Rifaximin 550 mg PO BID
18. Senna 8.6 mg PO BID
19. Simethicone 40-80 mg PO QID:PRN gas pain
20. Thiamine 100 mg PO DAILY
21. TraMADol 50 mg PO BID
22. Vitamin D ___ UNIT PO 1X/WEEK (MO)
23.Outpatient Lab Work
Please draw CBC, sodium, potassium, chloride, bicarb, BUN,
creatinine, AST, ALT, alk phos, Tbili, and albumin on ___.
Results should be faxed to ___. at ___ and
___ at ___
ICD-10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Anasarca
Pneumonia
Secondary:
Alcoholic cirrhosis
Anemia
Malnutrition
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were feeling short of breath when exerting yourself
- Your legs were more swollen than usual and you were having
pain as a result of this
What was done while I was in the hospital?
- You were given IV diuretics, which significantly improved your
leg swelling and shortness of breath; these were then switched
to oral diuretics
- You were started on antibiotics for pneumonia, which you
completed while you were in the hospital
- You had your G-tube replaced by the radiologists
What should I do when I get home from the hospital?
- Be sure to take all of your medications as prescribed,
especially your diuretics (torsemide and spironolactone)
- Weigh yourself every day in the morning; if you gain more than
3 pounds, please call your liver doctor so that they can decide
if they want to increase your diuretics
- Discharge weight: 106.6 kg (235.01 lb)
- Please go to your follow-up appointment with your primary care
doctor and your liver doctor
- If you have fevers, chills, shortness of breath, worsening leg
swelling, or generally feel unwell, please call your doctor or
go to the emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
I&D x3
Fistulogram
EGD
History of Present Illness:
___ with a h/o alcohol-induced
cirrhosis, h/o ascites, h/o SBP, h/o HE, h/o Roux-en-Y gastric
bypass with multiple complications, currently with G-tube for
enteral feedings, who presented initially to ___ for
abdominal pain and drainage from former J-tube site.
For the past few days, she has felt a bit rundown. She also
developed a tense swelling on her left anterior abdominal wall.
She denies fever or chills. She denies cough, sore throat,
runny
nose, dyspnea, pleurisy, hemoptysis, chest pain, diarrhea. She
is taking her lactulose. She has had some bleeding near her
G-tube site though this is not new. She continues w/ tube feeds
at night, but PO intake during day is increasing, she is having
3
meals per day.
She presented to ___, where CT showed no intra-abdominal
process, possible pneumonia, and hyponatremia to 123. Patient
was
given ceftriaxone. She was transferred to ___ for further
evaluation.
In the ED, pt underwent I+D of abdominal wall abscess. She was
also given Doxycycline and Ketorolac.
On arrival to the floor, patient reports feeling pretty well and
would like to go home, though says she does feel a bit more
fatigued and run down than usual.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy ___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5, HR 84, BP 114/54, RR 16, 96% RA
GENERAL: NAD woman, ambulatory
HEENT: AT/NC, EOMI, mildly icteric sclera
NECK: supple
HEART: RRR
LUNGS: CTAB, no wheezes, no rales, no rhonchi, good air
movement,
no respiratory distress
ABDOMEN: She has a G-Tube in place with some surrounding
bleeding
around the entry site, dressed. Her old J-tube site has a bit of
nonbloody, non-pus drainage, and lateral to this the abscess
site
that was I+D'd is dressed. Otherwise she has mild diffuse
tenderness but minimal distension.
EXTREMITIES: no edema
NEURO: A&Ox3, no asterixis
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
Vitals:
___ ___ Temp: 98.4 PO BP: 94/50 L Lying HR: 77 RR: 18 O2
sat: 94% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, mild scleral icterus.
NECK: supple
HEART: RRR, crescendo-decrescendo systolic murmur
LUNGS: crackles at the bases bilaterally, no wheezes or rhonchi
ABDOMEN: G tube site is dressed. Old J-tube site dressed, has
surrounding erythema and edema/induration. Area is minimally
tender to palpation. Abdomen less distended, soft, non tender to
palpation diffusely, large hepatomegaly. 3+ dependent pitting
edema in flanks bilaterally with L>>R.
EXTREMITIES: Improved 2+ pitting edema in lower left lower
extremitiy to the knees, RLE with improved 1+ edema in ankle
NEURO: Answering questions appropriately, alert.
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABORATORY STUDIES
============================================
___ 11:34PM BLOOD WBC-12.7* RBC-2.50* Hgb-9.6* Hct-27.4*
MCV-110* MCH-38.4* MCHC-35.0 RDW-15.3 RDWSD-61.9* Plt Ct-96*
___ 11:34PM BLOOD Neuts-73.9* Lymphs-11.3* Monos-12.1
Eos-1.7 Baso-0.2 Im ___ AbsNeut-9.35* AbsLymp-1.43
AbsMono-1.53* AbsEos-0.22 AbsBaso-0.03
___ 07:40AM BLOOD ___
___ 11:34PM BLOOD Glucose-87 UreaN-61* Creat-1.4* Na-125*
K-5.0 Cl-87* HCO3-25 AnGap-13
___ 11:34PM BLOOD ALT-60* AST-158* AlkPhos-138*
TotBili-3.1*
___ 11:34PM BLOOD Albumin-2.9* Calcium-8.7 Phos-5.4* Mg-2.3
___ 11:34PM BLOOD Osmolal-285
___ 06:25AM BLOOD TSH-1.6
___ 06:25AM BLOOD Cortsol-6.3
___ 11:41PM BLOOD Lactate-1.5
DISCHARGE LABORATORY STUDIES
============================================
___ 06:00AM BLOOD WBC-6.4 RBC-2.07* Hgb-7.5* Hct-22.1*
MCV-107* MCH-36.2* MCHC-33.9 RDW-19.9* RDWSD-76.5* Plt Ct-80*
___ 06:00AM BLOOD ___ PTT-40.7* ___
___ 06:00AM BLOOD ALT-11 AST-47* AlkPhos-113*
___ 06:00AM BLOOD Glucose-127* UreaN-56* Creat-0.9 Na-135
K-3.8 Cl-93* HCO3-27 AnGap-15
___ 06:00AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8
IMAGING/REPORTS
============================================
CXR ___
IMPRESSION:
Although no definite focal consolidation is seen, elevation of
the left
hemidiaphragm posteriorly obscures the left lung base on the
lateral view.
TTE ___
The left atrial volume index is moderately increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is normal
(LVEF>55%). Quantitative (3D) LVEF = 71%. The estimated cardiac
index is high (>4.0L/min/m2). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Doppler
parameters are most consistent with normal left ventricular
diastolic function. 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 structurally normal. Trivial mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Borderline mild LV cavity dilation with normal LV
function, borderline hyperdynamic. High cardiac index. Trivial
mitral regurgitation. Moderate pulmonary hypertension.
Borderline elevated Aortic and pulmonic velocities most likely
due to high cardiac output.
Compared with the prior study (images reviewed) of ___ LV
function appears slightly more vigorous. Severity of TR is
decreased and RV does not appear dilated on today's study. RAP
lower on today's study. Cardiac output higher on today's study.
LIVER US ___
IMPRESSION:
Cirrhotic morphology of the liver, with sequelae of portal
hypertension,
including ascites and splenomegaly.
SOFT TISSUE ULTRASOUND ___
IMPRESSION:
A fluid filled tract is seen between the site of the prior
J-tube and the
abdominal wall abscess, however, recommend fistulogram to
further evaluate the tract and evaluate for any intraperitoneal
communication.
RECOMMENDATION(S): Recommend fistulogram for further
evaluation.
CT ABD & PELVIS W/O CONTRAST ___:
IMPRESSION:
1. Skin thickening at the site of prior jejunostomy. No
liquified fluid
collection identified in this location.
2. Increased soft tissue deep to the previous jejunostomy site
located in the vicinity of matted loops of small bowel, without
oral contrast reaching this location, it is unclear if there is
an enterocutaneous fistula or if soft tissue findings just
represent inflammatory tissue or hematoma. Consider repeat
delayed imaging once oral contrast has traversed this location
to evaluate for underlying fistula.
3. Dilated small bowel loops increased in severity compared to
recent prior CT scans without transition point, findings favor
ileus.
4. Diffuse anasarca.
5. Cirrhosis with sequela of portal hypertension.
UNILAT LOWER EXT VEINS LEFT ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
ABDOMEN (SUPINE & ERECT): ___
IMPRESSION:
Findings compatible with ileus. Partial or early obstruction
cannot be
excluded
ABDOMEN (SUPINE & ERECT): ___
IMPRESSION:
Overall improvement in likely ileus.
FISTULOGRAM/SINOGRAM: ___
IMPRESSION:
Enterocutaneous fistula which involves the left lower quadrant
abscess cavity,
adjacent small bowel loop, and prior jejunostomy site.
ABDOMEN (SUPINE & ERECT): ___
IMPRESSION:
There is persistent diffuse dilatation of small and large bowel
loops,
compatible with a postoperative ileus. There is no free air.
There is no
pneumatosis. IUD projects over the pelvis. The imaged lung
bases are grossly clear. A G-tube projects over the gastric
body.
G-TUBE CHECK/REPLACE/REPO: ___
FINDINGS:
1. Completely clogged G-tube which was forcefully flushed and
cleared with contrast and saline.
MICROBIOLOGY
===========================================
___ 7:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT
___ Blood Culture, Routine (Final ___: NO
GROWTH.
___ 7:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT
___ Blood Culture, Routine (Final ___: NO
GROWTH.
___ 3:36 pm ABSCESS Source: abdominal abscess.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID 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.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___:
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
___ 7:40 am BLOOD CULTURE #1 . **FINAL REPORT
___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:02 am URINE Source: ___. **FINAL REPORT
___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 11:34 pm BLOOD CULTURE**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
BRIEF SUMMARY
=============
___ w/ EtOH cirrhosis (h/o SBP, ascites, HE), s/p RNYGB (w/
multiple complications, prior J-tube, current G-tube for enteral
feedings) transferred w/ abdominal pain and drainage from
J-tube, found to have an abdominal wall abscess, for which she
underwent I&D x3, s/p CTX/Flagyl), with hospital course
complicated by ___ and hyponatremia (which both improved with
colloid challenge), severe diuretic-resistant anasarca, and
intermittent hepatic encephalopathy.
# Abdominal wall abscess
# Enterocutaneous fistula
Patient presented with abdominal wall pain and erythema and
drainage from former J-tube site. Imaging notable for small
3x1x1cm superficial abscess the left lateral anterior abdominal
wall lateral to the old J-tube site. Underwent I&D on
presentation and initially started on doxycycline and augmentin,
and then transitioned to ceftriaxone and doxycycline. She
developed worsening pain at the site several days later and
underwent repeat I&D. Cultures of draining fluid from ___ with
mixed flora. She was transitioned from CTX/doxy to
CTX/metronidazole. Fistulogram demonstrated enterocutaneous
fistula involving abscess cavity, former J-tube site, and a loop
of bowel. Given that the fistula would likely heal itself over
time and that the wound would continue to drain allowing source
control, antibiotics were stopped when the abscess no longer
looked cellulitic/infected (about 10 days after last I&D). The
wound would not heal, became more erythematous, and had
persistent yellow drainage so the patient was taken to the OR on
___ for drainage of intraperitoneal abscess and JP drain
placement into the prior J tube site with the plan to send her
home with her drain in place to be emptied daily along with
twice daily wound care via ___ and follow up with Dr. ___ in
his transplant surgery office.
#Acute kidney injury
On admission, the patient was found to have acute kidney injury
on presentation with creatinine peak of 3 (from baseline Cr 1).
Thought to be secondary to recent diuretic use in the setting of
infection leading to pre-renal azotemia, and possibly also
contrast injury. She continued home midodrine. She improved
back to baseline with colloid challenge and volume
resuscitation. Her kidney function began to decline again when
diuretics started to treat her anasarca, but improved again with
colloid. After kidney function returned again to baseline, we
were able to give 120 mg BID torsemide without albumin with no
decline in kidney function. Throughout hospitalization,
intermittently had hyperkalemia with EKG changes. Her creatinine
was at baseline and stable at discharge.
#Cirrhosis c/b hepatic encephalopathy, ascites, spontaneous
bacterial peritonitis
The patient has a history of cirrhosis complicated by
diuretic-resistant anasarca and hepatic encephalopathy. During
admission, oral ciprofloxacin was held while on high dose
ceftriaxone and restarted when ceftriaxone was discontinued. She
continued on home lactulose and rifaximin. We held home
diuretics given her hyponatremia and ___ but restarted torsemide
prior to discharge. We were unable to restart spironolactone as
re-starting could cause hyperkalemia. Continued on multivitamin,
thiamine, folic acid. Continued on home midodrine. The plan at
discharge was to continue BID diuretics at home given volume
overload during admission. She will have follow up with Dr. ___
___ Dr. ___.
#Acute upper gastrointestinal bleeding
The patient also had acute on chronic anemia and Initially
received 2U PRBCs to help with colloid resuscitation. HGB later
downtrended, requiring 1U PRBCs. EGD demonstrated slow upper GI
bleed due to friability of stomach/slow oozing. She was given
vitamin K and high dose PPI with subsequent stabilization of
H&H.
Transitional Issues:
[] For wound care-
Twice daily
AM- Remove and gently replace packing in wound, wet-to-dry
gently into cavity and fresh drain sponge
___- wet-to-dry gently into cavity and fresh drain sponge
Abdominal drain-
-Drain Upkeep:
Drain and record the JP drain output twice daily and as needed
so that the drain is never more than ½ full. Ensure that the
bulb is compressed so that the vacuum is maintained. Call the
office if the drain output increases by more than 100
milliliters from the previous day, turns greenish in color,
becomes bloody or develops a foul odor.
Change the drain dressing once daily or after your shower. Do
not allow the drain to hang freely at any time. Inspect the site
for redness, drainage or bleeding. Make sure there is a stitch
at the drain site.
[]Patient's spironolactone was held given hyperkalemia, and will
need to be resumed in the outpatient setting
[]The patient will need weekly laboratory draw as below:
Chemistry 10 panel
Please fax results to- ATTN Dr. ___: ___
[] The patient is being discharged on 120mg of torsemide twice
daily so that she can continue diuresis at home. Her labs were
stable in the hospital for over 7 days on this regimen without
change in her creatinine or sodium
[] Patient should continue cycled home tube feeds present on
admission
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Bisacodyl ___ mg PO DAILY:PRN Constipation
3. Ciprofloxacin HCl 500 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
7. Lactulose 30 mL PO Q6H
8. LevETIRAcetam Oral Solution 1000 mg PO BID
9. Metoclopramide 5 mg PO Q6H
10. Midodrine 10 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Rifaximin 550 mg PO BID
15. Thiamine 100 mg PO DAILY
16. TraMADol 50 mg PO BID
17. Zolpidem Tartrate 5 mg PO QHS
18. Spironolactone 100 mg PO DAILY
19. Torsemide 120 mg PO DAILY
Discharge Medications:
1. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Duration:
3 Days
RX *erythromycin 5 mg/gram (0.5 %) 1 ribbon OPHTH four times
daily Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth twice daily Disp #*6
Tablet Refills:*0
3. Torsemide 120 mg PO BID
RX *torsemide 20 mg 6 tablet(s) by mouth twice daily Disp #*288
Tablet Refills:*0
4. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Doses
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth every ___ Disp #*6 Capsule Refills:*0
5. Zinc Sulfate 220 mg PO DAILY Duration: 12 Doses
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*14 Capsule Refills:*0
6. Acetaminophen 650 mg PO BID:PRN Pain - Mild
7. Bisacodyl ___ mg PO DAILY:PRN Constipation
8. Ciprofloxacin HCl 500 mg PO DAILY
9. Escitalopram Oxalate 20 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
12. Lactulose 30 mL PO Q6H
13. LevETIRAcetam Oral Solution 1000 mg PO BID
14. Metoclopramide 5 mg PO Q6H
15. Midodrine 10 mg PO TID
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY
19. Rifaximin 550 mg PO BID
20. Thiamine 100 mg PO DAILY
21. TraMADol 50 mg PO BID
22. Zolpidem Tartrate 5 mg PO QHS
23. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until you see Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic cirrhosis
Diruetic-resistant anasarca
Hyponatremia
Hepatic encephalopathy
Abdominal wall abscess
Acute on chronic anemia
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY YOU CAME TO THE HOSPITAL:
-You came to the hospital because you were having pain on your
stomach near your old J-tube site.
WHAT WE DID FOR YOU IN THE HOSPITAL
-We gave you antibiotics to treat the infection on your stomach,
and the surgeons cleaned out the infection
-We gave you medications to help your kidneys function better,
and then we gave you medications to help get remove fluid from
your body
WHAT YOU NEED TO DO WHEN YOU GET HOME:
-Weigh yourself every day and keep a log to bring to your
appointments
-Take all your medications as prescribed below
-You will get wound care twice daily at home
-Continue your tube feeds
-Drain Upkeep:
Drain and record the JP drain output twice daily and as
needed so that the drain is never more than ½ full. Ensure that
the bulb is compressed so that the vacuum is maintained. Call
the office if the drain output increases by more than 100
milliliters from the previous day, turns greenish in color,
becomes bloody or develops a foul odor.
Change the drain dressing once daily or after your shower.
Do not allow the drain to hang freely at any time. Inspect the
site for redness, drainage or bleeding. Make sure there is a
stitch at the drain site.
We wish you all the best!
-Your ___ team
Followup Instructions:
___
|
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DS
| 25 |
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2160-08-08 16:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Interventional radiology replacement of gastric tube - ___
History of Present Illness:
___ w/ EtOH cirrhosis (c/b SBP, ascites, HE), non-variceal
UGIB, s/p RNYGB, prior J-tube, current G-tube for enteral
feedings, recently hospitalized with an abdominal wall abscess
and EC fistula at her prior J-tube insertion site who is
presenting with abdominal pain, nausea and emesis.
She has not had any fevers or chills. She reports that her
constipation has improved. She had 4 BMs yesterday, that were
not diarrhea. She continues to have flatus. She has continued
to
have dressing changes twice daily, with minimal drain output.
The color of the drain output was slightly darker than normal
starting this morning. Normally the output is a yellowish
color,
and today, the color has become a light greenish color. She has
been tolerating her tube feeds via her G-tube. She currently
takes dilaudid twice a day for pain.
Past Medical History:
Per prior discharge summary
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy ___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
Per prior discharge summary
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION:
VITALS:97.9 PO 91 / 52 L Lying 83 18 96 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
murmur.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: no CVA tenderness
ABDOMEN:soft, mildly tender throughout but mostly on RUQ and RLQ
with firmness, no rebound, no guarding, well healed midline
incision, gtube in place, JP drain with light brown output, No
surrounding erythema or tenderness, no rebound or guarding
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE:
24 HR Data (last updated ___ @ 955)
Temp: 97.9 (Tm 99.0), BP: 94/57 (89-103/46-63), HR: 77
(74-81), RR: 17 (___), O2 sat: 94% (93-97), O2 delivery: RA
GENERAL: slightly jaundiced, NAD, smiling
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Icteric
sclera.
Moist mucous membranes, good dentition. Oropharynx is clear.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. II/VI
holosystolic murmur heard best at LSB
LUNGS: Clear to auscultation bilaterally w/ appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: right CVA tenderness
ABDOMEN: soft, non-tender, RLQ with firmness, no rebound, no
guarding, well healed midline incision, gtube in place, JP drain
with light brown output with some surrounding erythema and
purulence
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AO x 3 with fluctuating attention. No
asterixis.
Pertinent Results:
___ 05:15AM BLOOD WBC-6.0 RBC-2.13* Hgb-7.6* Hct-22.7*
MCV-107* MCH-35.7* MCHC-33.5 RDW-18.1* RDWSD-70.0* Plt Ct-70*
___ 09:00AM BLOOD Neuts-80.0* Lymphs-7.2* Monos-12.0
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.34* AbsLymp-0.66*
AbsMono-1.10* AbsEos-0.03* AbsBaso-0.02
___ 05:15AM BLOOD Plt Ct-70*
___ 05:15AM BLOOD ___
___ 05:50AM BLOOD ___ 05:15AM BLOOD Glucose-81 UreaN-23* Creat-1.0 Na-136
K-3.7 Cl-94* HCO3-25 AnGap-17
___ 05:45AM BLOOD ALT-17 AST-62* AlkPhos-118* TotBili-2.3*
___ 10:50AM BLOOD Lipase-36
___ 05:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.2
___ 05:41AM BLOOD Hapto-46
___ 04:30PM BLOOD Ethanol-NEG
___ 07:12AM BLOOD ___ pO2-175* pCO2-28* pH-7.36
calTCO2-16* Base XS--7 Comment-GREEN TOP
___ 07:12AM BLOOD Lactate-2.3*
___ 06:31AM BLOOD freeCa-1.05*
Brief Hospital Course:
___ w/ EtOH cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB,
s/p RNYGB, current G-tube for enteral feedings, recently
hospitalized with an abdominal wall abscess and EC fistula at
her prior J-tube insertion site with a current drain tube who is
presented with abdominal pain, nausea and emesis likely due to
recurrent ileus or SBO, complicated by ATN and encephalopathy.
Discharge delayed by recurrent clogging of G tube, replaced by
___ on ___.
#) Intermittent SBO
Pain and nausea have been intermittent throughout
hospitalization. Ileus may be contributing given imaging notable
for multiple dilated fluid-filled small bowel loops; no
transition point or decompressed loops identified to suggest
partial bowel obstruction although it may be spontaneously
resolving and returning. Low suspicion for SBP on presentation
given already on ciprofloxacin prophylaxis, lack of
leukocytosis, and afebrile. No tapable pocket on admission.
Transplant surgery felt unlikely related to enterocutaneous
fistulas. Most likely diagnosis at is intermittent SBO. Severe
pain initially managed with dilaudid, zofran but developed
encephalopathy and NG tube was placed to suction with
improvement in pain, N/V and encephalopathy. Pain managed well
on tylenol once BMs returned, and NG was discontinued. Educated
patient on reducing dilaudid use at home to prevent
constipation. Added simethicone to reduce bloating.
# G tube malfunction
Patient had intermittent G-tube clogging throughout
hospitalization, which was associated with abdominal pain,
nausea, and vomiting. On ___, she had her G-tube replaced by
___, with improvement in her abdominal symptoms. Prior to
discharge, she was tolerating tube feeds through the G-tube
without significant abdominal symptoms.
#) ATN
Patient recently had kidney injury during prior hospitalization
in the setting of contrast-induced nephropathy and hypovolemia.
She presented with Cr 1.4 (from ___ ~0.8), up to 4.8 with
associated hyperkalemia, hyperphosphatemia, hyponatremia. Renal
was consulted, felt the etiology was likely ATN due to contrast
induced nephropathy. He received insulin/dextrose/calcium for
hyperkalemia x 2, before kidney function improved. Discharge Cr
was 1.0.
#) Encephalopathy
Encephalopathy during this hospitalization likely due to
decreased bowel movements i/s/o probable partial vs full SBO,
with contribution of acute renal failure as well (now resolved).
Much improved with regular BMs (lactulose NG and enemas) and
improvement in renal function.
#) Thrombocytopenia
Downtrending from admission ~100 to a low of 52, on discharge up
to 70. Chronic, due to cirrhosis.
# Anemia # H/o UGIB
Chronic anemia and hemoglobin between ___. Hgb dipped and
received 2u pRBC ___, stable since.
#) Asymptomatic bacteriuria:
Urine culture grew enterococcus, likely contamination due to
bowel regiment. Patient asymptomatic and was not treated.
#) ETOH CIRRHOSIS
Followed by Dr. ___. Last drink ___. CP B-C. MELD-Na 23 on
admission.
- HE: lactulose and rifaximin through PEG
- SBP: cont home ciprofloxacin
- Ascites: torsemide (held during bp dips)
- Varices: EGD ___ with diffuse friability of stomach seen
with oozing, no intervenable lesions, no varices.
- Coagulopathy: secondary to cirrhosis, received a trial of
vitamin K during recent hospitalization with only limited
improvement in INR
- Transplant w/u: per previous documentation, not a candidate
due to comorbidities
CHRONIC ISSUES: seizure, GERD
==============
no changes
=================TRANSITIONAL ISSUES===========
-STARTED simethicone 80mg PRN for abdominal distension/pain
-educated patient on reducing dilaudid use to prevent
constipation
[] hepatology f/u
[] transplant surg f/u
Full code
Proxy name: ___
Relationship: Mother, Father Phone: ___
Date on form: ___
Comments: Pt. has named her boyfriend ___ as her
alternative health care proxy. ___ can be reached at
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Bisacodyl ___ mg PO DAILY:PRN Constipation
3. Ciprofloxacin HCl 500 mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO Q6H
7. LevETIRAcetam Oral Solution 1000 mg PO BID
8. Metoclopramide 5 mg PO Q6H
9. Midodrine 10 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Rifaximin 550 mg PO BID
14. Thiamine 100 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. TraMADol 50 mg PO BID
18. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
19. Neutra-Phos 2 PKT PO TID
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*100
Tablet Refills:*3
2. Acetaminophen 650 mg PO BID:PRN Pain - Mild
3. Bisacodyl ___ mg PO DAILY:PRN Constipation
4. Ciprofloxacin HCl 500 mg PO DAILY
5. Escitalopram Oxalate 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Lactulose 30 mL PO Q6H
9. LevETIRAcetam Oral Solution 1000 mg PO BID
10. Metoclopramide 5 mg PO Q6H
11. Midodrine 10 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. Neutra-Phos 2 PKT PO TID
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Rifaximin 550 mg PO BID
17. Thiamine 100 mg PO DAILY
18. Torsemide 20 mg PO DAILY
19. TraMADol 50 mg PO BID
20. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: small bowel obstruction, acute tubular necrosis
Secondary: hepatic encephalopathy, alcoholic cirrhosis, obesity
treated with gastric bypass complicated by abscess requiring
drainage now with gastric and jejunal tubes, epileptiform
seizures, gastroesophageal reflux disease, depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
================================================
MEDICINE Discharge Worksheet
================================================
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted to ___ for abdominal pain, nausea, and
vomiting likely due to an obstruction in your intestinal system
that self-resolved. You also had kidney damage likely due to the
combination of your recent post CT-contrast kidney injury and
the severe vomiting you experienced before hospitalization
leading to reduced blood flow to your kidneys.
What was done for me while I was in the hospital?
- You received a thorough investigation for the cause of your
abdominal pain, nausea, vomiting, and kidney damage including
urine and blood tests, abdominal Xray, electrocardiogram for
your heart electrical activity. You also received many
medications to treat your kidney damage while managing your
existing conditions. Your G tube was intermittently clogged so
it was replaced. When your kidney function returned and you were
able to eat enough nutrition without vomiting, you were
discharged from the hospital.
What should I do when I leave the hospital?
- Weigh yourself every day and call your hepatologist if your
weight changes by 3 pounds or more in one day
- Schedule an appointment to follow-up with your hepatologist
- Call ___ at ___ (ask to have ___ fellow on call
paged) if you have any trouble with your G tube
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19612461-DS-26
| 19,612,461 | 22,868,607 |
DS
| 26 |
2160-08-16 00:00:00
|
2160-08-17 17:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of alcoholic
cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
current G-tube for enteral feedings, recent admissions for
abdominal wall abscess with EC fistula and recurrent ileus/SBO
c/b ATN, encephalopathy, and recurrent clogging of G-tube, who
now presents with diffuse abdominal pain and nausea. She
described the pain as ___, constant, non-radiating, with no
mitigating or aggravating factors. She has been having bowel
movements. She has not been vomiting. She denied headache,
fevers, chills, hematemesis, coffee-ground emesis, hematochezia,
melena, diarrhea, or constipation. She was referred to the ___
ED.
Upon arrival to the ED, her initial vital signs were: T 97.5F BP
102/48 mmHg P 87 RR 16 O2 100% RA. Examination was notable for
hepatic encephalopathy, no scleral icterus, no sublingual
jaundice, normal S1/S2, RRR, clear lungs, soft abdomen, TTP
diffusely, distended, no masses, no lower extremity edema.
Bedside ultrasound did not demonstrate an accessible pocket for
paracentesis. Labs were notable for Na 133, K 4.3, Cl 95, HCO3
21, BUN/Cr 35/1.0, WBC 4.5, H/H 7.3/21.9 (MCV 107), PLT 61,000,
INR 1.9, ALT 14, AST 54, alk phos 151, Tbili 2.4, albumin 2.8.
UA
with moderate leukocyte esterase, 8 WBC, few bacteria, lactate
1.8. CT of the abdomen and pelvis was performed with oral
contrast, which demonstrated distended distal small bowel with
extensive fecalized material suggesting slow transit. No
discrete
transition point identified nor decompressed distal small bowel
loops to support obstruction. Colon moderately distended with
stool. No evidence of abscess. Pigtail catheter seen along left
anterior abdominal wall without associated collection. Nodular
liver with small volume ascites. She received 1L IV NS, morphine
4 mg x2 and 2 mg x2, as well as ondansetron 4 mg IV. She was
admitted to the hepatology service.
On arrival to the floor, she reports that her pain was of the
same quality as usual, but was persistent. She stopped her tube
feeds, but that did not help the pain. She otherwise endorsed
the
narrative as above. She has not been taking tramadol at home and
has been taking Dilaudid once per day. She denied fevers,
chills,
chest pain, shortness of breath. She reports that she has been
having three bowel movements per day
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy ___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
Per prior discharge summary
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9F BP 100/63 mmHg P 88 RR 20 O2 92% RA
General: Comfortable, NAD.
HEENT: Anicteric sclerae; EOMs intact.
Neck: Supple.
CV: RRR, III/VI holosystolic murmur best heard over LUSB with
prominent S2 component; no thrills or heaves. No rubs or
gallops.
Pulm: Scant crackles at base; no wheezes. No accessory muscle
usage.
Abd: Obese, soft, moderate diffuse tenderness predominantly in
RLQ, RUQ with firmness, no rebound or guarding. Well-healed
midline incision. G-tube in place, c/d/I. JP drain with minimal
serosanguinous output; no surrounding erythema or tenderness.
Extremities: Warm and well-perfused. L>R ___ edema, well-healed
ankle scar, chronic asymmetry per patient report.
Neuro: A&Ox3; no asterixis.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 513)
Temp: 98.3 (Tm 98.3), BP: 93/56 (81-98/36-60), HR: 82
(75-90), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: Ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink.
NECK: Supple with no LAD or JVD.
CARDIAC: RRR, normal S1, S2. III/VI systolic murmur best heard
over the LUSB.
LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA
bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN: Obese, very mild diffuse tenderness predominantly in
lower abdomen, soft, RUQ with firmness, no rebound or guarding.
JP drain with serosanguinous output; no surrounding erythema or
tenderness. G-tube site in place, no drainage or surrounding
erythema.
EXTREMITIES: Trace edema. Distal pulses palpable and symmetric.
SKIN: Warm, dry, no rashes or obvious lesions.
Pertinent Results:
ADMISSION LABS:
___ 04:50PM BLOOD Neuts-64.2 ___ Monos-13.8*
Eos-0.9* Baso-0.0 Im ___ AbsNeut-2.89 AbsLymp-0.93*
AbsMono-0.62 AbsEos-0.04 AbsBaso-0.00*
___ 04:50PM BLOOD WBC-4.5 RBC-2.04* Hgb-7.3* Hct-21.9*
MCV-107* MCH-35.8* MCHC-33.3 RDW-18.5* RDWSD-73.0* Plt Ct-61*
___ 04:50PM BLOOD ___ PTT-38.0* ___
___ 04:50PM BLOOD Glucose-91 UreaN-35* Creat-1.0 Na-133*
K-4.3 Cl-95* HCO3-21* AnGap-17
___ 04:50PM BLOOD ALT-14 AST-54* AlkPhos-151* TotBili-2.4*
___ 04:50PM BLOOD Albumin-2.8*
IMAGING:
CT ABD & PELVIS WITH CONTRAST (___):
IMPRESSION:
1. Enteric contrast reaches the mid-distal small bowel. The
more
distal small bowel is distended, perhaps slightly worse compared
to prior and now contains more extensive fecalized material
suggesting slow transit. No discrete transition point
identified
nor decompressed distal small bowel loops to further support an
obstruction. Colon is also moderately distended with stool.
Could consider repeat abdominal radiographs to confirm enteric
contrast passage through the bowel as clinically warranted.
2. No evidence of abscess. Pigtail catheter seen along the left
anterior abdominal wall without associated collection in this
region.
3. Nodular liver with small volume ascites.
4. Persistent moderate right hydronephrosis with mild dilation
of
proximal right ureter, unchanged.
5. Cholelithiasis.
6. Persistent small left pleural effusion with some left lower
lobe
atelectasis.
DISCHARGE LABS:
___ 07:22AM BLOOD WBC-4.3 RBC-2.05* Hgb-7.3* Hct-22.5*
MCV-110* MCH-35.6* MCHC-32.4 RDW-18.6* RDWSD-74.9* Plt Ct-69*
___ 07:22AM BLOOD Plt Ct-69*
___ 07:22AM BLOOD Glucose-106* UreaN-36* Creat-1.4* Na-135
K-4.2 Cl-96 HCO3-21* AnGap-18
___ 07:22AM BLOOD ALT-12 AST-44* AlkPhos-150* TotBili-2.3*
___ 07:22AM BLOOD Calcium-8.4 Phos-5.8* Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a PMH of alcoholic
cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
current G-tube for enteral feedings, recent admissions for
abdominal wall abscess with EC fistula and recurrent ileus/SBO
c/b ATN, encephalopathy, and recurrent clogging of G-tube, who
now presents with diffuse abdominal pain and nausea.
#Acute on chronic abdominal pain
#Opioid induced constipation
#Concern for ileus
Recently admitted with abdominal pain, nausea, and emesis
thought secondary to recurrent ileus or intermittent small bowel
obstruction and now presents with similar symptoms; main
presenting symptom right now is abdominal pain. CT abdomen and
pelvis negative for acute obstruction but did demonstrate
extensive fecalization and findings consistent with slow
transit. Her symptoms are likely worsened by chronic opioid use,
and on her prior admission, she was placed on simethicone and
advised to limit her opioid use. Has not taken tramadol in 1
week due to her pharmacy not having it. Unlikely SBP, on ppx.
Unlikely to represent complication of prior abdominal wall
abscess given the reassuring CT findings. Med rx refill history
shows that she was started on methylnaltrexone and Linzess,
however patient is unsure if she has been getting these. These
meds were not on her pre-admission or discharge medication lists
on her last admission. After speaking with patient's boyfriend
who manages her medications, it was determined that she does
have a Linzess as well as methylnaltrexone at home, however was
not being given these medications because he was following the
last discharge paperwork medication list. Spoke with transplant
surgery regarding her JP drain, they will not see her on this
admission as her drain is functioning well and there is no
purulent drainage or complications currently.
The following was done on this admission:
-Continued home tramadol 50 mg PO BID and hydropmorphone 2 mg
daily--minimize opioid use where possible
-Continued home lactulose/rifaximin to ensure regular bowel
movements
-We are reinitiating Linzess and methylnaltrexone on discharge.
-Recommended to ___ that she should be having ___ bowel
movements per day with lactulose, and uptitration of dosage if
she is not stooling this frequently.
-Continued ondansetron ___ mg IV q8h PRN: nausea, vomiting
-Continued metoclopramide 5 mg PO q6h
-Continued home Simethicone 40-80 mg PO QID:PRN bloating
___
Likely in the setting of tube feeds being held overnight ___.
Tube feeds were restarted on ___ evening. On ___ prior to
discharge we gave her 25 g of 5% albumin. Labs were not
rechecked as this was felt to be well explained by her tube
feeds being held and will expect it to quickly resolve.
#Alcoholic cirrhosis
Previously complicated by hepatic encephalopathy, SBP, and
ascites. Followed by Dr. ___ cirrhosis, MELD-Na
20 on admission. Checked daily MELD labs.
-HE: lactulose and rifaximin through PEG
-SBP: continued home ciprofloxacin
-Ascites: continued torsemide
-Varices: EGD ___ with diffuse friability of stomach seen
with oozing, no intervenable lesions, no varices.
-Coagulopathy: secondary to cirrhosis, received a trial of
vitamin K during recent hospitalizations with only limited
improvement in INR
-Transplant w/u: per previous documentation, not a candidate due
to comorbidities
-Continued home midodrine 10 mg PO TID
#Poor appetite
#Tube feeds
#S/P RNYGB abdominal wall abscess and enterocutaneous fistula
Chronic tube feeding dependence via G-tube, replaced on her last
hospitalization. Was having nausea at home which has now
resolved. Home TF regimen: Osmolite 1.5 @ 80 mL/hr x 12
hours flush 50 mL q6h. reports that she still eats along with
her tube feeds, proximately 2 meals per day approximately 2
small meals a day such as cereal or a sandwich. Initially on
admission she was cautiously placed on a liquid diet, however
her diet was advanced to a regular diet on the morning of ___
as she was feeling better and had an appetite. Tube feeds were
restarted on ___ night, which the patient tolerated well.
Nutrition service assisted with tube feed recommendations.
_______________
CHRONIC ISSUES
#Epileptiform seizures
Continued home Keppra 1000 mg PO BID
#GERD
Continued home omeprazole 40 mg daily
#Anemia
Stable during admission, will continue to monitor.
_____________________
Transitional issues:
Medication changes: restarted Linzess (standing) and
Methylnaltrexone (prn).
[ ] For hepatology: Please review patient's home medications and
ensure that she is doing well on Linzess and methylnaltrexone
which we restarted on this admission.
[ ] At next outpatient appointment please recheck Chem-7 and
ensure kidney function has returned to baseline.
#CODE: Full (presumed)
#CONTACT: ___, parents, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Bisacodyl ___ mg PO DAILY:PRN Constipation
3. Ciprofloxacin HCl 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO Q6H
6. LevETIRAcetam Oral Solution 1000 mg PO BID
7. Midodrine 10 mg PO TID
8. Rifaximin 550 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
12. Multivitamins 1 TAB PO DAILY
13. Neutra-Phos 2 PKT PO TID
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. TraMADol 50 mg PO BID
17. Metoclopramide 5 mg PO Q6H
18. Escitalopram Oxalate 20 mg PO DAILY
19. Simethicone 40-80 mg PO QID:PRN bloating
20. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Linzess (linaCLOtide) 145 mcg oral DAILY
2. Methylnaltrexone 12 mg Subcut ONCE Duration: 1 Dose
3. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablets by mouth daily Disp #*60
Tablet Refills:*0
4. Acetaminophen 650 mg PO BID:PRN Pain - Mild
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
9. Lactulose 30 mL PO Q6H
10. LevETIRAcetam Oral Solution 1000 mg PO BID
11. Metoclopramide 5 mg PO Q6H
12. Midodrine 10 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Neutra-Phos 2 PKT PO TID
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Rifaximin 550 mg PO BID
18. Simethicone 40-80 mg PO QID:PRN bloating
19. Thiamine 100 mg PO DAILY
20. Torsemide 20 mg PO DAILY
21. TraMADol 50 mg PO BID
22. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal pain
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. - sometimes holds on
to walls/furniture for support
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you were having severe
abdominal pain.
What was done for you while you were here?
-You had a CT scan of your abdomen which did not show an
obstruction.
-We started you on a laxative called senna which she will take
twice daily to keep your bowels moving.
-We continued your lactulose and gave you an extra dose.
What should you do when you go home?
-You should continue taking all of her medications as directed
on this paperwork.
-If you do not have a bowel movement one day, you should call
your primary liver doctor. Your abdominal pain will worsen if
you become constipated and stool builds up in your abdomen.
We wish you the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19612461-DS-27
| 19,612,461 | 25,425,408 |
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| 27 |
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|
2160-09-03 16:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness, weight gain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This a ___ year-old woman with a PMH of decompensated alcoholic
cirrhosis (SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
prior J-tube, current G-tube for enteral feedings, abdominal
wall abscess and EC fistula at prior J-tube insertion site,
recurrent ileus/SBO, and recent admission (___) for
abdominal pain who now presents with weight gain and weakness,
found to have acute on chronic anemia.
The patient states that she has experienced a 10 pound weight
gain since ___ of last week. She notes most of the weight
in her lower legs/thighs and denies worsening abdominal
distention. Her torsemide had been increased from 20 mg QD to 60
mg QD at that time though she continued to gain weight. She
denies any dietary indiscretion. Her appetite has not changed.
She notes intermittent abdominal pain which she says is chronic.
On ___ evening, the patient developed acute onset weakness
when walking up the stairs. She explains that her "legs just
gave out" when about ___ way up the stairs in her home. Family
members were able to help her the rest of the way up the stairs.
No fall. She denies associated shortness of breath, chest pain,
palpitations but does endorse lightheadedness.
The patient specifically denies melena, hematemesis, nausea,
vomiting, diarrhea, fevers, chills, night sweats, dysuria,
hematuria, hematochezia.
In the ED initial vitals: T 97.1, HR 81, BPO 103/42, RR 18, 99%
on RA
Exam notable for: Abdomen diffusely tender. Left lower extremity
swollen.
Labs notable for:
CBC: 4.9 >- 6.9/21.5 -< 70
Chem7: 137 | 95 | 23
---------------< 79 (AGap 17)
3.7 | 25 | 0.9
LFTs: ALT 11, AST 45, AP 120, Tbili 2.3, Alb 2.7, Lip 24
Coags: ___: 18.9 PTT: 37.4 INR: 1.7
Imaging notable for:
CXR:
1. Low lung volumes.
2. Opacification of the left lung base may represent atelectasis
or
consolidation depending upon the clinical setting.
3. Unchanged moderate cardiomegaly. No pulmonary edema, pleural
effusion, or pneumothorax.
CT ABDOMEN/PELVIS:
1. Cirrhosis with findings or portal hypertension and small
amount of ascites and unchanged trace bilateral pleural
effusions.
2. Chronic partial small bowel obstruction with improved small
bowel
distention compared to prior.
3. Mild right-sided hydronephrosis and proximal hydroureter
appears slightly improved compared to prior.
4. Unchanged position of a left upper quadrant approach catheter
which terminates in the subcutaneous tissues at this location.
No surrounding fluid collection.
RIGHT ___ DOPPLER:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Consults:
HEPATOLOGY: "No ascites on bedside ultrasound. Hgb 6.9, but not
too far from baselin. Can transfuse 1 unit of PRBC. No signs of
UGIB or LGIB, but will need to be continued to be monitored for
this.
Patient was given:
OxyCODONE (Immediate Release) 5 mg
HYDROmorphone (Dilaudid) 2 mg
Subcut Methylnaltrexone 12 mg
Ciprofloxacin HCl 500 mg
Escitalopram Oxalate 20 mg
FoLIC Acid 1 mg
HYDROmorphone (Dilaudid) 2 mg
LevETIRAcetam 1000 mg
Metoclopramide 5 mg
Omeprazole 40 mg
Thiamine 100 mg
Torsemide 60 mg
Rifaximin 550 mg
Midodrine 15 mg
Lactulose 30 mL
Potassium Chloride 40 mEq
Magnesium Sulfate 4 gm
Furosemide 50 mg
ED Course: Patient received home medications and was diuresed
with 100 mg IV Lasix in addition to home torsemide 60 mg once.
She was transfused 1 U pRBC.
On arrival to the floor, patient appears sleepy but comfortable.
She endorses the above history and complains of total body
weakness. She denies pain.
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy ___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
Per prior discharge summary
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION EXAM:
===============
VS: T 97.9 BP 99/60 HR 79 RR 18 Sa 96% RA
GENERAL: NAD, appears fatigued and somnolent
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclera, pink
conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur heard best at ___ but
also appreciated at ___ and apex, no gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Obese, mildly distended, diffusely TTP, no
rebound/guarding, no hepatosplenomegaly. G-tube site c/d/i, RUQ
drain c/d/i
EXTREMITIES: Left ___ with ___ pitting edema up to the knee. RLE
with trace edema. Both ___ exquisitely TTP. No cyanosis,
clubbing.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, naming intact, able to state ___ backwards without
error. CN exam unremarkable. Strength ___ throughout limited by
pain, no asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
VS: T 98.7, BP 102/56, HR 69, RR 18, Sa 97% Ra
GENERAL: NAD, supine in bed
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclera, pink
conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, harsh ___ systolic murmur heard best at ___
but also appreciated at ___ and apex, no gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Obese, mildly distended, mildly TTP, no
rebound/guarding, no hepatosplenomegaly. G-tube site c/d/i
without purulence, LUQ drain c/d/I, draining tan colored
purulence
EXTREMITIES: Left ___ with trace pitting edema up to the knee.
RLE without appreciable edema. No cyanosis, clubbing.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, naming intact, able to state ___ backwards without
error. CN exam unremarkable. Strength ___ throughout. No
asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM GLUCOSE-117* UREA N-19 CREAT-0.8 SODIUM-134*
POTASSIUM-3.4* CHLORIDE-93* TOTAL CO2-28 ANION GAP-13
___ 09:30PM CALCIUM-8.6 PHOSPHATE-3.8 MAGNESIUM-2.2
___ 09:30PM WBC-4.9 RBC-2.24* HGB-7.8* HCT-23.2* MCV-104*
MCH-34.8* MCHC-33.6 RDW-20.3* RDWSD-74.4*
___ 09:30PM PLT COUNT-65*
___ 10:45AM GLUCOSE-124* UREA N-21* CREAT-0.9 SODIUM-136
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-27 ANION GAP-14
___ 10:45AM ALT(SGPT)-10 AST(SGOT)-42* LD(LDH)-156 ALK
PHOS-116* TOT BILI-2.5*
___ 10:45AM CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.5*
___ 10:45AM WBC-4.9 RBC-1.79* HGB-6.5* HCT-19.7* MCV-110*
MCH-36.3* MCHC-33.0 RDW-19.0* RDWSD-75.3*
___ 10:45AM PLT COUNT-63*
___ 10:45AM ___ PTT-37.4* ___
___ 11:25PM WBC-4.9 RBC-1.93* HGB-6.9* HCT-21.5* MCV-111*
MCH-35.8* MCHC-32.1 RDW-19.0* RDWSD-76.8*
___ 11:25PM NEUTS-60.8 ___ MONOS-15.1* EOS-0.8*
BASOS-0.2 IM ___ AbsNeut-2.98 AbsLymp-1.11* AbsMono-0.74
AbsEos-0.04 AbsBaso-0.01
___ 11:25PM PLT COUNT-70*
___ 10:54PM LACTATE-2.0
___ 10:44PM GLUCOSE-79 UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
___ 10:44PM estGFR-Using this
___ 10:44PM ALT(SGPT)-11 AST(SGOT)-45* ALK PHOS-120* TOT
BILI-2.3*
___ 10:44PM LIPASE-24
___ 10:44PM cTropnT-<0.01
___ 10:44PM ALBUMIN-2.7* CALCIUM-8.3* PHOSPHATE-3.4
MAGNESIUM-1.7
___ 10:44PM ___ TO PTT-UNABLE TO ___ TO
R
___ 07:20PM URINE HOURS-RANDOM
___ 07:20PM URINE UHOLD-HOLD
___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 07:20PM URINE RBC-<1 WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-1
___ 07:20PM URINE MUCOUS-RARE*
INTERVAL LABS:
==============
___ 06:04AM BLOOD VitB12-1660* Folate->20
DISCHARGE LABS:
===============
___ 06:13AM BLOOD WBC-4.9 RBC-2.22* Hgb-7.9* Hct-24.1*
MCV-109* MCH-35.6* MCHC-32.8 RDW-20.4* RDWSD-80.1* Plt Ct-85*
___ 06:13AM BLOOD ___ PTT-34.2 ___
___ 06:13AM BLOOD Glucose-119* UreaN-20 Creat-0.7 Na-137
K-3.6 Cl-96 HCO3-30 AnGap-11
___ 06:13AM BLOOD ALT-13 AST-57* LD(LDH)-156 AlkPhos-119*
TotBili-2.0*
___ 06:13AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.1
IMAGING:
========
CXR ___:
1. Low lung volumes.
2. Opacification of the left lung base may represent atelectasis
or
consolidation depending upon the clinical setting.
3. Unchanged moderate cardiomegaly. No pulmonary edema, pleural
effusion, or pneumothorax.
CT ABDOMEN/PELVIS WITH CONTRAST ___:
1. Cirrhosis with findings or portal hypertension and small
amount of ascites and unchanged trace bilateral pleural
effusions.
2. Chronic partial small bowel obstruction with improved small
bowel
distention compared to prior.
3. Mild right-sided hydronephrosis and proximal hydroureter
appears slightly improved compared to prior.
4. Unchanged position of a left upper quadrant approach catheter
which
terminates in the subcutaneous tissues at this location. No
surrounding fluid collection.
UNILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
TTE ___:
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is moderately enlarged. The estimated right atrial
pressure is ___ mmHg. There is normal left ventricular wall
thickness with a moderately increased/dilated cavity. There is
normal regional left ventricular systolic function. Global left
ventricular systolic function is normal. Quantitative biplane
left ventricular ejection fraction is 65 %.
Left ventricular cardiac index is normal (>2.5 L/min/m2) There
is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Mildly dilated right
ventricular cavity with normal
free wall motion. The aortic sinus diameter is normal with
normal ascending aorta diameter. The aortic arch diameter is
normal. There is no evidence for an aortic arch coarctation. The
aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral leaflets appear
structurally normal with no mitral valve prolapse. There is mild
[1+] mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
A left pleural
effusion is present.
IMPRESSION: Good image quality. No valvular pathology or
pathologic flow identified. Mild biventricular cavity dilation
with normal regional/global biventricular systolic function.
Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
PATIENT SUMMARY:
================
This a ___ year-old woman with a PMH of decompensated alcoholic
cirrhosis (SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
prior J-tube, current G-tube for enteral feedings, abdominal
wall abscess and EC fistula at prior J-tube insertion site,
recurrent ileus/SBO, and recent admission (___) for
abdominal pain
who presented with weight gain and weakness, found to have acute
on chronic anemia. Diuresed with IV Lasix gtt to dry weight.
ACUTE ISSUES:
=============
# Volume Overload
# Weight Gain
Patient with reported 10 pound weight gain prior to admission.
She had been inconsistent diuretic dose, with torsemide
increased to 60 mg daily immediately prior to her admission. CT
abdomen performed in the ED on this admission revealed chronic
partial small bowel obstruction with improved small bowel
distention compared to prior CT. Minimal ascites on CT and none
on ultrasound. TTE from ___ showed borderline mild LV cavity
dilation with normal LV function, borderline hyperdynamic.
Etiology of fluid overload likely multifactorial in the setting
of hypoalbuminemia and known cirrhosis. Patient was diuresed
with IV Lasix drip at 15 mg/hour then transitioned to oral
regimen of torsemide 60 mg daily. Discharge weight: 224.2 pounds
down from 238.91 on admission.
# Acute on Chronic Macrocytic Anemia
# Weakness
Hgb nadir 6.5 on admission. Anemia is chronic and baseline is in
the mid 7s typically. Macrocytic, likely related to prior
history of RNYGB. Vitamin B12 and folate both WNL this
admission. She received 1 U pRBC transfusion and required no
further blood transfusions. Weakness improved with diuresis. Hgb
7.9 on day of discharge.
# Nutrition
# Tube Feeds
Chronic tube feeding dependence via G-tube. Continued home TF
regimen of Osmolite 1.5 @ 80 mL/hr x 12 hours, flush 50 mL q6h.
# EtOH Cirrhosis
# Coagulopathy
# Thrombocytopenia
Previously complicated by hepatic encephalopathy, SBP, and
ascites. Followed by Dr. ___ B cirrhosis. MELD 17
on admission. No evidence of ascites on imaging. Patient was
continued on lactulose, rifaximin, ciprofloxacin, and midodrine.
Platelets stable at 85 on discharge. INR 1.6 on discharge, which
is her baseline.
CHRONIC ISSUES:
===============
# Abdominal Pain/Distention
Continued home tramadol 50 mg PO BID and hydropmorphone 2 mg
daily though monitored mental status closely. No HE this
admission though patient was somnolent at times. Continues
metoclopramide and simethicone as well.
# Epileptiform seizures
Continued home Keppra 1000 mg PO BID.
# GERD
Continued home omeprazole 40 mg daily.
TRANSITIONAL ISSUES:
====================
# Patient noted to have some purulence at G tube insertion site.
Evaluated by transplant surgery who felt that everything looked
stable and some purulence is to be expected. Please continue to
monitor in outpatient setting.
# Patient transitioned to oral torsemide 60 mg daily upon
discharge. Patient may require further uptitration of oral
torsemide in the outpatient setting.
# TTE this admission: Compared with the prior TTE of (images
reviewed) of ___, there is now biventricular cavity
enlargement.
NEW MEDICATIONS:
- Multivitamins W/minerals 1 TAB PO/NG DAILY
CHANGED MEDICATIONS:
- Torsemide increased from 20 mg PO daily to 60 mg PO daily
HELD MEDICATIONS: NONE
# Discharge weight: 224.2 pounds
# Discharge Cr: 0.7
# Discharge diuretic regimen: Torsemide 60 mg PO QD
# CONTACT: ___
Relationship: Mother, Father
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO Q6H
6. LevETIRAcetam Oral Solution 1000 mg PO BID
7. Metoclopramide 5 mg PO Q6H
8. Midodrine 15 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Neutra-Phos 2 PKT PO TID
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Rifaximin 550 mg PO BID
14. Simethicone 40-80 mg PO QID:PRN bloating
15. Thiamine 100 mg PO DAILY
16. Torsemide 60 mg PO DAILY
17. TraMADol 50 mg PO BID
18. Vitamin D ___ UNIT PO 1X/WEEK (___)
19. Senna 17.2 mg PO BID
20. Linzess (linaCLOtide) 145 mcg oral DAILY
21. Methylnaltrexone 12 mg Subcut ONCE
22. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
2. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*0
3. Acetaminophen 650 mg PO BID:PRN Pain - Mild
4. Ciprofloxacin HCl 500 mg PO DAILY
5. Escitalopram Oxalate 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
8. Lactulose 30 mL PO Q6H
9. LevETIRAcetam Oral Solution 1000 mg PO BID
10. Linzess (linaCLOtide) 145 mcg oral DAILY
11. Methylnaltrexone 12 mg Subcut ONCE
12. Metoclopramide 5 mg PO Q6H
13. Midodrine 15 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Neutra-Phos 2 PKT PO TID
16. Omeprazole 40 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. Rifaximin 550 mg PO BID
19. Senna 17.2 mg PO BID
20. Simethicone 40-80 mg PO QID:PRN bloating
21. Thiamine 100 mg PO DAILY
22. TraMADol 50 mg PO BID
23. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Alcoholic cirrhosis
Acute on Chronic Macrocytic Anemia
Thrombocytopenia
Fluid overload
SECONDARY:
==========
Epileptiform seizures
Gastroesophageal reflux 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. ___,
It was a pleasure taking care of you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were in the hospital because of weakness and because you
gained some weight in your legs.
WHAT HAPPENED IN THE HOSPITAL?
- You had a CT scan of your abdomen to make sure that there was
no fluid in the belly.
- You were given an IV medication to help remove extra fluid
from your lower extremities.
- Your leg swelling improved significantly and you were deemed
safe to go home.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- Take all of your medications as prescribed
- Follow up with your medications as outlined below.
- Weigh yourself every day and call your doctor if you notice
weight gain of more than 3 pounds.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19612461-DS-28
| 19,612,461 | 21,364,289 |
DS
| 28 |
2161-04-02 00:00:00
|
2161-04-11 21:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman EtOH cirrhosis c/b ascites,
SBP,
HE, and HRS, s/p Roux-en-Y gastric bypass c/b G-J stricture
requiring endoscopic dilations c/b perforation now with
abdominal
wall EC fistula c/b abscesses status post I&D in the past from
her tube sites, presenting here after she was evicted from her
house 2 weeks ago had no access to her medications with
complaints of severe abdominal pain with worsened and now
purulent foul smelling drainage coming from her previous abscess
I&D of abdominal wall and intra-abdominal abscess on ___.
She was evaluated today by in surgery clinic and was advised to
come to emergency department to be admitted to the hospital.
She
denies any fevers, reports chills. She does have a dry cough
which is new for her. She also reports that she is got
significant bilateral lower extremity edema as she has not had
access to her medications most notably her diuretics. She has no
chest pain shortness of breath or trouble breathing. No nausea
vomiting or diarrhea.
In the ED initial vitals:
97.6 |94 |97/53 |18 |100% RA
- Exam notable for:
Gen: Middle-aged woman ___ mildly uncomfortable secondary to
pain
Pulm: Bibasilar crackles no focal consolidation
CV: Tachycardic rate no appreciable murmurs
HEENT: Dry mucous membranes, no scleral icterus
Abdomen: Firm abdomen multiple surgical sites well-healed, 2
punctate lesions over the left abdomen serosanguineous mildly
purulent drainage appreciated faint surrounding erythema
tenderness to palpation no crepitus or dishwater fluid
appreciated.
Extremities: 3+ pitting edema to the posterior buttocks
Skin: Hot dry
Neuro: No gross neurologic deficits, alert and oriented, moves
all extremities no obvious facial abnormalities
- Labs notable for:
___ 03:00PM BLOOD WBC: 4.6 RBC: 3.12* Hgb: 11.0* Hct: 32.3*
MCV: 104* MCH: 35.3* MCHC: 34.1 RDW: 14.3 RDWSD: 54.2* Plt Ct:
65*
___ 03:00PM BLOOD Neuts: 59.1 Lymphs: ___ Monos: 7.9 Eos:
2.6 Baso: 0.4 Im ___: 0.2 AbsNeut: 2.70 AbsLymp: 1.36 AbsMono:
0.36 AbsEos: 0.12 AbsBaso: 0.02
___ 03:00PM BLOOD ___: 15.1* PTT: 33.9 ___: 1.4*
___ 03:00PM BLOOD Glucose: 90 UreaN: 7 Creat: 0.6 Na: 138
K:
4.1 Cl: 102 HCO3: 25 AnGap: 11
___ 03:00PM BLOOD ALT: 12 AST: 36 AlkPhos: 134* TotBili:
1.6*
___ 03:00PM BLOOD Albumin: 3.2* Calcium: 8.5 Phos: 3.5 Mg:
1.7
- Imaging notable for:
CT ABDOMEN/PELVIS
1. Redemonstration of persistent enterocutaneous fistulous at
prior percutaneous gastrostomy tube and percutaneous jejunostomy
tube sites. No evidence of a drainable fluid collection.
2. Re-demonstration of a cirrhotic appearing liver with evidence
of portal hypertension including ascites, upper abdominal
collaterals and splenomegaly.
3. Cholelithiasis without evidence of acute cholecystitis.
CXR:
IMPRESSION:
1. Opacification of the left lung base likely represents
atelectasis.
2. Interval improvement in cardiomegaly, now within normal
limits.
- Consults: Hepatology
- Patient was given:
___ 15:17 IV Morphine Sulfate 4 mg
___ 15:17 IVF LR 150 mL/hr
___ 16:15 IV CefTRIAXone 2 g
On the floor she reports the history as above. She is anxious
and
visibly tremulous/shaking. She denies alcohol use for >1 week.
Collateral from son that she is drinking heavily daily. She
denies HA, n/v/d, dysuria, fevers or chills.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy (___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy (___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
Per prior discharge summary
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 1850)
Temp: 98.4 (Tm 98.4), BP: 131/87, HR: 108, RR: 20, O2 sat:
95%, O2 delivery: Ra, Wt: 246.3 lb/111.72 kg
GENERAL: Anxious appearing, tremulous, tearful, in NAD.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting from 3.5mm to
3.0 mm bilaterally. EOMI in all cardinal directions of gaze
without nystagmus. Vision is grossly intact, hearing grossly
intact. Nares patent with no nasal discharge. Oral cavity and
pharynx are without inflammation, swelling, exudate, or
lesions.
Teeth and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Tachycardic. Normal S1 and S2. No S3, S4 or murmurs.
Rhythm is regular. There is 2+ peripheral edema to thighs
b/l,Extremities are warm and well perfused.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: 5x2cm wound on L abdomen with mild seropurulent
drainage. Normoactive bowel sounds. Soft, moderately distended.
Tender to palpation diffusely, most in RUQ. No guarding or
rebound. No masses.
Neuro: Alert and oriented x3. Severely tremor b/l at rest and
with intention.
Psych: The mental examination revealed the patient was oriented
to person, place, and time. The patient was able to demonstrate
good judgement and reason, without hallucinations or abnormal
behaviors during the examination. Tearful, anxious.
Skin: Skin type III. 5x2cm wound on L upper abdomen with
seropurulent drainage, no lesions or eruptions.
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 731)
Temp: 98.4 (Tm 98.5), BP: 91/57 (91-107/57-74), HR: 80
(80-95), RR: 18, O2 sat: 95% (90-96), O2 delivery: Ra, Wt: 231.3
lb/104.92 kg
GENERAL: WDWN woman in NAD.
HEENT: PERRL, constricting from 3.5mm to 3.0 mm bilaterally.
EOMI
in all cardinal directions of gaze without nystagmus. Vision is
grossly intact, hearing grossly intact. Nares patent with no
nasal discharge. Oral cavity and pharynx are without
inflammation, swelling, exudate, or lesions. Teeth and gingiva
in
good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: RRR. Normal S1 and S2. ___ systolic murmur.
Extremities: There is 2+ peripheral edema to thighs b/l. warm
and
well perfused.
Pulmonary: CTAB
Abdomen: 5x2 cm wound on L abdomen with mild seropurulent
drainage. Normoactive bowel sounds. Soft, moderately distended.
Tender to palpation diffusely, most in RUQ. No guarding or
rebound. No masses.
Neuro/psych: Alert and oriented x3. The patient was able to
demonstrate good judgement and reason, without hallucinations or
abnormal behaviors during the examination.
Skin: 5x2cm fistulous tract on L upper abdomen with seropurulent
drainage, no lesions, or eruptions.
Pertinent Results:
ADMISSION LABS:
=============
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-MOD*
___ 03:00PM WBC-4.6 RBC-3.12* HGB-11.0* HCT-32.3*
MCV-104* MCH-35.3* MCHC-34.1 RDW-14.3 RDWSD-54.2*
___ 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:00PM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-1.7
___ 03:00PM ALT(SGPT)-12 AST(SGOT)-36 ALK PHOS-134* TOT
BILI-1.6*
___ 03:00PM GLUCOSE-90 UREA N-7 CREAT-0.6 SODIUM-138
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-11
DISCHARGE LABS:
=============
___ 05:31AM BLOOD WBC-6.1 RBC-3.02* Hgb-10.5* Hct-31.1*
MCV-103* MCH-34.8* MCHC-33.8 RDW-14.4 RDWSD-54.2* Plt Ct-68*
___ 05:31AM BLOOD ___ PTT-32.8 ___
___ 05:31AM BLOOD Glucose-83 UreaN-9 Creat-0.8 Na-137 K-3.6
Cl-93* HCO3-31 AnGap-13
___ 05:31AM BLOOD ALT-10 AST-31 AlkPhos-112* TotBili-2.0*
___ 05:31AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.6
1
MICROBIO:
========
Urine and Blood cultures negative
IMAGING:
=======
CHEST (PA & LAT)Study Date of ___ 3:29 ___
Persistent mild atelectasis in the lower lungs. No convincing
evidence for
pneumonia.
CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 5:16 ___
1. Redemonstration of persistent enterocutaneous fistulous at
prior
percutaneous gastrostomy tube and percutaneous jejunostomy tube
sites. No
evidence of a drainable fluid collection.
2. Re-demonstration of a cirrhotic appearing liver with evidence
of portal
hypertension including ascites, upper abdominal collaterals and
splenomegaly.
3. Cholelithiasis without evidence of acute cholecystitis.
LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___
9:19 ___
1. Cirrhotic liver, without evidence of focal lesion. Sequela
of portal
hypertension including splenomegaly and small volume ascites are
again noted.
To and fro flow in the portal vein.
2. No evidence of choledocholithiasis.
OTHER SELECTED RESULTS:
=====================
___ 05:27AM BLOOD Ethanol-NEG
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a PMH of decompensated
alcoholic cirrhosis (SBP, ascites, HE), non-variceal UGIB, s/p
RNYGB, prior J-tube, G-tube for enteral feedings, abdominal wall
abscess and EC fistula at prior J-tube insertion site who
presented with
abdominal pain, lower extremity edema, and
anxiety/tremulousness. She was treated for alcohol withdrawal
and underwent imaging which showed no active abdominal
infection.
#Abdominal pain
#Enterocutaneous fistula
Patient presented with diffuse abdominal pain most tender over
RUQ and additionally near wound site. Cholelithiasis on CT
ab/pelvis without cholecystitis. Labs not consistent with
alcoholic hepatitis. Patient empirically started on ceftriaxone
in ED due to concern of infection of enterocutaneous fistula. CT
abdomen with no drainable abscess and ceftriaxone was stopped. A
RUQUS was performed due to cholelithiasis and was without
concerning findings. She received occasional oxycodone for pain.
# Volume Overload
# Lower extremity edema
Patient 246.3 lbs on admission up from 224.2 lbs on discharge in
___ with lower extremity edema. She had not been taking home
torsemide/ spironolactone in setting of eviction. She was
resumed on home torsemide/spironolactone an diuresed well. She
was discharged on Torsemide 60 mg, Spironolactone 50mg daily.
#Alcohol use disorder
#Alcohol withdrawal
Patient denies recent alcohol use though son presented to floor
and informed nursing staff that she has been drinking
excessively daily. Unknown true last use. On presentation she
was tachycardic, anxious, tremulous and with CIWA score > 18
clinically c/w diagnsosis of alcohol withdrawal. She was
maintained on CIWA scale with Ativan which was stopped with
resolution of signs of withdrawal. Thiamine continued. She was
seen by social work.
# EtOH Cirrhosis
# Coagulopathy
# Thrombocytopenia
EtOH cirrhosis complicated by hepatic encephalopathy, SBP, and
ascites. Followed by Dr. ___ B cirrhosis. MELD 13
on admission No sign of hepatic encephalopathy this admission,
she was continued on lactulose 30mL TID and rifaximin 550 BID.
No history of varices in past last EGD ___ with portal
hypertensive gastropathy. Small ascites this admission not
amenable to tap. She was continued on torsemide 60mg and
spironolactone 50 mg. No history of SBP in past.
#Nutrition
Patient s/p Roux-en-y. Previously on tube feeds.
- Continued Thiamine, multivitamins
CHRONIC ISSUES:
===============
# Acute on Chronic Macrocytic Anemia
- at baseline
# Epileptiform seizures
Continued home Keppra 1000 mg PO BID which pt not recently
taking.
# GERD
Continued home omeprazole 40 mg daily.
TRANSITIONAL ISSUES:
====================
[] Please follow up repeat labs in one week, complete metabolic
panel after resuming home diuretics.
[] Continue to assess for signs of volume overload, adjust
diuretics as needed.
[] Please evaluate abdominal enterocutaneous fistula site for
signs of erythema
Full Code
HCP: Mother, Father, ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO Q6H
6. LevETIRAcetam Oral Solution 1000 mg PO BID
7. Rifaximin 550 mg PO BID
8. Senna 17.2 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Torsemide 60 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Sarna Lotion 1 Appl TP BID
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to skin
around fistula twice a day Refills:*0
2. Acetaminophen 650 mg PO BID:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO DAILY
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Lactulose 30 mL PO Q6H
RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours
Disp #*120 Package Refills:*0
7. LevETIRAcetam Oral Solution 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
8. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
9. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
10. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
11. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.8 mg/5 mL 10 ml by mouth twice a day
Refills:*0
12. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
13. 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
14. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
15.Outpatient Lab Work
Please collect Complete metabolic panel ___
K70.30
Please fax results to: ___, Dr. ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==============
Enterocutaneous fistula
Lower extremity edema
Secondary Diagnoses
================
hypervolemia
Alcohol use disorder
Alcohol cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because had abdominal pain
and had not taken your meds in 2 weeks.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital were given your medications and the extra
fluid in your legs went down.
- Imaging of your abdomen showed that there was no active
infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19612562-DS-15
| 19,612,562 | 24,697,174 |
DS
| 15 |
2193-02-11 00:00:00
|
2193-02-13 21:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Nortriptyline / Iodine-Iodine Containing
Attending: ___
Chief Complaint:
Hypertensive Emergency, Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F w/ Hypertension who presents with headache
and dizziness in setting of systolic BP 200+/100+ most consitent
with hypertensive emergency.
She reports increased confusion and complaince with her
medications. Originally confused, but non focal neuro exam,
however did have some difficulty with word finding per traiage
report.
Per PCP, patient has been under significant stress lately due to
social issues with son (improving) but ___ days of neck pain
with headache, no visual changes. Reportedly compliant with BP
regimen.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals: pain ___ HR 62 194/124 16 100%
- Vitals at time of transfer: pain ___ 66 113/93 18 96% RA
- EKG: sinus 65, PR 220, NA, no ST changes
- Trop <0.01 x1
- Labetalol IV
- Lorazepam
- Percocet x2
- Neurology consulted: recommended consideration of CTA to r/o
dissection given concern for this and R neck pain; did not feel
that MRI is necessary at that time.
On medicine floor, patient reporting neck pain which improved to
___ from ___ w/ one dose of perocet. She says she has a
history of neck problems for which she wears a brace at home,
but this is different pain. Patient states that neck pain has
been lasting x3 days which was associated w/ a headache mostly
on the top of her head. The headache was different than her
migraines. No current headache.
Patient says the dizziness was w/ walking for past 4 days, not
at rest or w/ head turns. On floor, denied any current
dizziness.
With respect to the word finding difficulty noted in ED, patient
reports that when she gets "upset" she has difficulty swallowing
and has to hold her tongue out which is not a new issue per pt.
Patient voiced that the has been under a lot of stress recently,
without being asked.
ROS: Full 10 pt review of systems negative except for above. Of
note, no fevers, chest pain or dyspnea.
Past Medical History:
PAST MEDICAL HISTORY:
- Hypertension
- ?Hx Diabetes (normal to borderline A1c since ___: off meds
- Autonomic Dysfunction w/ h/o multiple syncopal episodes
- Seizures: last seizure in ___, questionable sz ___
- Migraines
- PTSD
- Depression
- Anxiety
- GERD
- Chronic Back/Hip Pain
- Osteoarthritis
- Right Ankle Fracture s/p ORIF
- Pelvic leiomyoma s/p TAH with Right oophorectomy
- Right Breast Nodule
- Galactorrhea
- Hx Angina (chest pain relieved by NTG and also pain related to
anxiety)
Social History:
___
Family History:
FAMILY HISTORY: Mother died of anaphylactic shock, No family
history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 112/72 HR 65 sat 98% on RA 68 kg
Gen: anxious, fidgeting
HEENT: clear OP
Neck: pain is very reproducible in R trapezius muscle which
caused radiation of pain down R arm; good active ROM, pain is
also reproduced w/ active ROM when looking left
CV: NR, RR, no murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND
GU: no Foley
Ext: no edema
Skin: no lesions noted
Neuro: CN's intact, ___ strength, finger-to-nose wnl, rapid
alternating movements wnl
Psych: anxious
DISCHARGE PHYSICAL EXAM:
VS: 98.9/98.9 126/61 (99-138/59-82) 61 (56-70) 18 98RA
Gen: anxious, fidgeting, awake, alert, pleasant
Neck: pain is reproducible in R trapezius muscle which caused
radiation of pain down R arm, improved since yesterday, no
longer reproducible with downward pressure on elbow.
CV: RRR, S1S2 no murmur
Pulm: CTAB, nonlabored breathing, no wheezes, rales or rhonchi
Abd: +BS, soft, NT, ND, no gaurding or rebound
Ext: warm 2+ DP pulses, no edema
Skin: no lesions noted
Neuro: CN II-XII intact, ___ strength in LUE, ___ ___ut
___ R hand strength. Intact sensation bilaterally, intact range
of motion
Pertinent Results:
ADMISSION LABS
___ 04:40PM BLOOD WBC-7.2 RBC-4.69 Hgb-14.1 Hct-42.1 MCV-90
MCH-30.1 MCHC-33.5 RDW-13.2 Plt ___
___ 04:40PM BLOOD Neuts-49.1* ___ Monos-6.0 Eos-3.1
Baso-1.4
___ 04:40PM BLOOD ___ PTT-32.2 ___
___ 04:40PM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-144
K-4.2 Cl-105 HCO3-33* AnGap-10
___ 04:40PM BLOOD ALT-18 AST-28 AlkPhos-85 TotBili-0.2
___ 04:40PM BLOOD Albumin-4.8 Calcium-10.1 Phos-2.6* Mg-2.5
___ 04:48PM BLOOD Lactate-0.9
MICRO: none
Utox negative
trop neg x2, CKMB flat
IMAGING:
- CT Head w/o contrast ___: IMPRESSION: No acute
intracranial findings.
- CXR portable ___: no gross infiltrate
- EKG ___: sinus 65, PR 220, NA, no ST changes
troponin negx1 in the ED
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.3 RBC-4.37 Hgb-13.2 Hct-39.8 MCV-91
MCH-30.3 MCHC-33.2 RDW-13.1 Plt ___
___ 07:45AM BLOOD Glucose-122* UreaN-14 Creat-1.1 Na-139
K-3.9 Cl-102 HCO3-30 AnGap-11
Brief Hospital Course:
Ms. ___ is a ___ F w/ Hypertension who presents with headache
and dizziness in setting of systolic BP 200+/100+ most consitent
with hypertensive emergency.
ACTIVE ISSUES
# Hypertensive Emergency: HTN + end organ symptoms (headache,
blurry vision, dizziness). No chest pain trops neg x 2, CKMB
flat and Cr at baseline. LFTs wnl Reports compliance w/ anti-HTN
meds, however, other reports of patient not taking medications,
and questionable whether they were tampered with at home. Utox
was negative and the patient denies using other drugs.
Hypertensive emergency thought to be due to non-compliance with
medications. She was restarted on her home blood pressure
medications and her blood pressure remained within normal limits
with no further episodes of hypertension. Patient was encouraged
to split the timing of her medications to decrease reported
episodes of hypotension, and medication compliance as an
outpatient was encouraged.
# Dizziness / Headache: Neuro team in ED thought possibly some R
sided "clumsiness" on exam which may be chronic. CT head
noncontrast ___ showed no acute abnormalities making CVA
less likely. DDx includes dissection, but pain is very
reproducible in R trapezius muscle on exam. When seen by
neurology in the morning after admission, they had a low
suspicion for a dissection and had no further recommendations
for imaging. They thought her pain was likely musculoskeletal
and related to her resolving hypertensive emergency. Her blood
pressure was measured to be the same in both arms and she was
monitored with neuro checks q4h. Her exam remained stable with
improvements in her dizziness and headache with blood pressure
control. She was seen by physical therapy before discharge who
recommended further outpatient ___.
#Acidosis: metabolic alkalosis with HCO3 of 33 on admission. ___
be due to contraction from poor PO intake (patient reports
decreased PO and nausea). PO intake was encouraged and she
received Zofran PRN nausea with some improvement in her
alkalosis by the time of discharge.
# Neck Pain: Most consistent with musculoskeletal etiology. Hx
of neck problems per patient. Very reproducible in R trapezius
muscle which caused radiation of pain down R arm; good active
ROM, pain is also reproduced w/ active ROM when looking left.
She was continued on her home doses of percocet and started on a
lidocaine patch for pain control.
# Depression / Anxiety / PTSD: Likely playing a significant role
in neck pain. She was continued on her home clonazepam and
venlafaxine. Patient endorses a lot of stress at home. A social
work consult was obtained while the patient was an inpatient and
she was set up with outpatient mental health follow up.
CHRONIC ISSUES
# Seizure Disorder: last seizure in ___, questionable sz
___. Continue on home Topiramate
# GERD: continue PPI
TRANSITIONAL ISSUES
Admitted for hypertensive emergency, highest BP 260/100+,
restarted on home medications.
# Please encourage medication compliance for blood pressure
control
# Asked to take amlodipine at night and lisinopril in the
morning to decrease possible hypotension (patient reports some
episodes at home of dizziness)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
2. Amlodipine 10 mg PO DAILY
3. azelastine 137 mcg NU qPM PRN
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
5. ClonazePAM 0.5 mg PO QHS:PRN anxiety
6. cromolyn 4 % ___ 2 drops TID PRN
7. Diltiazem Extended-Release 300 mg PO DAILY
8. Diltiazem Extended-Release 180 mg PO HS
9. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection PRN
anaphylaxis
10. esomeprazole magnesium 40 mg Oral daily
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Gabapentin 600 mg PO TID
14. Ibuprofen 800 mg PO Q8H:PRN pain
15. Lisinopril 40 mg PO DAILY
16. Naproxen 500 mg PO Q8H:PRN joint pain
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
19. Topiramate (Topamax) 100 mg PO BID
20. Venlafaxine XR 75 mg PO DAILY
21. Aspirin 81 mg PO DAILY
22. Loratadine 10 mg PO DAILY
23. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
3. Amlodipine 10 mg PO DAILY
Please take at night
4. Aspirin 81 mg PO DAILY
5. ClonazePAM 0.5 mg PO QHS:PRN anxiety
6. Diltiazem Extended-Release 180 mg PO HS
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Gabapentin 600 mg PO TID
10. Lisinopril 40 mg PO DAILY
Please take in the mornings
11. Loratadine 10 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
13. Topiramate (Topamax) 100 mg PO BID
14. Venlafaxine XR 75 mg PO DAILY
15. Diltiazem Extended-Release 300 mg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to your right
shoulder daily Disp #*30 Transdermal Patch Refills:*0
17. azelastine 137 mcg NU qPM PRN
18. cromolyn 4 % ___ 2 drops TID PRN
19. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection PRN
anaphylaxis
20. esomeprazole magnesium 40 mg Oral daily
21. Ibuprofen 800 mg PO Q8H:PRN pain
22. Multivitamins 1 TAB PO DAILY
23. Naproxen 500 mg PO Q8H:PRN joint pain
24. Nitroglycerin SL 0.3 mg SL PRN chest pain
25. Outpatient Physical Therapy
Requesting Outpatient ___
Dx: right shoulder and neck pain
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: hypertensive emergency
secondary diagnosis: musculoskeletal right arm pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the general inpatient medicine service for
right arm pain, dizziness and headache for 3 days. When you came
to the Emergency room it was noted that your blood pressure was
very high. You had a condition we call hypertensive emergency
(blood pressure that is so high that you have symptoms). We also
think the pain in your right arm is due to musculoskeletal pain.
We restarted you on your home medications and monitored your
blood pressure. Your blood pressure has been stable on these
medications and you are safe for discharge home.
It is very important that you continue taking your medications
as prescribed. We would like you to change the time you take you
amlodipine and lisinopril so that you take the amlodipine at
night and the lisinopril in the morning. We think this will
decreased the likelihood that your blood pressures will be too
low on your medications.
We would like you to follow up with your primary care doctor in
the appointment listed below. We also made an appointment with a
psychiatrist to discuss the anxiety and stress that you have
been having at home. Please seek immediate medical care if you
experience any worsening headaches, blurry vision, difficulty
urinating or chest pain.
It was a pleasure taking care of you!
Followup Instructions:
___
|
19612651-DS-7
| 19,612,651 | 26,802,085 |
DS
| 7 |
2125-07-27 00:00:00
|
2125-07-27 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
R IJ placed ___ in ED (removed on floor ___
Therapeutic Paracentesis ___
History of Present Illness:
Mr. ___ is a ___ with h/o hep C cirrhosis, CAD/MI s/p stent
___ yrs ago, ___), HTN, diverticulitis s/p partial bowel
resection, osteomyelitis of right thumb, motor vehicle accident
in ___ with chronic back pain s/p spinal fusion in ___ c/b
infection, admitted to MICU with septic shock.
Patient reports feeling unwell for 5 weeks. It began with
nausea, emesis, diffuse abdominal pain with worsening
distension, and worsening of his chronic lumbar back pain. Also
with non-bloody diarrhea. 3 weeks ago he developed daily fevers,
max ___. Diminished PO intake with 15lb weight loss over 5
weeks.
He presented to ___ ___ ___ and had temp 100.3, HR
112, BP low of 65/39, 90%ra and placed on 3L. WBC 33.8 11%bands,
Creat 1.9, lactate 3.1. Got 2L IVF with improvement in BPs to
90/60, 1g ceftriaxone and transferred to ___
At ___ ED:
- initial vitals: 98.1 70 100/66 20 97% Nasal Cannula. Remained
afebrile.
- diag para negative for SBP
- BP dropped to 78/49. Started levophed. Placed RIJ CVL.
- CT abd/pelv with massive ascites, no impressive source of
infection
- Received vanc/zosyn, 500cc IVF, 75g 25% albumin, IV dilaudid
1g x 5 doses, levophed gtt.
On arrival, he reports severe abdominal and low back pain which
responded to IV dilaudid and requests add'l doses. Otherwise no
new complaints.
Regarding his cirrhosis, he was diagnosed within past year.
Presumably from HCV though he's unsure how he got this, no EtOH
use/abuse, no history of blood transfusions or IVDU. He was
admitted to ___ with massive ascites s/p 9L therapeutic
paracentsis ___, neg for SBP ___ and had therapeutic
paracenteses there, but has yet to establish care with a
hepatologist.
ROS:
+ as per HPI
denies chest pain, dyspnea, melena, hematochezia, dysuria,
hematuria, skin wounds, rash.
Otherwise 10 point ROS is negative.
Past Medical History:
Hepatitis C cirrhosis (within past year, not yet established
care)
MI s/p stent ___ years ago, ___)
Diverticulitis s/p partial bowel resection ___ years ago)
Motor Vehicle Accident with chronic L back pain s/p spinal
fusion, c/b infection
R hand osteomyelitis ___ fish-hook injury
Social History:
___
Family History:
Father with MI. Mother healthy and lived to ___. Daughter with
MS. ___ grandmother with MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.3 72 127/74 (levophed 0.1) 17 99% 2L
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, poor mostly absent dentition
NECK: RIJ in place. L JVP to lower earlobe at 45 degrees.
LUNGS: Diminished at right base. Crackles at L base. No wheezes.
CV: Regular rate and rhythm, II/VI systolic murmur LUSB. S1, S2.
ABD: distended, diffuse tenderness, +caput medusa, dull to
percussion throughout
EXT: cool distal lower extremities; absent sensation in dorsal
feet to lower shins b/l. No edema.
SKIN: no juandice
NEURO: no meningismus; PERRL; face symmetric; hip flexors ___,
___ knee flexion/extension, upper extremity strength is full
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 ___ %Ra
General: Pleasant middle-aged man in NAD. Interviewed sitting
comfortably in bed
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes
CV: RRR, normal S1 + S2, no M/R/G
Abdomen: Tight, diffusely TTP though most significant across
RLQ, BS+
Ext: WWP, no c/c/e
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS
===================
___ 02:22AM BLOOD WBC-28.8* RBC-3.37* Hgb-9.2* Hct-28.8*
MCV-86 MCH-27.3 MCHC-31.9* RDW-16.4* RDWSD-51.3* Plt ___
___ 02:22AM BLOOD Neuts-85.0* Lymphs-8.0* Monos-5.1
Eos-0.3* Baso-0.3 Im ___ AbsNeut-24.47* AbsLymp-2.30
AbsMono-1.47* AbsEos-0.09 AbsBaso-0.08
___ 03:52AM BLOOD ___ PTT-28.3 ___
___ 02:22AM BLOOD Glucose-89 UreaN-14 Creat-1.6* Na-131*
K-4.1 Cl-98 HCO3-22 AnGap-15
___ 02:22AM BLOOD proBNP-2559*
___ 02:22AM BLOOD Lipase-34
___ 02:22AM BLOOD Albumin-3.0* Calcium-8.1* Phos-4.9*
Mg-1.8
___ 09:52PM BLOOD calTIBC-276 Ferritn-127 TRF-212
___ 09:52PM BLOOD Osmolal-283
___ 09:52PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Borderline
___ 09:52PM BLOOD CRP-70.1*
___ 09:36AM BLOOD Type-CENTRAL VE pO2-43* pCO2-46* pH-7.34*
calTCO2-26 Base XS--1
___ 02:28AM BLOOD Lactate-0.9
___ 09:36AM BLOOD O2 Sat-72
___ 02:35AM URINE Color-Straw Appear-Clear Sp ___
___ 02:35AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:35AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0
___ 12:18AM URINE Hours-RANDOM UreaN-350 Creat-59 Na-55
PERTINENT LABS
=================
___ 03:58AM BLOOD WBC-13.0* RBC-3.13* Hgb-8.7* Hct-27.0*
MCV-86 MCH-27.8 MCHC-32.2 RDW-16.8* RDWSD-52.9* Plt ___
___ 03:58AM BLOOD Neuts-84.3* Lymphs-5.1* Monos-5.5 Eos-3.9
Baso-0.5 Im ___ AbsNeut-10.96* AbsLymp-0.66* AbsMono-0.72
AbsEos-0.51 AbsBaso-0.06
___ 03:58AM BLOOD Glucose-96 UreaN-14 Creat-1.4* Na-134
K-3.9 Cl-99 HCO3-24 AnGap-15
___ 03:58AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8
DISCHARGE LABS
=====================
___ 07:40AM BLOOD WBC-9.7 RBC-3.86* Hgb-10.5* Hct-33.3*
MCV-86 MCH-27.2 MCHC-31.5* RDW-17.1* RDWSD-53.1* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-136
K-4.5 Cl-102 HCO3-26 AnGap-13
___ 07:40AM BLOOD ALT-8 AST-20 LD(LDH)-187 AlkPhos-199*
TotBili-0.4
___ 07:40AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0
MICRO
=====================
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
___ 3:47 am PERITONEAL FLUID PERITONEAL.
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.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
MRSA SCREEN (Final ___: No MRSA isolated.
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING
======================
___ CHEST (PA & LAT)
In comparison with the study of ___, the patient has taken
a much better inspiration. There is a moderate right pleural
effusion with compressive atelectasis at the base. Dense streak
of atelectasis is seen in the left lower zone. In the
appropriate clinical setting, it would be difficult to
unequivocally exclude a right lower lung pneumonia.
___ MR ___ W/O CONTRAST
1. Incomplete examination with lack of postcontrast images of
the cervical and thoracic spine as the patient could not
tolerate the entirety of the exam. Within the confines of the
study, no evidence of an epidural fluid collection or abnormal
enhancement.
2. 6 lumbar-type vertebral bodies with lumbarization of S1.
Accounting for this anatomic labeling, patient is status post
posterior spinal fusion of L5 through S2 level, with
susceptibility artifact associated with the hardware obscuring
visualization of the neural foramina.
3. Mild degenerative changes of the lumbar spine without
evidence of
high-grade spinal canal or neural foraminal stenosis within the
confines of this study.
___ Portable TTE
Mildly dilated right and left ventricles with globally preserved
biventricular systolic function in the setting of mild
hypokinesis of the basal inferior and inferolateral walls.
Mildly dilated aortic root and ascending aorta. Ascites is
present.
___BD & PELVIS WITH CO
1. Massive ascites with associated compression and mass effect
on intra-abdominal contents.
2. Slight thickening/enhancement of the peritoneum posteriorly.
Peritonitis cannot be excluded.
3. Minimal intrahepatic biliary dilatation in the left lobe and
prominent
appearance of the common bile duct. Please correlate with liver
function
testing to evaluate for possible obstruction.
4. Small left and moderate right pleural effusions.
5. Status post posterior fusion from L4-S1, with bilateral
pedicle screws and posterior rods. Screws at L4 extends slightly
beyond the vertebral body anteriorly. No evidence of hardware
loosening.
___ Imaging CHEST (PORTABLE AP)
Right IJ catheter terminates in the low SVC/cavoatrial junction
without
evidence of pneumothorax. Low lung volumes and bibasilar and
left mid lung atelectasis/scarring, underlying infection not
excluded. Small right pleural effusion.
Brief Hospital Course:
___ with hx of HCV cirrhosis, remote MI s/p stent, L4-S1 spinal
fusion c/b infection, presents with 5 weeks of abdominal pain,
distension, emesis, diarrhea, cough, and fevers, who was
admitted to ICU with septic shock.
# SEPTIC SHOCK OF UNKNOWN SOURCE:
Patient presented hypotensive requiring levophed with unclear
etiology of infection. He had no meningismus or CNS symptoms to
suggest meningitis and had a clear urinalysis. Diagnostic
paracentesis was negative for SBP. Patient was started on broad
spectrum antibiotics and weaned off pressors. Given his back
pain and known hardware, MRI was ordered to evaluate for
epidural abscess and showed no evidence of infection. TTE showed
no vegetation. He continued to spike fevers, and was put on
vancomycin, flagyl, and ceftriaxone. He was stabilized and
transferred to the floor. His cultures from ___
were negative, along with a negative MRSA swab. He was switched
to flagyl and cefpodoxime for an 8 day total course (END: ___
for CAP vs. SBP. Suspicion was not strong enough for SBP to
recommend future prophylaxis, but this could be considered.
#Elevated Alk Phos: Unclear etiology as patient was improving
clinically and no new medications that seemed to be the culprit.
Rest of LFTs increasing but still within normal range. Some
suggestion of obstruction on prior CT. Spoke to hepatology who
suggest repeating in the morning. RUQ U/S w/o evidence of
obstruction. Was seen to be falling on repeat and will have this
rechecked with ___ hepatology f/u.
# HEPATITIS C CIRRHOSIS:
Patient was diagnosed within the past year. Of note, was found
to be Mitochondrial M2 antibody positive. He was found on
admission to have ascites and had a diagnostic and therapeutic
tap. MELD-Na on admission 19, but improved throughout his stay.
He had a negative ___, AMA, and anti-smooth muscle antibody.
Also found to be HIV negative, with a positive HCV (viral load =
5.8). His spironolactone was initially held, but continued on
discharge. His IgG, IgA, and IgM were all within normal limits.
He will require outpatient hepatology follow-up and endoscopy.
# Chronic back pain:
Patient's PCP recently weaned him off of opioids. His pain was
managed on oxycodone in the hospital. An MRI of the back was
done and showed no evidence of epidural abscess or discitis. He
should follow-up for appropriate pain control.
# CORONARY ARTERY DISEASE: Continued aspirin. Restarted his
statin.
# HYPERTENSION: Held atenolol while admitted, continued upon
discharge.
TRANSITIONAL ISSUES
=====================
[] Continue flagyl and cefpodoxime for an 8 day total course
(END: ___ for CAP vs. SBP. Suspicion was not strong enough for
SBP to recommend future prophylaxis, but this could be
considered.
[] Follow-up for appropriate pain control for chronic back pain
[] Needs HAV and HBV vaccination per serology
[] Will have outpatient hepatology follow-up and EGD w/ Dr.
___ at ___
[] Blood cultures were pending and should be followed-up in
clinic
# Communication: HCP: ___ ___
# Code: Full Code, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 100 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Morphine SR (MS ___ 30 mg PO Q12H
5. OxyCODONE (Immediate Release) 10 mg PO BID
6. Diazepam 2 mg PO QHS:PRN back spasm
7. Gabapentin 300 mg PO BID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*5 Tablet Refills:*0
2. Lactulose 30 mL PO DAILY
RX *lactulose 20 gram/30 mL 30 mL by mouth daily Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*7 Tablet Refills:*0
4. Pravastatin 20 mg PO QPM
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Diazepam 2 mg PO QHS:PRN back spasm
7. Gabapentin 300 mg PO BID
8. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*28 Tablet Refills:*0
9. OxyCODONE (Immediate Release) 10 mg PO BID
RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
10. Spironolactone 100 mg PO DAILY
11. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until seeing your PCP
___:
Home
Discharge Diagnosis:
PRIMARY
SEPTIC SHOCK
SECONDARY
CHRONIC BACK PAIN
HEPATITIS C CIRRHOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ because of septic shock causing low
blood pressure.
WHILE YOU WERE HERE:
- We did studies, but we were unable to find the exact source of
your infection
- We observed you carefully, watching for signs of infection
- Your blood pressure and fever stabilized
- We drained the fluid causing you discomfort from your abdomen
WHEN YOU GO HOME:
- Please continue all medications as directed
- Please follow-up with your primary doctor and ___ hepatologist
- For any fevers, diarrhea, vomiting or any other concerning
symptoms, please call your doctor or return to the emergency
department immediately
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19612977-DS-2
| 19,612,977 | 26,542,950 |
DS
| 2 |
2112-01-05 00:00:00
|
2112-01-07 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline / Neurontin / Demerol / venom-wasp
Attending: ___.
Chief Complaint:
constipation, n/v
Major Surgical or Invasive Procedure:
___ ___ Myotomy
History of Present Illness:
___ female with a past medical history of nutcracker
esophagus, achalasia, gastroesophageal reflux disease, empty
sella syndrome, chronic back pain and opiod use following a
motor
vehicle accident over ___ years ago, morbid obesity, anxiety,
depression, and concern for gastroparesis, presenting with
persistent abdominal distention and epigastric pain.
Her abdominal pain is sharp, radiating to the back, similar to
her previous episodes of epigastric abdominal pain. Pt
attributes
symptoms to worsening esophageal achalasia. Unable to take
anything po for the last 5 days as she vomits up everything she
swallows. Also reports severe constipation at this time. Has
tried Mg citrate with limited success. She was instructed by her
gastroenterologist to come in to be admitted for potential
evaluation of her esophageal achalasia.
Of note, she has had some dysphagia to solids since ___. In
___ developed dysphagia to liquids and regurgitation
thereof. She was hospitalized in ___ for chest pain and
intractable nausea and vomiting.
She was diagnosed with achalasia type II in ___. In ___
she was hospitalized at ___ in ___
secondary to 'vomiting and could not keep any food down and
aspirated'. She was intubated for a period of time. She has had
botox injections to the LES, which helped somewhat. Had a prior
study that was equivocal for gastroparesis. Timed barium swallow
___, consistent with achalasia.
Following her hospitalization, she was only eating glucerna,
yoghurt, and water, but continued to have "some choking". Has
tried Reglan in the past with some benefit, but was told to stop
due to potential side effects.
Subsequently seen at GI by thoracic surgery in ___.
Recommended to attempt POEM with backup for conversion to
___.
In the ED:
- Initial vital signs were notable for: 97.6 107 149/79 19 100%
RA
- Exam notable for: very dry MM, moderately distended, firm abd
with epigastric tenderness without rebound, RLE > LLE pitting
edema
- Labs were notable for: WBC 10.4, hgb 14.8 plt 141, Cr 0.7, ALT
131, AST 49, AP 268, tbili 1.1, trop neg x1
- Studies performed include:
CT C/A/P - esophageal obstruction at the GE junction, presumably
caused by known achalasia w/ superimposed esophagitis. No e/o
perforation.
LENIs: No e/o DVT
- Patient was given: 1L LR, Reglan 5mg IV x1
- Consults: GI: trial methylnaltrexone for opiate-induced
constipation; formal GI c/s in am
- Vitals on transfer: 97.8 95 124/75 18 93% RA
Upon arrival to the floor, states that she is able to swallow
salive and thinks that at least some of her meds are staying
down. Notes that constipation is at baseline (last BM yesterday)
without any recent change.
Of note, she adds that she was diagnosed with LLE DVT at an
urgent care in ___ and started on Xarelto. No w/u for PE
pursued at that time. States that she has been feeling more SOB
recently, but has been feeling that way for several weeks w/o
recent change. No pre-syncope / syncope.
Past Medical History:
- Nutcracker esophagus
- Achalasia, s/p previous endoscopic dilations as well as a
Botox
injection on ___ at the esophagogastric junction.
- Gastroesophageal reflux
- Constipation
- small hiatal hernia
- gastritis
- LLE DVT dx in ___
- Lower back pain on dilaudid
- Empty sella syndrome on dex
- Diabetes mellitus, insulin dependent
- Anxiety on Valium
- Hyperlipidemia
- Reflex sympathetic dystrophy
- Serotonin syndrome
- Fatty liver
- Depression
- stool impaction/constipation ___ chronic opiod use
- central sleep apnea
- ___
- hx serotonin syndrome
- "grapefruit sized R ovarian growth compressing bladder?"
Social History:
___
Family History:
No family history of GI malignancies or disorders or
coagulopathy
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Laying in bed. Eyes open. Alert and interactive. In no
acute distress. Intermittently swallowing without regurgitation.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
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, mild tenderness to
deep palpation in epigastric area, no rebound. No organomegaly.
EXTREMITIES: b/l ___ edema ___ to both knees), no skin changes
SKIN: Warm.
NEUROLOGIC: AAOx3, no dysarthria, face symmetric, moving all
extremities with purpose.
DISCHARGE PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 701)
Temp: 98.8 (Tm 98.8), BP: 124/77 (124-152/77-82), HR: 84
(84-98), RR: 18 (___), O2 sat: 94% (94-95), O2 delivery: Ra,
Wt: 260.1 lb/117.98 kg
GENERAL: Sitting at the edge of the bed. No NC. Alert and
interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
NECK: Supple. Erythema at the nape of the neck, no warmth, no
open excoriations
CARDIAC: rrr, no m/r/g
LUNGS: cta b.
ABDOMEN: Normal bowels sounds, non distended, tenderness to
deep palpation in epigastric area, no rebound. Surgical sites
with mild but improving erythema, no purulence, no discharge, no
warmth.
EXTREMITIES: b/l ___ edema (1+ to both knees), no skin changes
SKIN: Warm. mild erythema surrounding neck.
NEUROLOGIC: AAOx3, no dysarthria, face symmetric, moving all
extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:25PM BLOOD WBC-10.4* RBC-5.03 Hgb-14.8 Hct-47.0*
MCV-93 MCH-29.4 MCHC-31.5* RDW-16.9* RDWSD-56.7* Plt ___
___ 09:25PM BLOOD Neuts-84.5* Lymphs-10.6* Monos-4.3*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-8.76* AbsLymp-1.10*
AbsMono-0.45 AbsEos-0.01* AbsBaso-0.01
___ 09:25PM BLOOD ___ PTT-28.2 ___
___ 09:25PM BLOOD Glucose-116* UreaN-22* Creat-0.7 Na-144
K-4.0 Cl-102 HCO3-28 AnGap-14
___ 09:25PM BLOOD ALT-131* AST-49* AlkPhos-268* TotBili-1.1
___ 09:25PM BLOOD Lipase-13
___ 09:25PM BLOOD cTropnT-<0.01
___ 09:25PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-2.3
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-6.7 RBC-4.41 Hgb-13.1 Hct-40.8 MCV-93
MCH-29.7 MCHC-32.1 RDW-16.4* RDWSD-54.4* Plt Ct-91*
___ 06:08AM BLOOD WBC-7.0 RBC-4.33 Hgb-13.1 Hct-40.7 MCV-94
MCH-30.3 MCHC-32.2 RDW-16.4* RDWSD-55.8* Plt Ct-89*
___ 05:40AM BLOOD Plt Ct-91*
___ 06:08AM BLOOD Plt Ct-89*
___ 05:40AM BLOOD Glucose-224* UreaN-10 Creat-0.6 Na-142
K-3.8 Cl-99 HCO3-30 AnGap-13
___ 06:08AM BLOOD Glucose-177* UreaN-10 Creat-0.7 Na-142
K-3.6 Cl-100 HCO3-30 AnGap-12
___ 05:40AM BLOOD ALT-138* AST-33 AlkPhos-154* TotBili-0.9
___ 05:40AM BLOOD ALT-138* AST-33 AlkPhos-154* TotBili-0.9
___ 06:08AM BLOOD ALT-150* AST-55* AlkPhos-141* TotBili-0.9
___ 05:40AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8
___ 06:08AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.8
MICRO:
======
None
IMAGING:
========
RIGHT LOWER EXTREMITY US ___
No evidence of deep venous thrombosis in the right lower
extremity veins. The peroneal veins were not identified.
CT CHEST/A/P ___
1. Esophageal obstruction at the gastroesophageal junction,
presumably caused
by known achalasia, with superimposed esophagitis. No evidence
of
perforation.
2. Incidental 6.2 cm right adnexal cyst. Recommend nonemergent
pelvic
ultrasound for further evaluation.
PELVIC ULTRASOUND ___
FINDINGS:
The patient is status post hysterectomy.
The ovaries were not identified.
Simple right adnexal cystic lesion was incompletely evaluated
due to overlying
bowel loops and measures approximately 6.5 x 5.4 x 5.8 cm. No
internal
vascularity or suspicious features.
The lesion could not be visualized on transvaginal exam.
IMPRESSION:
The right adnexal cystic lesion was incompletely evaluated due
to overlying
bowel loops, within this limitation the lesion measures
approximately 6.5 x
5.4 x 5.8 cm and demonstrated no internal vascularity or
suspicious features.
Please note that due to limited evaluation a solid component
cannot be
excluded with certainty. Repeat gynecologic ultrasound advised
in 3 months to
assess for stability.
UGIS ___
IMPRESSION:
No evidence of leak or obstruction. Unchanged dilatation of the
distal
esophagus with brief holdup of contrast.
___
LLE US
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
SUMMARY
=======
___ female with a past medical history of nutcracker
esophagus, achalasia, gastroesophageal reflux disease, empty
sella syndrome, chronic back pain and opioid use following a
motor vehicle accident over ___ years ago, morbid obesity,
anxiety, depression, and concern for gastroparesis, presenting
with persistent abdominal distention and epigastric pain,
consistent with constipation and esophageal obstruction
secondary to achalasia. Given recurrent episodes of esophageal
obstruction, decision was made to move forward with ___
myotomy per Thoracic surgery which was done on ___. The patient
tolerated the procedure very well. Her diet was advanced and she
was tolerating soft solids at the time of discharge.
TRANSITIONAL ISSUES
===================
[] Patient's anticoagulation was changed to apixaban 5 po BID
[] Holding metoprolol succinate as patients heart rates and BPs
WNL, ___ at home will check BPs, HR
[] Pt with diagnosis of cirrhosis, hx ___ connect to
outpatient GI
[] Pt noted to have adnexal cyst did have repeat imaging here,
needs follow-up in 3 months to assess for stability
[] Pt noted to be mildly thrombocytopenic. She will follow-up
with heme as outpatient
[] Insulin was changed to glargine 24u (was 32 on admission)
ACUTE ISSUES
============
# Esophageal obstruction secondary to achalasia
s/p previous endoscopic dilations, Botox injection,
metoclopramide therapy. Presented with pain w/ swallowing and
inability to keep food down x5 days. Also complaining of
regurgitation of solid food immediately following ingestion. Had
similar symptoms in ___ last year prior to dilatation. CT
notable for esophageal obstruction, likely in setting of known
achalasia. NGT placed in hospital, kept NPO for decompression.
Following discussions with GI and thoracic surgery, decision was
made to move forward with ___ myotomy which was done
successfully on ___. Patient tolerated soft solids upon
discharge, with plans to advance as outpatient with GI/Thoracics
guidance.
# Concern for recurrent aspiration in the setting of esophageal
obstruction
Patient with one witnessed episode of likely aspiration, similar
to many recent episodes that she had at home. This continued to
be high risk so she was kept NPO until her procedure. Kept head
of bed elevated and kept on aspiration precautions even after
the myotomy, so that risk of aspiration will be minimized.
# ? cirrhosis
# hx of ___
There is mention in the op report of a visualized cirrhotic
liver, potentially ___ steatosis, which would be a new diagnosis
for this patient. She has known ___, seen by GI in the past.
She did present with mild LFT abnormalities and
thrombocytopenia, but recent CT abd/pelvis (___) does not
describe cirrhotic appearing liver. Would consider RUQUS,
fibroscan, biopsy, reasonable to be done as outpatient with
guidance from hepatology.
# LLE DVT
Diagnosed in ___. Held home Xarelto, started on heparin
IV while NPO. Restarted on apixaban upon discharge, as her po
intake is unpredictable. Her LLE was noted to be slightly larger
and more tender than at her baseline, and so a repeat LLE US was
done which was negative.
# Thrombocytopenia
Platelet count of 141 on admission to ___, downtrended to 90
during hospital stay. Likely dilutional and coagulation
artifact, although could be related to liver disease given
findings of cirrhosis intraoperatively. Will follow with Heme as
outpatient.
# right adnexal cyst
CT abd/pelvis ___ noted 6.2 x 4.1 cm right adnexal cyst,
pelvic ultrasound was performed on ___ with stability of the
cyst. Ultrasound report recommends repeat imaging in 3 months
# Diabetes mellitus, insulin dependent
- On glargine (24 units at bedtime) and ISS. This was a decrease
from 32 which was her home regimen.
CHRONIC ISSUES:
===============
# tachycardia
Pt had been taking metop succinate 100 for "fast heart rates".
No
hx of arrhythmia. HRs have been variable here, but mostly in the
___. Her metoprolol was held upon discharge as she did not
require it while hospitalized.
# Code status
Has previously wanted to be DNR/DNI, but wants to remain full
code for surgery. Ongoing conversation with Palliative Care. She
remained ambivalent about her wishes for code status,
conversation should be continued with her PCP.
# Constipation
CT on admission negative for obstruction. Per pt
at baseline. Continued on her home bowel reg.
# Gastroesophageal reflux / hiatal hernia / gastritis
continued home PPI: pt on lansporazole
# Lower back pain
Transitioned from IV dilaudid to po home regimen, was
successful. Palliative Care was consulted to aid in the
management of her chronic pain. She has been on an extensive
pain regimen in the past and the current 8mg po 5x/day is a
significant decrease in dosing than what she had been on in the
past. ___ was reviewed prior to discharge.
# Empty sella syndrome
Was on stress dose steroids, then was put back on her home dose.
# Anxiety
home Valium
# Hyperlipidemia
home statin
# Depression
home DULoxetine ___ 30
# Central sleep apnea - stable
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) 8 mg PO FIVE TIMES DAILY
2. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
3. DULoxetine ___ 30 mg PO DAILY
4. Metoclopramide 5 mg PO TID W/MEALS
5. dexlansoprazole 60 mg oral daily
6. Dexamethasone 1.5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
9. Linzess (linaCLOtide) 290 mcg oral daily
10. Movantik (naloxegol) 12.5 mg oral daily
11. Atorvastatin 40 mg PO 5X/WEEK (___)
12. L-Methylfolate (levomefolate calcium) 15 mg oral EVERY OTHER
DAY
13. Vitamin D ___ UNIT PO DAILY
14. Diazepam 5 mg PO DAILY:PRN anxiety
15. Cyproheptadine 4 mg PO BID:PRN nausea
16. Maxalt (rizatriptan) 10 mg oral TID:PRN migraine headaches
17. Magnesium Citrate 300 mL PO DAILY:PRN constipation
18. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
19. Fleet Enema (Saline) ___AILY:PRN constipation
20. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
2. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Atorvastatin 40 mg PO 5X/WEEK (___)
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Cyproheptadine 4 mg PO BID:PRN nausea
6. Dexamethasone 1.5 mg PO DAILY
7. dexlansoprazole 60 mg oral daily
8. Diazepam 5 mg PO DAILY:PRN anxiety
9. DULoxetine ___ 30 mg PO DAILY
10. Fleet Enema (Saline) ___AILY:PRN constipation
11. HYDROmorphone (Dilaudid) 8 mg PO FIVE TIMES DAILY
12. L-Methylfolate (levomefolate calcium) 15 mg oral EVERY
OTHER DAY
13. Linzess (linaCLOtide) 290 mcg oral daily
14. Magnesium Citrate 300 mL PO DAILY:PRN constipation
15. Maxalt (rizatriptan) 10 mg oral TID:PRN migraine headaches
16. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
17. Metoclopramide 5 mg PO TID W/MEALS
18. Movantik (naloxegol) 12.5 mg oral daily
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Achalasia leading to esophageal obstruction
Secondary:
Constipation
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for an exacerbation of your
achalasia (a narrowing of your esophagus) which caused you to
have trouble eating and drinking.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- We used a nasogastric tube to help diminish the blockage in
your esophagus
- We worked with our gastrointestinal specialists and thoracic
surgery colleagues to plan myotomy to provide a more durable
solution to your esophageal obstruction which you had on ___.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!!
Sincerely,
Your ___ Team
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting.
-Increased shortness of breath
Pain
-You may need pain medication once you are home but you can wean
it over the next week as the discomfort resolves. Make sure
that you have regular bowel movements while on narcotic pain
medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
-No driving while taking narcotic pain medication.
-Take Tylenol on a standing basis to avoid more opiod use.
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk ___ times a day for ___ minutes increase to a Goal of
30 minutes daily
Diet:
Full liquid diet for ___ days. Increase to soft solids as
tolerates
Eat small frequent meals. Sit in chair for all meals. Remain
sitting up for ___ minutes after all meals
NO CARBONATED DRINKS
Followup Instructions:
___
|
19613088-DS-18
| 19,613,088 | 29,832,854 |
DS
| 18 |
2111-06-11 00:00:00
|
2111-06-11 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:
Abdominal Pain, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old male with history of Crohn's
disease presenting with abdominal pain, diarrhea, and nausea.
Patient established care with a new gastroenterologist at ___ 2
weeks ago and recently restarted Pentasa (was in non-medicated
remission for the past ___ years based on advice of GI in
___ after upper endoscopy and colonoscopy) in the
setting of a return of symptoms starting early ___
including fatigue, intermittent/crampy lower abdominal pain and
constipation that then transitioned into up to ___ loose/formed
stools daily usually 2 hrs after eating. He also noted new
onset, atraumatic L hip and L knee pain 3 weeks ago that lasted
for ___ weeks and made walking difficult but that pain has
since resolved. ESR was elevated to 44 and CRP to 97.1 on
___. Prior to that, he was on Pentasa 750mg TID since
diagnosis at ___ years old. He has never required steroids or
immune modulatory agents.
___ morning had one episode of emesis of small
amount of bright red globules of blood and was referred to
urgent care clinic by his new gastroenterologist on ___.
Blood work done at that time was normal, and he was restarted on
Omeprazole 40 mg. GI was planning for MR enterography, but was
unable to get it done due to insurance issues.
He is having generalized abdominal pain (currently feels
epigastric and lower abdominal pain most) and variable nausea.
He has been limiting PO intake due to symptoms and reports
weight loss of 7 lbs (180 to 173 lbs) over the last 1.5 months.
Denies fevers, visual changes, chest pain, dyspnea,
hematochezia, melena, dysuria, hematuria. He reports joint pain
that was worse two weeks ago and reports night sweats.
He would estimate this is the ___ flare since his diagnosis was
made. He does not know what may have triggered this flare but in
the past his triggers have been ibuprofen and aspirin use.
In the ED, initial vital signs were: T97.7, HR76, BP 112/79,
RR19, SaO2 100% on RA
- Exam notable for: epigastric and lower abdominal pain
- Labs were notable for: CRP 128.6, plts 492, INR 1.2 ___ 13.1)
- Studies performed include: MR ___
- Patient was given: PO Mesalamine 750 mg, PO Omeprazole 40 mg
- Vitals on transfer: T98.5 P87 BP116/70 RR18 SaO2 99% RA
Upon arrival to the floor, the patient is resting comfortably.
He continues to have some nausea as well as epigastric and lower
abdominal discomfort but is in no visible discomfort/pain.
Past Medical History:
- Crohns disease
- Prothrombin A gene mutation (previously taking ASA 81)
- Migraine headaches
Social History:
___
Family History:
-h/o autoimmune conditions: MS ___ uncle), SLE (maternal
great grandmother)
-MGM - died at ___ from unknown cancer
-Prothrombin A gene mutation on father's side
-no h/o IBD, GI cancers
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals- T 98.1F, HR 72, BP 114/73, RR 18, SaO2 98% on RA
GENERAL: NAD, resting comfortably, A&Ox3
HEENT: EOMI, visual fields full to confrontation, moist MM,
clear oropharynx
NECK: supple, FROM
CARDIAC: RRR, nl S1/S2, no murmurs
LUNGS: CTAB, normal work of breathing
ABDOMEN: soft, NT/ND, +BS, tenderness to palpation in
epigastrium, lower abdomen at midline and RLQ, no
guarding/rebound tenderness
EXTREMITIES: WWP
SKIN: no rashes
NEUROLOGIC: CN II-XII grossly intact, full strength and
sensation in all extremities
DISCHARGE PHYSICAL EXAM
=================
Vitals: 97.9 101/63-123/71 67 18 96%RA
GENERAL: NAD, resting comfortably, A&Ox3
HEENT: EOMI, visual fields full to confrontation, moist MM,
clear oropharynx
NECK: supple, FROM
CARDIAC: RRR, nl S1/S2, no murmurs
LUNGS: CTAB, normal work of breathing
ABDOMEN: soft, NT/ND, +BS, minimal tenderness to palpation in
epigastrium, lower abdomen at midline and RLQ improved from
prior. Mild tenderness in LLQ. no guarding/rebound tenderness
EXTREMITIES: WWP
SKIN: no rashes
NEUROLOGIC: CN II-XII grossly intact, full strength and
sensation in all extremities
Pertinent Results:
ADMISSION LABS
===========
___ 08:52PM BLOOD WBC-9.3 RBC-5.28 Hgb-13.7 Hct-42.6
MCV-81* MCH-25.9* MCHC-32.2 RDW-11.7 RDWSD-33.7* Plt ___
___ 08:52PM BLOOD Neuts-66.1 Lymphs-17.2* Monos-11.8
Eos-4.1 Baso-0.4 Im ___ AbsNeut-6.13* AbsLymp-1.59
AbsMono-1.09* AbsEos-0.38 AbsBaso-0.04
___ 08:52PM BLOOD ___ PTT-36.0 ___
___ 08:52PM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-139
K-4.1 Cl-100 HCO3-24 AnGap-19
___ 08:52PM BLOOD Albumin-3.7
___ 08:52PM BLOOD CRP-128.6*
___ 09:00PM BLOOD Lactate-1.2
___ 08:59PM BLOOD SED RATE-19
NOTABLE LABS
=========
___ 07:50AM BLOOD WBC-11.0* RBC-5.00 Hgb-13.0* Hct-40.2
MCV-80* MCH-26.0 MCHC-32.3 RDW-11.8 RDWSD-33.9* Plt ___
___ 07:50AM BLOOD Neuts-79.6* Lymphs-10.7* Monos-9.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-8.90* AbsLymp-1.20
AbsMono-1.04* AbsEos-0.00* AbsBaso-0.01
___ 07:20AM BLOOD Glucose-136* UreaN-12 Creat-0.7 Na-138
K-4.9 Cl-101 HCO3-21* AnGap-21*
___ 07:20AM BLOOD Calcium-10.0 Phos-5.8* Mg-2.3
___ 07:20AM BLOOD CRP-126.2*
___ 07:50AM BLOOD CRP-63.4*
___ 07:25AM BLOOD CRP-30.5*
___ 07:20AM BLOOD CRP-12.5*
___ 07:20AM BLOOD HIV Ab-Negative
MICROBIOLOGY
=========
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
IMAGING
======
___
MR ENTEROGRAPHY:
Approximately 10 cm of terminal ileum shows wall thickening with
edema and
abnormal mucosal enhancement without convincing evidence of
transmural
enhancement. Patchy involvement of the bowel 5-10 cm proximal
to this segment in the terminal ileum is also present to a
lesser degree with few areas of focal mucosal thickening and
abnormal enhancement predominantly along the mesenteric side of
the small-bowel; other areas in this segment show increased
enhancement without wall thickening.
Cecum, ascending colon, and transverse colon to the splenic
flexure
demonstrate wall thickening with edema and abnormal mucosal
enhancement
without evidence of transmural enhancement. Disease is most
advanced in the cecum and ascending colon. In the descending
colon and sigmoid colon there are patchy areas which show lesser
degrees of involvement.
The affected segments of bowel show multiple prominent
mesenteric lymph nodes and fibrofatty mesenteric changes with
vascular engorgement. No mesenteritis. No obstruction or
stenosis. No fistula. No collection. The rectum is spared.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Visualized Liver: Visualized parenchyma is normal in signal and
enhancement. No solid mass.
Biliary: There is no intrahepatic bile duct dilation. Common
bile duct is notdilated. Gallbladder wall is normal thickness.
No pericholecystic fluid. No gallstone.Pancreas: Normal in size.
Parenchyma is normal in signal and enhancement. Main pancreatic
duct is not dilated. .
Spleen: Normal in size, signal, and enhancement.
Adrenal Glands: Normal in size, signal, and enhancement. No
nodularity.
Kidneys: No hydronephrosis. Normal in size, signal, and
enhancement. No solid mass.
Lymph Nodes: No enlarged pelvic or retroperitoneal lymph node.
Vasculature: Aorta and iliac arteries are of normal caliber.
Osseous and Soft Tissue Structures: No mass. Normal bone marrow
signal.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
No pelvic mass. Normal bladder.
Grossly normal prostate and seminal vesicles.
IMPRESSION:
Contiguous active inflammation involving the distal 10 cm of
terminal ileum
and the colon from cecum through the splenic flexure without
evidence of
transmural enhancement. There is patchy lesser involvement
affecting 5-10 cm of ileum adjacent to the affected segment as
well as the descending and
sigmoid colon. The rectum is spared.
No obstruction or stenosis. No fistula. No collection.
DISCHARGE LABS
===========
___ 07:20AM BLOOD WBC-13.0* RBC-5.06 Hgb-13.4* Hct-41.8
MCV-83 MCH-26.5 MCHC-32.1 RDW-12.1 RDWSD-36.0 Plt ___
___ 07:20AM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-137
K-5.3* Cl-98 HCO3-25 AnGap-19
___ 07:20AM BLOOD Calcium-9.7 Phos-5.2* Mg-2.2
Brief Hospital Course:
___ is a ___ year-old male with history of Crohn's
disease including 2 prior flares who presented with abdominal
pain, diarrhea, nausea, emesis, and 7 lb weight loss admitted
for expedited Crohn's flare work-up. He was started on IV
methylprednisolone with which his CRP improved. He was
discharged with oral prednisone with plan for a slow taper to be
determined by his outpatient gastroenterologist. He was started
on Bactrim prophylaxis while on high dose prednisone.
ACTIVE ISSUES
=============
#Crohn's Disease flare:
Patient presenting with 1 month of vague abdominal discomfort, 1
week of diarrhea, emesis and nausea, and 7-lb weight loss in the
setting of poor PO intake. Admission CRP 128.6. C. difficile and
fecal cultures were negative. MR enterography demonstrates
active inflammation of terminal ileum and colon through the
splenic flexure without involvement of the rectum; there is no
evidence of strictures, obstruction, or perforation. The
gastroenterology team was consulted and provided
recommendations. He was started on methylprednisolone 20mg IV
Q8H on ___ that was continued until ___ when he was
transitioned to prednisone at 40mg daily. Pentasa was continued
at 750mg TID, dose confirmed with patient. He was started on
bactrim prophylaxis on ___. His CRP improved on ___ but he had
persistent intermittent abdominal pain. CRP downtrended. On
discharge CRP was 12.5. Hepatitis serologies had been obtained
as an outpatient on ___ and showed HAV nonimmunized, HBV
Immunized, HCV not exposed. HIV was negative. TB quant gold was
negative on ___. He was continued on heparin subcutaneous
prophylaxis and encouraged to ambulate during his stay.
#Thrombocytosis
Plt count 492 on admission ___ with increase to 509 on ___.
Likely reactive in setting of Crohn's flare (with CRP elevated).
He will need to follow up with CBC as outpatient to ensure
resolution as Crohn's symptoms improve. Discharge platelet count
481.
#Leukocytosis
WBC to 11 on ___ in the setting of methylprednisolone. He has
no urinary symptoms, respiratory symptoms or rash. No fevers.
Discharge white blood cell count 13.
#AG Metabolic Acidosis
AG of 16 on ___. Lactate 1.2 on ___. Etiology unclear. may be
linked to Pentasa and mild volume depletion given poor PO intake
in setting of Crohn's with bicarbonate loss with diarrhea.
Improved with PO intake.
CHRONIC ISSUES
==========
#Prothrombin A gene mutation: held ASA 81 as the patient was not
taking this at home. Maintaind on DVT ppx with subQ heparin.
TRANSITIONAL ISSUES
==============
#NEW MEDICATIONS
- PredniSONE 40 mg PO DAILY
- Multivitamins 1 TAB PO DAILY
- Sulfameth/Trimethoprim SS 1 TAB PO DAILY
#CHANGED MEDICATIONS
- None
#STOPPED MEDICATIONS
- None, patient is not taking aspirin 81mg
[] Discuss prednisone dosing and taper plan with outpatient
gastroenterologist
[] Discuss additional therapeutics including anti-TNF with
outpatient gastroenterologist and timing of colonoscopy.
[] Discuss duration of bactrim prophylaxis with outpatient
gastroenterologist
[] Avoid NSAIDs
[] Follow up CBC as outpatient when Crohn's flare improves to
assess for resolution of thrombocytosis
[] Discuss whether patient should be taking aspirin 81mg for
prothrombin gene mutation
#Contact: ___ (mother) (___), Page (finace)
___
#Code status: Full code (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Sumatriptan Succinate 50-100 mg PO ONCE MR1
3. Omeprazole 40 mg PO DAILY
4. Mesalamine 750 mg PO TID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*1
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*40 Tablet
Refills:*0
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Mesalamine 750 mg PO TID
7. Omeprazole 40 mg PO DAILY
8. Sumatriptan Succinate 50-100 mg PO ONCE MR1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Crohn's disease flare
Secondary:
Prothrombin A gene mutation
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 a Crohn's disease flare. You
were seen by the GI doctors who recommended ___. The imaging
showed inflammation in the small bowel and colon caused by
Crohn's disease.
You were admitted to the medicine service. You were given IV
steroids and were continued on your home dose of Pentasa. You
were started on an antibiotic called Bactrim to help prevent
infections to which you may be susceptible while you are on
steroids.
Your blood tests showed that the inflammation slowly was getting
better with steroid treatment while you were in the hospital. It
is very important that you continue to take these medications as
prescribed by your GI doctor.
You should continue Prednisone at 40 mg daily until you follow
up with your GI doctor who will give further recommendations.
If you experience worsening abdominal pain, fevers, chills,
continued weight loss, vomiting, diarrhea, please call you
doctor or return to the emergency department.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19613207-DS-23
| 19,613,207 | 22,157,918 |
DS
| 23 |
2170-10-19 00:00:00
|
2170-10-19 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
___
Attending: ___
Chief Complaint:
Wound drainage
Major Surgical or Invasive Procedure:
status post L ___ wound washout ___
History of Present Illness:
This is a ___ y/o man well known to our service who underwent a
L4/5 disc excission on ___ and has been followd in our clinic.
He had called in this past ___ stating that he is back on his
coumadin and fell forward the day prior and developed a large
lump in his back that feels hot. He represents today with blood
draining from his wound and a small opening at his surgical site
with visiable hematoma beneath.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
(Patient denies this as per pre-procedure interview dated
___ but in old notes)
2. CARDIAC HISTORY:
- Paroxysmal atrial fibrillation, on Amiodarone, Coumadin and
Toprol s/p cardioversion x2 (___)
- Coronary Artery Disease
- PERCUTANEOUS CORONARY INTERVENTIONS: Initial stenting done in
___, clean cath in ___, repeat cardiac catheterization in ___ for chest discomfort in the setting of AFib, which
demonstrated mild in-stent restenosis to 30% in the LAD stent.
- PACING/ICD: None
- CABG: None
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Left hernia repair, excision of inclusion cyst from chest wall
(___)
- Ptosis surgery
- Bilateral cataract surgery
Social History:
___
Family History:
Father (___), uncle (___) and grandfather (___) all had MIs at ages
provided. Sister with DM, valve disease and heart failure at age
___.
Otherwise, no family history of arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout.
Sensation: Intact to light touch
Wound: Sizeable hard hematoma palpated beneath the incision and
extending down to the buttock region.
On the day of discharge ___:
alert and oriented to person, place, time, PERRLA, face
symettric
full strength
full sensation
incision and drain site well approximated and closed with
staples
ambulating independently
at upper pole of incision elevated - skin/hard round area-which
is thought to be scar tissue secondary to hematoma and since
prior to surgery
Pertinent Results:
___ 03:13PM ___ PTT-48.1* ___
___ 03:13PM PLT COUNT-236
___ 03:13PM WBC-4.7 RBC-3.25* HGB-10.9* HCT-32.2* MCV-99*
MCH-33.4* MCHC-33.8 RDW-13.0
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 4:03
FINDINGS: In comparison with the study of ___, the patient
has taken a much poorer inspiration. There is some elevation of
the left
hemidiaphragmatic contour. The substantial pleural effusions
and bibasilar atelectasis seen previously is no longer present.
Pulmonary vessels are no longer engorged.
Pathology Report Tissue: LUMBAR HEMATOMA. Procedure Date of
___
Report not finalized.
Assigned Pathologist ___.
Please contact the pathology department, ___
Brief Hospital Course:
Mr. ___ presented to the ED for evaluation and was to have
an opening at the surgical site with blood from an underlying
clot drainig out. He was admitted to the Neurosurgery service
for monitoring and planning of a surgical washout.
On ___ the patient was prepared for the OR.
On ___ he underwent wound wash out. The patient tolerated the
procedure well. He recovered in PACU then was transferred to the
floor. He received perioperative antibiotics. Pain was
controlled.
On ___, the patients hemovac drain was removed and staples were
placed to close the wound. The patient was neurologically
intact and was able to ambulate independedntly. It was
discussed that he would seek follow up as an outpatient with
hematology and that he would not retart his Coumadin. The
patient was tolerating a regular diet , was voiding on his own.
He was looking forward to his discharge home.
Medications on Admission:
amiodorone, aspirin, ativan, coumadin, lasix, lisinopril,
metformin, metoprolol, viagra, prandin
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*1
4. Furosemide 20 mg PO DAILY
5. Lisinopril 20 mg PO HS
6. Lorazepam 2 mg PO HS
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 12.5 mg PO BID
9. Repaglinide 1 mg PO TID:PRN hyperglycemia
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
do not drive while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 hours PRN Disp #*50
Tablet Refills:*0
11. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L2 burst fracture
Discharge Condition:
alert and oriented to person, place, time
full strength
full sensation
incision and drain site well approximated and closed with
staples
ambulating independently
at upper pole of incision elevated - skin/hard round area-which
is thought to be scar tissue secondary to hematoma and since
prior to surgery
Discharge Instructions:
hematoma- wound washout at level of L ___
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
incision on your low back only after staples have been removed.
You may shower before this time if you can cover your incision
and keep it dry during your shower.
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 were on a medication such as Coumadin (Warfarin) prior to
your injury and surgery.Do not take Coumadin until cleared by
your hematologist/cardiologist and Dr ___.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
19613672-DS-18
| 19,613,672 | 28,909,272 |
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| 18 |
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2120-06-26 05:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip dislocation with nonconcentric reduction and
incarcerated intra-articular fragments, right knee traumatic
arthrotomy
Major Surgical or Invasive Procedure:
Right hip and acetabulum ORIF, right knee exploration and I&D
History of Present Illness:
___ female polytrauma status post MVC with right hip
dislocation and posterior wall acetabular fracture, right knee
traumatic arthrotomy, left sided rib fractures.
Past Medical History:
Anxiety
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity:
Thigh and leg compartments soft and compressible
Dressing c/d/I
SILT ___ distributions
Firing ___, 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 right hip dislocation with nonconcentric reduction
associated with a posterior wall acetabular fracture and
incarcerated fragment, right knee traumatic arthrotomy and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for right knee I&D, right
hip and acetabulum ORIF which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing with posterior hip precautions in the
right lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Senna 8.6 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right hip dislocation and posterior wall acetabular fracture,
right knee traumatic arthrotomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing right lower extremity with posterior
hip precautions
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Touchdown weightbearing right lower extremity with posterior hip
precautions
Range of motion as tolerated right knee
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
19613926-DS-23
| 19,613,926 | 29,918,825 |
DS
| 23 |
2187-01-09 00:00:00
|
2187-01-16 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Trazodone / Thioridazine / Risperidone / Oxycodone Hcl
/ Morphine / Gabapentin / Dextroamphetamine / Codeine /
Clindamycin / Chlorpromazine / Bupropion / fentanyl / ketorolac
/ Methadone
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
MRCP
History of Present Illness:
Ms. ___ is a ___ lady with anxiety, chronic pain syndrome,
and psoriatic arthritis who was referred to the ED from the
___ because of the need for pre-medication
for MRCP.
She was admitted ___ for upper abdominal/RUQ abdominal pain.
Was found to have CBD dilation which was felt by the Medical
team to possibly be incidental but warranted close GI follow-up.
She was seen by GI on ___ and the plan was as follows:
"At this time, recommendation includes MRCP for further
evaluation of the dilated CBD. At this time, no clear evidence
of cholangitis. MRCP is not a sensitive for detecting
malignancies. Narcotics can also increase the size of the CBD
and age, but the patient is ___ years old and the patient has
been on chronic narcotics for some time and previous ___
ultrasound demonstrated ___ile duct. Choledochoceles
are also possible. At this time, pending MRI results, further
discussion of treatment will ensue."
She presented for the MRCP today but due to her long list of
allergies (including iodine allergy) she was referred to the ED
for Prednisone/Benadryl premedication.
In the ED, initial VS were: 8 97.9 107 119/77 16 99%RA. CBC,
CHEM7, and LFTs were checked and were stable from 3 days prior,
normal. She asked for pain medication and was given Dilaudid 1mg
IV x2. The ED radiologist felt that the premedication was not
needed. She is admitted to Medicine in order to plan for the
MRCP. VS prior to transfer were 98 72 18 128/86 99%RA.
On arrival to the floor, she is in tears because she thinks she
has cancer (her mother died of metastatic cancer). Some
abdominal pain. Also some back pain that seems to be worse by
the end of the days.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
chronic pain syndrome ___
psoriatic arthritis on MTX
C/section
Scoliosis
PSYCHIATRIC HISTORY:
Previous diagnosis: Pt was seen in the BI ED on ___ for SI
in the context of her pain meds being tapered. At this time she
was not psychotic. Diagnosis was opioid dependence/withdrawal,
mood
d/o NOS, PTSD and Cluster B traits Psychiatrist:___. ___
Mental ___ by ___ ___, phone: ___
___, N. ___
Admits: ___ to ___ for SI in context of tapering pain meds,
x ___ for safe bed, b/c of home abuse, ___ admit in
___ for "nervous break down" after mother's death from cancer
Long h/o trauma
h/o DBT tx
Denies self-harm/SA but chart reports are conflicting
Med Trials: mood stabilizers, antidepressants, antipsychotics,
benzos, MAOIs
Social History:
Lives in ___ with her Dad.
Divorced.
Has 4 children.
denies ETOH and drugs
Tobacco: 1 pk/day
Per d/c summary ___:
SUBSTANCE ABUSE HISTORY:
denies ETOH and drugs
Tobacco: 1 pk/day
SOCIAL HISTORY:
Pt is currently living with her dad and is not working. She
has
a dog.
From OMR:
B+R in MA by bio parents
Denies having siblings
___ grade education but obtained GED
Pt withdrew from college courses recently ___ pain (hoping to
obtain medical assistance license)
h/o severe trauma by ex-husband
___
4 children (2 sons and 2 daughters) - 2 children are grown. 1
child in custody of ex-husband and the other in foster care -
major sources of stress for pt
Pt lives alone
No social supports
1 dog at home
Family History:
Mother died of metastatic cancer including the GI tract.
Family h/o CAD, HTN, DM2.
Physical Exam:
Admission exam:
GENERAL: Well-developed, nourished, anxious appearing female,
with pressured and rapid speech.
HEENT: Normocephalic; atraumatic; sclerae are anicteric;
negative conjunctival erythema.
COR: S1, S2, regular rate and rhythm, negative murmurs, rubs or
gallops.
LUNGS: CTAB
ABDOMEN: Soft, obese without mass; mild tenderness to deep
palpation of upper epigastric area with no rebound or guarding;
she winces but is easily distracted during the exam.
PV: Skin is warm and dry without peripheral edema.
SKIN: No notable rashes other than psoriatic plaques/scaling
noted on extremities, abdomen, and back
MSK/NEURO: A cursory exam of the LS spine shows limited and
tender range of motion of the L spine, most notably with flexion
and extension, with right and left lateral rotation, and with
right lateral flexion. Normal gait.
Exam on discharge essentially unchanged
Pertinent Results:
Admission Labs:
___ 09:45PM BLOOD WBC-7.6 RBC-3.99* Hgb-12.9 Hct-37.3
MCV-94 MCH-32.3* MCHC-34.6 RDW-13.8 Plt ___
___ 09:45PM BLOOD Neuts-63.3 ___ Monos-4.3 Eos-0.9
Baso-0.3
___ 09:45PM BLOOD Glucose-95 UreaN-6 Creat-0.8 Na-139 K-3.8
Cl-104 HCO3-25 AnGap-14
___ 09:45PM BLOOD ALT-20 AST-21 AlkPhos-68 TotBili-0.7
___ 09:45PM BLOOD Albumin-4.1
Discharge Labs:
Urine:
___ 09:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:40PM URINE UCG-NEGATIVE
Urine culture - PENDING
Brief Hospital Course:
Ms. ___ is a ___ lady with anxiety, chronic pain syndrome,
and psoriatic arthritis who has CBD dilatation and was referred
for outpatient MRCP but is admitted due to continued abdominal
pain and concern for iodine allergy.
Active issues:
# Abdominal pain/CBD dilatation: unclear etiology. Exam was not
particularly concerning, and neither were labs. Imaging,
however, showed CBD dilatation that should be further evaluated.
MRCP was attempted as an outpatient but she was referred to the
ED for concern for iodine allergy. Despite no reported
cross-reactivity between iodine and gadolinium, it was decided
after significant discussion with inpt and outpt care team that
pt would be predmedicated with Prednisone and Benadryl prior to
MRCP. Pt received MRCP.
Chronic issues:
#. Constipation: chronic. Continued Colace, Senna, Docusate,
Miralax
#. Psoriatic arthritis: stable. continued MTX weekly
Transitional issues:
# Abdominal pain - will need to follow up her MRCP results to
see if they suggest a cause
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN wheezing/shortness
of breath
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Clonazepam 1 mg PO TID
5. DiphenhydrAMINE 25 mg PO DAILY:PRN itching/allergies
6. Divalproex (DELayed Release) 250 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate 110mcg 1 PUFF IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Methotrexate 20 mg PO 1X/WEEK (FR)
11. Omeprazole 20 mg PO DAILY
12. Oxycodone SR (OxyconTIN) 80 mg PO Q12H
13. Senna 1 TAB PO BID:PRN constipation
14. ProAir HFA *NF* (albuterol sulfate) ___ puffs Inhalation
every 6 hours as needed for wheezing/shortness of breath
15. CLOBEX *NF* (clobetasol) 0.05 % Topical daily
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN wheezing/shortness
of breath
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Clonazepam 1 mg PO TID
5. DiphenhydrAMINE 25 mg PO DAILY:PRN itching/allergies
6. Divalproex (DELayed Release) 250 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate 110mcg 1 PUFF IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Methotrexate 20 mg PO 1X/WEEK (FR)
11. Omeprazole 20 mg PO DAILY
12. Oxycodone SR (OxyconTIN) 80 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID:PRN constipation
15. CLOBEX *NF* (clobetasol) 0.05 % Topical daily
16. ProAir HFA *NF* (albuterol sulfate) 1 INH INHALATION EVERY 6
HOURS AS NEEDED for wheezing/shortness of breath
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic abdominal pain
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your time here at ___.
You were admitted with abdominal pain and back pain. An MRCP,
which is an MRI guided procedure to look at your bile ducts and
pancreas, was performed. It showed a stable and benign
dilatation of your common bile duct. We discussed the case
___ with your outpatient gastroenterology team. They feel
that your ongoing abdominal pain and bile duct dilation is not
dangerous at this time and that it should be worked up as an
outpatient. You have appointments with Gastroenterology and with
your PCP within the next week. They will continue caring for you
as an outpatient.
No new medications were started during this stay. Please take
your medicines as instructed from your previous discharge.
Followup Instructions:
___
|
19614400-DS-10
| 19,614,400 | 25,341,152 |
DS
| 10 |
2153-04-09 00:00:00
|
2153-04-10 16:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP w/ sphincterotomy and stone extraction
History of Present Illness:
___ yo F presented for elective uterine biopsy with 3 day
epigastric/RUQ abdominal pain, acute onset, non-radiating,
associated with nausea, vomiting, diaphoresis, worse with
eating, better with hot water and spoon of olive oil. Pain was
"severe" at ___ at times. After her biospy procedure she
informed her PCP who sent her to the ER, where labs and RUQ US
was suggestive of cholodocholithiasis with biliary obstruction
without cholecystitis. After 1 dose of IV Ciprofloxacin, she
was referred for urgent ERCP, which confirmed
choldocholithiasis. She underwent sphincterotomy and CBD stone
extraction. There is still a small stone in the cystic duct. I
discussed the results of ERCP study with ERCP attending (Dr.
___ and evaluated patient in ERCP PACU suite. She
currently c/o ___ epigastric pain (improved from earlier), and
abdominal distention without nausea.
ROS: Other 13 detail ROS is negative in full including absence
of SOB, DOE, chest pain, fever or dysuria.
Past Medical History:
- Asthma
- GERD
- Obesity
- Sinus bradycardia (HR 55)
- (+) PPD ___ s/p 9 mo INH
- Non-ischemia ETT, EF 60%, +1MR
- Stress urinary incontinence with urethral hypermobility.
- Anterior wall prolapse.
- Posterior enterocele.
- Rectocele.
SURGERIES:
- ___: SPARC (urethral sling)
- ___: R lumpectomy for Right breast biopsy atypical ductal
hyperplasia )
- ___: Monarc suburethral sling, Anterior colporrhaphy,
Posterior enterocele repair with Veritas graft in the posterior
compartment, Rectocele repair
Social History:
___
Family History:
No FHx GI ___ malignancy.
Physical Exam:
In NAD
Afebrile 153/84, HR 49, RR 18, SpO2 100%
Anicteric, OP clear w/o lesions or petechiae, neck supple
No ___ about head/neck/axillae
LUNGS - CTA bilat w/o wheezes
COR - RRR, no audible MRG, nl PMI
ABD - mildly distended, (+) bs, mild epigastric tenderness, no
masses, no HSM
EXT - no C/C/E
SKIN - no rashes / lesions
NEURO - non-focal, A&O x 3, fluent speech, moving all 4s
PSYCH - calm, pleasant
Pertinent Results:
___ 11:30AM WBC-4.5 RBC-4.01* HGB-12.1 HCT-37.4 MCV-93
MCH-30.3 MCHC-32.4 RDW-13.3
___ 11:30AM NEUTS-54.8 ___ MONOS-4.7 EOS-4.5*
BASOS-0.8
___ 11:30AM PLT COUNT-216
___ 11:30AM ALBUMIN-4.3
___ 11:30AM LIPASE-37
___ 11:30AM ALT(SGPT)-772* AST(SGOT)-544* ALK PHOS-209*
TOT BILI-1.2
___ 11:30AM GLUCOSE-126* UREA N-8 CREAT-0.8 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
___ 01:38PM ___ PTT-32.4 ___
___ 02:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:00PM URINE UCG-NEGATIVE
___ 02:00PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ RUQ US: 1. Cholelithiasis without findings suggestive
of cholecystitis. 2. Possible filling defect in the common duct
concerning for choledocholithiasis. Correlation with liver
function tests is suggested; evaluation with MRCP may be helpful
to confirm or refute the possibility of a ductal stone.
___ ECC, EMB, CERVICAL LESION -- pending
___ ERCP: Normal major papilla. Cannulation of the biliary
duct was successful and deep with a sphincterotome using a
free-hand technique.
Contrast medium was injected resulting in complete
opacification. A mild diffuse dilation was seen at the biliary
tree with the CBD measuring 9 mm. A single 8 mm stone that was
causing partial obstruction was seen at the biliary tree **NOTE
TO SURGERY: A 6 mm stone was also noted in the cystic duct.
Given finding of bile duct stone, a sphincterotomy was performed
in the 12 o'clock position using a sphincterotome over an
existing guidewire. Given the size of the stone sphincteroplasty
was performed to 10mm. Stone, sludge was extracted successfully
using a balloon. Final cholangiogram did not show any residual
stones.
Brief Hospital Course:
The patient was admitted to the acute care service with right
upper quadrant and epigastric pain. Upon admission, she was made
NPO, given intravenous fluids, and underwent ultrasound imaging
which showed cholelithiasis and a possible filling defect in the
common duct concerning for choledocholithiasis. No evidence of
cholecystitis. Her liver enzymes were elevated upon admission.
Because of these findings, she underwent an ERCP where she was
reported to have a stone causing biliary obstruction and for
this reason she underwent a sphincterotomy and spincteroplasty.
After a decrease in the liver enzymes, she was taken to the
operating room for a laparoscopic cholecystectomy.
The operative course was stable with minimal blood loss. She
was extubated after the procedure and monitored in the recovery
room. Her post-operative course has been stable. Her surgical
pain was controlled with intravenous analgesia with conversion
to an oral agent. Her vital signs have been stable and she has
been afebrile. The white blood cell count has normalized. She
is preparing for dishcharge home with follow up in the acute
care clinic.
.
# Communication - ___ PCP (___) emailed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezy
2. Multivitamins 1 TAB PO DAILY
Patient used to be on ASA 81mg daily, but discontinued this some
time ago because couldn't remember to take it.
Discharge Medications:
1. Albuterol ___ PUFF IH Q6H:PRN Bronchospasm
2. Senna 1 TAB PO BID:PRN Constipation
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have gallstones and swelling of the gallbladder. You
were taken for a special test where the gallstone and sludge
were removed. Once your liver enzymes stablilized, you were
takne to the operating room for removal of your gallbladder.
You are recovering from you surgery and you are preparing for
discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
19614718-DS-3
| 19,614,718 | 26,874,236 |
DS
| 3 |
2144-12-15 00:00:00
|
2144-12-18 08:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / propofol
Attending: ___
Chief Complaint:
Fever and pain around the chest tube
Major Surgical or Invasive Procedure:
Chest tube removal ___
History of Present Illness:
___ M with history of paroxysmal Afib on rivaroxaban and severe
bullous emphysema (on home O2 4L at rest, 10L on movement, s/p
bilateral bullectomy in ___ with recent admission in ___ for PE and PNA c/b bleb rupture and spontaneous
hydropneumothorax s/p chest tube placement and persistent air
leak despite placement of 3 RUL EBVs and 2x blood patch
pleurodesis, ultimately discharged to home with a pneumostat in
place.
Patient was recovering at home since discharge ___ until
yesterday morning, when he started having sharp R-sided lower
chest pain around the area of insertion of the chest tube. He
also reports pain in the mid-chest slightly superior to the
epigastrium. The pain worsened with cough and deep breaths, and
was slightly alleviated by home PO dilaudid. He also noted that
the drainage from the chest tube turned dark yellow and looked
"dirtier" than prior. Last night, he felt fatigued and SOB, and
noted a fever of ___. Due to these concerns, he reported to
___ ED for further evaluation. There his O2 sat was 88% on
10L but improved to 99% at rest. He received
Piperacillin-Tazobactam and was transferred to ___.
In the ___ ED, initial vitals were T 99.1, HR 88, BP 138/72,
RR
26, O2 98% on NC. Pain ___. Pleural fluid was sent for
analysis. He received pain medication and nebulizer, with
improvement of his symptoms.
On the floor, he feels better but reports persistent chest pain
that is worst when coughing.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Pulmonary embolism, ___
Pneumonia ___
COPD (bullous emphysema) s/p bilateral bullectomy ___ and
ruptured emphysematous bleb ___
Paroxysmal atrial fibrillation on rivaroxaban
Obesity
Obstructive sleep apnea s/p UPPP in ___, minimal OSA per ___
study
Ischemic Colitis
Hiatal Hernia
Reflux esophagitis
HTN
Depression
HLD
Past Surgical History:
___ 3x endobronchial valve to right-upper lung
___ blood patch pleurodesis
___ blood patch pleurodesis
___ pleuravac conversion
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Exam ___:
Vital Signs: T 98.0, BP 160/84, HR 108, RR 22, O2 96% RA
General: Alert, oriented, no acute distress but intermittently
uncomfortable and grimacing from pain
HEENT: Sclerae anicteric, MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse crackles over the RLL. Intermittent coarse lung
sounds over left mid-lung field. Decreased breath sounds at the
bases bilaterally. Atrium with persistent air leak, recently
emptied.
Abdomen: Soft, non-tender, non-distended, hypoactive bowel
sounds, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm and well perfused. No cyanosis, 1+ posterior tibialis
pulses bilaterally, no edema, clubbing of the fingers and toes
Neuro: Face grossly symmetric. Moving all extremities
spontaneously against gravity.
Discharge Exam ___:
Vital Signs: Tmax 99.0, Tcurrent 97.8, BP 126-148/63-78, HR
81-94, RR 18, O2 91-96% on 3L NC
I/O = 1700/1260 mL
General: Alert, oriented, appears more comfortable than previous
day, using accessory muscles with breathing. No acute distress.
HEENT: Sclerae anicteric, MMM, no LAD, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Inspiratory and expiratory coarse crackles over the RLL.
Dullness to percussion over RLL. No wheezing or rhonchi.
Abdomen: Soft, non-tender, non-distended, hypoactive bowel
sounds, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, no cyanosis or edema, 1+ posterior tibial pulse
bilaterally, clubbing of the fingers and toes
Neuro: Face grossly symmetric. Moving all extremities
spontaneously against gravity.
Pertinent Results:
======================
ADMISSION LABS
======================
___ BLOOD CULTURE Blood Culture, Routine-FINAL.
NO GROWTH.
___ 02:10AM BLOOD WBC-9.2# RBC-3.71* Hgb-9.6* Hct-30.5*
MCV-82 MCH-25.9* MCHC-31.5* RDW-17.2* RDWSD-51.3* Plt ___
___ 02:10AM BLOOD Neuts-74.5* Lymphs-11.6* Monos-9.1
Eos-3.5 Baso-0.3 Im ___ AbsNeut-6.84* AbsLymp-1.06*
AbsMono-0.83* AbsEos-0.32 AbsBaso-0.03
___ 02:10AM BLOOD Plt ___
___ 08:50AM BLOOD Plt ___
___ 02:10AM BLOOD Glucose-123* UreaN-11 Creat-0.6 Na-129*
K-3.8 Cl-93* HCO3-23 AnGap-17
___ 08:50AM BLOOD Calcium-9.1 Phos-3.9
___ 05:40AM BLOOD CRP-> 300
======================
DISCHARGE LABS
======================
___ 04:47AM BLOOD WBC-8.3 RBC-3.19* Hgb-8.2* Hct-26.3*
MCV-82 MCH-25.7* MCHC-31.2* RDW-16.7* RDWSD-50.3* Plt ___
___ 04:47AM BLOOD Plt ___
___ 04:47AM BLOOD ___ PTT-35.2 ___
___ 04:47AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-135
K-3.6 Cl-96 HCO3-27 AnGap-16
___ 04:47AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
=======================
IMAGING
=======================
CXR ___:
Compared to chest radiographs since ___ most recently
___ read
in conjunction with chest CT on ___.
The relatively small fluid component of the moderate loculated
right
hydropneumothorax is slightly smaller today. Multi loculated
left
hydropneumothorax occupying most of the left upper hemithorax is
stable.
Heart size normal.
CXR ___:
Compared to chest radiographs ___ through one ___.
Fluid component in the multiloculated right hydropneumothorax
has increased
slightly since ___ following removal of the right pleural
drainage
catheter. Large loculated left hydropneumothorax in the upper
chest is also
unchanged. Heart size normal. Emphysema is severe.
CXR ___:
Interval removal of the right chest tube. Otherwise no
significant interval
change since the prior radiograph.
CXR ___: Moderate loculated right pleural effusion is
stable to minimally decreased.
Right-sided pleural catheter is in overall unchanged position
and may be
within a loculated pleural fluid collection.
Multiloculated, left-sided hydropneumothorax is stable.
Severe, bullous emphysema without new large pneumothorax.
CT Chest ___: 1. Significant interval decreased size of a
right basilar pneumothorax, with
improvement of left-sided mediastinal shift.
2. New loculated right pleural fluid containing gas bubbles, for
which
superinfection is suspected given the provided clinical history.
3. A multiloculated left-sided hydropneumothorax demonstrates
similar
appearance compared to previous.
4. Extensive upper lobe predominant emphysematous changes with
multiple
bullae, not significantly changed compared to previous.
=======================
MICROBIOLOGY
=======================
___ 4:45 am PLEURAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by ___, 10:20 AM
___.
FLUID CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
UNASYN (AMPICILLIN/SULBACTAM) sensitivity testing
performed by
___.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. THIRD
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA OXYTOCA
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN/SULBACTAM-- S
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- 2 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM------------- 1 S <=0.25 S 1 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
SUMMARY: ___ h/o severe COPD (on home O2 4L at rest, s/p
bilateral bullectomy), paroxysmal Afib on rivaroxaban, sp recent
admission for bleb rupture and spontaneous hydropneumothorax s/p
chest tube placement and persistent air leak despite placement
of 3 RUL EBVs and 2x blood patch pleurodesis. He presented with
fever and pain near chest tube entry site. CT showed a new
loculated R pleural effusion thought to be an empyema. ID and IP
were consulted; he was managed with antibiotics for a planned
4-week course of cefepime. Risks of complete drainage were felt
to outweigh the benefits at this time. During the admission, IP
evaluated the chest tube and found no air leak, and the chest
tube was discontinued on ___. Patient remained stable and at his
baseline level of O2 so he was discharged with plan to follow up
with the ___ lung transplant program as outpatient.
# Empyema:
Patient presented with fevers to ___, dyspnea, pain around site
of chest tube insertion, and purulent and bloody pleural
drainage which grew Pseudomonas Aeruginosa of three different
morphologies, and Klebsiella Oxytoca, all found to be sensitive
to Cefepime. He was started on a 4-week course of Cefepime 2g IV
TID. Interventional Pulmonology were consulted and recommended
not draining the new effusion as the risks of thoracocentesis
outweigh the benefits.
# Pneumothorax: Patient had a pneumothorax and presented with
chest tube in place. Our interventional pulmonology team
followed his chest tube closely. On ___ there was no air leak
seen in the chest tube and it was clamped. On ___ the chest tube
spontaneously dislodged on ___. Patient remained hemodynamically
stable and CXR did not reveal new or enlarged pneumothorax, with
improved O2 compared to baseline. Oxygen requirement also
improved and on discharge O2 saturation was 92 on 2L NC at rest
and 93 on 8L NC on ambulation.
# Anemia: Normocytic anemia observed on current and last
hospitalization, likely consistent with AOCD. Patient remained
hemodynamically stable. Will continue to monitor as outpatient
# Hyponatremia: Patient presented with asymptomatic
hyponatremia. Na levels were monitored and uptrended throughout
hospital stay and stabilized within normal limits. Etiology
could be SIADH in the setting of pulmonary illness versus low
solute intake in diet given low appetite recently.
CHRONIC ISSUES:
# Severe COPD: Patient on 4L O2 at rest and 10L oximizer with
ambulation. Will be evaluated for lung transplant at ___ on
___. Continued home medications (with adjustments to
formulary equivalents) as below:
-Albuterol 0.083% Neb Q2H:PRN SOB
-Tiotropium Bromide 1 CAP IH QD
-Umeclidinium 62.5mcg INH QD
-Ipratropium Bromide Neb Q6H
-Fluticasone-Salmeterol (500/50) 1 INH BID
-Roflumilast 500mcg PO QD
-Prednisone 10mg PO QD
# Paroxysmal Atrial Fibrillation: Continued loading dose of
rivaroxaban 15mg PO BID, to be transitioned to rivaroxaban 20mg
daily.
# GERD: Continued home omeprazole
# Depression: Continued home bupropion and escitalopram
TRANSITIONAL ISSUES:
- Patient to complete course of IV cefepime via midline (last
day ___
- Will follow up in ___ clinic with Dr. ___
- ___ check weekly CBC, BUN, Cr and fax results to ID
department at ___ (___)
- Patient to continue loading dose of rivaroxaban 15mg BID until
___, at which point he will transition to 20mg daily
- Outpatient f/u with ___ lung transplant program scheduled for
___
- titrate home O2 to 88-92%
- Pain control with acetaminophen, lidocaine patch, and PO
dilaudid
- Chest tube removed inpatient. Recommend repeat CXR at ___
follow up appointment for assessment of accumulation of the
pleural effusion
- Please continue to evaluate anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. PredniSONE 10 mg PO DAILY
4. Rivaroxaban 15 mg PO BID
5. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
6. Daliresp (roflumilast) 500 mcg oral DAILY
7. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
8. Omeprazole 40 mg PO BID
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
10. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 2 gm IV every eight (8) hours
Disp #*84 Vial Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % 1 PTCH QPM Disp #*30 Patch Refills:*0
3. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Daliresp (roflumilast) 500 mcg oral DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Moderate
8. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
9. Omeprazole 40 mg PO BID
10. PredniSONE 10 mg PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
12. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*18 Tablet Refills:*0
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13.Outpatient Lab Work
RESULTS FAX TO ATTN: ___ CLINIC - FAX: ___
PLEASE PERFORM WEEKLY: CBC with differential, BUN, Cr
ICD-9: 510.9 Empyema without fistula
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
COPD
Empyema
Atrial fibrillation
SECONDARY DIAGNOSIS:
Hypertension
OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to ___ due to fever and pain around your
chest tube. This was thought to be due to infected fluid inside
your lung. We treated you with antibiotics. Your chest tube was
found to have no air leak and it was taken out.
PLEASE TAKE NOTE OF THE FOLLOWING:
- You will need to continue antibiotics until ___.
You will work with the home infusion company to receive your
treatments
- You will need to follow up with the ___ Lung Transplant
program on the morning of ___. They will call you with
the exact appointment time.
- Please take your xarelto as prescribed. On ___ you
will need to change the dose to 20mg daily.
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
19614931-DS-16
| 19,614,931 | 26,324,238 |
DS
| 16 |
2187-05-01 00:00:00
|
2187-05-01 20:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
trimethoprim / Sulfa (Sulfonamide Antibiotics) / amoxicillin
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year-old man
with a history of alcohol use disorder, who presents as a
transfer from ___ with jaundice.
Patient reports that jaundice has been progressive over the last
several months. Symptoms acutely worsened over last 2 weeks.
Referred to ___, where he was found to have tbili 46,
direct bili 38, lipase 800-900, Na 128,INR 2.2, creat 1.8.
Transferred to ___ for further evaluation. Patient reports no
pain. He has been drinking heavily, 3 L per week. Reports last
drink yesterday. Reports history of alcohol withdrawal in the
past, usually after 3 days, signaled by worsening tremors.
Patient does not feel that he is currently withdrawing. Denies
hallucinosis, seizure. No medication. Lives at home with his
father. ___ fevers, chills, nausea, vomiting, chest pain,
shortness of breath, abdominal pain, change in bowel or bladder
function, calf swelling or edema, new lesion or lymphadenopathy
In the ED initial vitals: T 98.1, HR 106, BP 119/83, RR 18, O2
sat 99% RA
- Exam notable for: Patient tachycardic. Grossly icteric and
jaundiced. Mildly tremulous. No asterixis. Reduced breath sounds
bilaterally. Abdomen mildly distended, stretch marks visible. No
calf swelling or edema.
- Labs notable for:
-INR 2.2
-CBC: WBC 13.8, Hgb 12.3 Plt 158
-LFTs: ALT 31, AST 89, AP 187 Tbili 47.2, Dbili 35, Alb 3.3
-Chemistry: Na 133, BUN 15, Sr Cr 1.6
-Lactate: 1.3
-UA: Notable for 11RBC, 18WBC bacteria, small leuks
-Utox: Negative
- Imaging notable for: CT abdomen ___ at ___
consistent with cirrhosis and portal hypertension. Atelectasis
with and without superimposed developing infiltrate in the right
lower lobe. 0.9 cm hypodense lesion in the dome of the liver,
not
characterized on this examination indeterminate. While this may
represent a cyst, this can be further evaluated with nonemergent
MRI of the abdomen with and without contrast, given the higher
risk of malignancy in this patient given the suggested
cirrhosis.
Acute right-sided colitis versus under distention. Some
limitation of the absence of oral contrast.
CXR ___: minimal elevation of the right hemidiaphragm and
minimal associated right basilar atelectasis. No discrete lobar
consolidation, congestive heart failure or pleural effusion.
RUQ US ___: 1. Patent portal venous vasculature, however
with
slow flow demonstrated in the main portal vein and reversal of
flow within the anterior and posterior branches of the right
portal vein.
2. Coarsened liver without evidence of concerning focal lesions.
3. Moderate splenomegaly, measuring up to 18.9 cm.
4. Mildly distended common bile duct measuring up to 9 mm and
tapering
distally. Recommend further evaluation with MRCP on a
nonemergent
basis.
- Consults: Hepatology-
- chest x ray, US abd and diagnostic para, urine blood culture.
- IV albumin
- admit to Farr10
- Patient was given: T 99.2 HR 107, BP 119/81, RR 16, O2 sat 95%
RA
- ED Course:
IV Albumin 25% (12.5g / 50mL) 25 g
PO/NG LORazepam 2 mg
On the floor, the patient confirmed the above history. He states
that his jaundice has progressed over the past several months.
Of
note, the patient has a history of DTs in the past. No history
of
withdrawal seizures or intubations. Does not report fevers,
chills, chest pain, shortness of breath, nausea, vomiting,
abdominal pain, and changes in bowel or bladder habits.
Past Medical History:
Alcohol use disorder
Depression
Social History:
___
Family History:
Mother with bipolar disorder. Both mother and
father with alcohol use disorder.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: 99.6 PO 133 / 88 118 18 95 RA
GENERAL: NAD, pleasant, comfortable
HEENT: AT/NC, EOMI, PERRL, icteric sclerae, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: tachycardic, regular rhythm, nl S1/S2, no murmurs,
gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: diffusely jaundiced
DISCHARGE PHYSICAL EXAMINATION:
==============================
24 HR Data
Temp: 99.1 (Tm 99.2), BP: 126/79 (110-153/71-82), HR: 103
(94-109), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery:
RA,
Wt: 180.4 lb/81.83 kg
GENERAL: sitting in bed, NAD, alert and responding to questions.
Jaundiced
HEENT: EOMI, PERRL, icteric sclerae, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, nl S1/S2, systolic flow murmur+. No gallops, or rubs
LUNGS: CTAB, breathing comfortably
ABDOMEN: distended, mildly tender in RUQ and RLQ, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. Mild
tremors
in hands
SKIN: diffusely jaundiced. Para site with recent dressing that
was clean and dry
Pertinent Results:
ADMISSION LABS:
=======================
___ 08:15PM BLOOD Neuts-86.4* Lymphs-2.6* Monos-8.1 Eos-1.5
Baso-0.5 Im ___ AbsNeut-11.88* AbsLymp-0.36* AbsMono-1.11*
AbsEos-0.21 AbsBaso-0.07
___ 08:15PM BLOOD ___ PTT-42.0* ___
___ 08:15PM BLOOD Glucose-105* UreaN-15 Creat-1.6* Na-133*
K-3.6 Cl-93* HCO3-21* AnGap-19*
___ 08:15PM BLOOD ALT-31 AST-89* AlkPhos-187* TotBili-47.2*
DirBili-35.0* IndBili-12.2
___ 08:15PM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.0* Mg-1.8
___ 07:15AM BLOOD Triglyc-286* HDL-LESS THAN
___ 08:15PM BLOOD Osmolal-277
___ 01:05PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
EtGlycl-LESS THAN Tricycl-NEG
___ 01:05PM BLOOD HCV Ab-NEG
___ 08:26PM BLOOD Lactate-1.3
___ 10:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-LG* Urobiln-2* pH-7.5 Leuks-SM*
___ 10:00PM URINE RBC-11* WBC-18* Bacteri-FEW* Yeast-RARE*
Epi-0
___ 10:00PM URINE Hours-RANDOM UreaN-285 Creat-90 Na-32
___ 10:00PM URINE Osmolal-330
___ 10:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICRO:
====================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES:
=======================
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
10:07 ___
1. Coarsened liver echotexture concerning for cirrhosis without
evidence of
worrisome focal lesions.
2. Patent portal venous vasculature, however with slow flow
demonstrated in
the main portal vein.
3. Findings indicative of portal hypertension including
splenomegaly and
hepatofugal flow in the main portal and anterior and posterior
branches of the
right portal vein.
4. Mildly dilated common bile duct measuring up to 9 mm without
intrahepatic
biliary dilatation. Recommend further evaluation with MRCP if
there is
concern for biliary obstruction.
MRCP (MR ABD ___ Study Date of ___ 5:21 ___
Findings most consistent with acute on chronic hepatic injury
including portal
hypertension. No evidence for biliary obstruction or filling
defects.
Increased retroperitoneal fluid; query coinciding acute
pancreatitis.
___ EGD (___)
Grade II v arices at distal esophagus
Congestion, petechiae and mosaic pattern in the stomach fundus
and stomach body compatible with portal hypertensive gastrophaty
Normal muscoase in duodenum
NJ tube was placed passed the third portion of the duodenum
___ US ABD LIMIT, SINGLE OR
Minimal ascites, most notable in the right lower quadrant.
___ ABD & PELVIS W/O CON
1. No evidence of acute intra-abdominal process within the
confines of a noncontrast study. Specifically, no bowel
obstruction, ileus, or gross perforation.
2. Cirrhotic liver with small to moderate ascites, moderate to
severe splenomegaly, paraumbilical vein recanalization, and
intra-abdominal varices.
DISCHARGE LABS:
========================
___ 04:30AM BLOOD WBC-36.8* RBC-3.07* Hgb-9.9* Hct-28.0*
MCV-91 MCH-32.2* MCHC-35.4 RDW-28.5* RDWSD-94.1* Plt ___
___ 04:30AM BLOOD ___ PTT-38.2* ___
___ 04:30AM BLOOD Glucose-113* UreaN-57* Creat-1.6* Na-136
K-3.6 Cl-101 HCO3-15* AnGap-20*
___ 04:30AM BLOOD ALT-67* AST-79* LD(LDH)-292* AlkPhos-204*
TotBili-43.6*
___ 04:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.6 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of alcohol use
disorder, who presents as a transfer from ___ with
jaundice. Overall picture most concerning for severe alcoholic
hepatitis, complicated by SBP and found to be steroid non
responder.
ACTIVE ISSUES:
===============
#GOC
Given poor response to steroids and patient was not a transplant
candidate (due to refractory depression, poor psychosocial
dynamics), palliative care was consulted. Patient has been
incongruent in past with medical wishes - wanting to stop all
medical management but then wanting ABx when SBP was identified.
He was put on Ativan 4mg TID PRN and oxycodone 5 mg Q8 PRN for
symptom relief. Patient wished to stop all other medical
management and be discharged. Family meeting on ___ with
Palliative care following which ultimately in the setting of his
poor prognosis and desire to return, plan to discharge patient
home with hospice. He is able to follow up in the Liver Clinic
if he chooses to. He was discharge with short course of
lorazepam and oxycodone for symptom management in the interim to
establishing with hospice.
# Alcoholic cirrhosis
# Alcoholic Hepatitis
Patient presented severely jaundiced with severe alcoholic
hepatitis iso of underlying cirrhosis with overall poor
prognosis. ___ discriminant function of 105 on admission.
He was started on steroids following infectious work-up.
Steroids were stopped on day 10 (___) due to poor response
(Lille score 0.5; bili stayed elevated 44-49, INR ranged
1.7-2.1, MELD remained in mid to upper ___. EGD on ___ showed
grade II varices in distal esophagus. Urosodiol was used to
treat jaundice. He was treated with rifaximin though never
demonstrated hepatic encephalopathy, lactulose was held due to
diarrhea when started on tube feeds. Paracentesis was performed
on ___ (diagnostic, 400cc fluid removed) and ___ (diagnostic
and therapeutic 1.1L removed). No diuretics were given due to
___.
#SBP:
Patient had minimal ascites on admission though often he had
abdominal distension that was attributed to starting tube feeds.
___ guided paracentesis on ___ was concerning for >250PMN. He
was given albumin and completed 5-day course of ceftriaxone 2g
(___). Infectious work-up repeated on ___ was negative.
# Leukocytosis
Patient presented with leukocytosis of 13.8 that continued to
rise, peaking at 51.4 on ___. It was most likely multifactorial
due to alcoholic hepatitis, steroid initiation and SBP (found on
___. Once steroids were stopped, medical management focused on
treating possible underlying infection (Ceftriaxone ___.
Leukocytosis started downtrending following completion of ABx.
On discharge WBC was 36.8. Besides SBP, all infectious work-up
was unremarkable.
# ___
Cr 1.6 on admission poor PO intake as pt has been not
drinking/eating well. Cr stayed elevated 1.4-1.8 during
admission, likely new baseline, though also due to loose stools.
Patient was started on loperamide which initially helped, but
then he stopped on his own decision. IV albumin challenge
without improvement. Bicarb was notable low to 10 on ___,
unclear etiology, though he was started on PO sodium bicarb
which raised serum bicarb to 15.
# Coagulopathy
Likely related to underlying liver disease (combination of
alcoholic hepatitis and likely cirrhosis). No signs of active
bleeding during admission. Vitamin K challenge did not change
INR indicating underlying synthetic dysfunction.
#Diarrhea
Began once TFs, he started having diarrhea which is a known side
effect. Different formulations were attempted with minimal
impact. He was started on loperamide with some initially
improvement, though he then stopped on his own volition. C. diff
testing was negative.
# Alcohol use disorder:
Patient was drinking at least 3L of vodka weekly leading up to
admission. Last drink on ___. Patient scored no higher than
4 during first 3 days and then was asymptomatic, CIWA was then
discontinued. He was supplemented with thiamine, MVI and folate.
#Depression
Per email from outpatient psychiatrist, he had failed depression
medications in the past. Psychiatry assessed him while inpatient
and determined he did not meet ___ criteria. Patient was
not interested in medical management or ECT for depression.
TRANSITIONAL ISSUES:
=====================
[ ] Patient discharged home with ___ services and plan for
hospice.
[ ] Liver clinic follow up scheduled for ___ with Dr.
___ patient would like to follow up
[ ] Tube feeding discontinued on discharge given patient
preference.
[ ] Patient prescribed short course of Lorazepam 0.25mg BID and
Oxycodone 5mg Q8H PRN for abdominal pain.
Medications on Admission:
None
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. HydrOXYzine ___ mg PO Q4H:PRN Itching
RX *hydroxyzine HCl 25 mg ___ tablets by mouth every four (4)
hours Disp #*120 Tablet Refills:*0
3. LORazepam 0.25 mg PO BID insomnia
RX *lorazepam 0.5 mg 1 by mouth twice a day Disp #*6 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp
#*10 Tablet Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice daily
Disp #*120 Tablet Refills:*0
8. 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
9. TraZODone 50 mg PO QHS
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. Ursodiol 600 mg PO BID
RX *ursodiol 300 mg 2 capsule(s) by mouth twice a day Disp #*120
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Alcohol Hepatitis
Alcohol Cirrhosis complicated by:
-Ascites
-Coagulopathy
SECONDARY DIAGNOSIS:
=====================
#Spontaneous Bacterial Peritonitis
#Acute Kidney Injury
#Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to the hospital because acute on chronic
liver failure
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We did two paracenteses, on of which found an infection in
your abdomen, this is known as spontaneous bacterial peritonitis
- We had palliative care speak with you and help optimize your
medications to treat your symptoms
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Please follow up with your ___ services. You will also be
seen by the hospice team at your home
- We set up appointments with your primary care physician and
the liver team.
Thank you for involving us in your care.
-Your ___ Care Team
Followup Instructions:
___
|
19614937-DS-10
| 19,614,937 | 21,300,807 |
DS
| 10 |
2159-06-07 00:00:00
|
2159-06-09 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ is a ___ year old woman with malignant esophageal
tumor
of G-E junction, on ___ and concurrent radiation, along
with COPD and s/p LLL resection for prior lung cancer, who is
admitted with dyspnea.
Patient was admitted ___/ - ___ with malaise and
abdominal
pain. Treated with tlenol, Maalox, and omeprazole. She was seen
in ___ clinic on ___ with plan for her weekly ___.
She received 2L NS on arrival. However, she appeared unwell with
increasing respiratory distress/pursed lips/tripoding, so
chemotherapy was held. She was given albuterol nebulizer x2,
20mg
IV Lasix, and 60mg IV methylprednisolone and transferred to the
ED.
In the ED, initial VS were pain 0, T 97.9, HR 88, BP 149/68, RR
18, O2 98% RA. VS recheck 30 minutes later noted RR 32 and 100%
'nasal cannula'. Initial labs were notable for WBC 1.3 (ANC
880),
HCT 27.5, PLT 209, INR 1.1. Na 143, K 3.9, HCO3 18, Cr 0.5, Ca
8.3, Mg 1.5, P 3.4, ALT 13, AST 17, ALP 61, TBili 0.3, Alb 3.5,
lipase 11, lactate 1.2, UA negative (40 ketones). CXR was
performed, read without acute process. ___ given IVF
prior to admission for further management.
On arrival to the floor, patient reports generalized malaise.
Her
greatest complaint is odynophagia with burning in her throat
even
with water. She has mild chronic abdominal pain and intermittent
nausea without emesis that is unchanged. She reports acutely
worsened shortness of breath over the last few days, but denies
frank cough or purulence. No significant wheeze, either. No
fevers or chills. No headache or recent URTI. No CP. No
diarrhea,
last BM two days ago. No lower extremity edema or pain. No new
rashes.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
History of lung cancer s/p left lower lobectomy, COPD, asthma
who
was in her usual state of health until a few months ago when she
developed atypical chest pain and epigastric pain, along with a
40-lb weight loss over the past ___ months. She was admitted for
workup to ___, where cardiac workup was negative. CT of
the abdomen on ___ showed abnormal nodular appearing area
in
the gastric antrum near the duodenal bulb and pyloric channel.
There was a noncalcified 5 mm left lower lung nodule, as well as
hepatic cysts and a heterogeneous uterus, suspicious for a large
uterine fibroid. EGD on ___ showed a partially obstructing,
likely malignant esophageal tumor at the gastroesophageal
junction and in the cardia. The gastric fundus, body, antrum and
duodenum were normal. Biopsy of the GEJ mass confirmed a well to
moderately differentiated adenocarcinoma without intestinal
metaplasia. EUS performed by Dr. ___ on ___ showed a 5
cm fungating mass of malignant appearance which was friable at
the gastroesophageal junction and cardia with partial
obstruction; EUS showed the lesion 5 cm in length and 3.2 cm in
maximum depth with invasion beyond the muscularis propria
compatible with a T3 lesion; there were 2 small lymph nodes in
the periesophageal mediastinum and one in the celiac area
ranging
in size from 3.4 mm to 5.6 mm and felt indeterminate and it was
not possible to biopsy these lymph nodes. PET/CT was scheduled
for ___ but Ms. ___ did not make it for this examination
because of transportation issues.
PET/CT on ___ showed a rounded contour of the left hilum
with SUV of 3.4 compatible with either pulmonary artery or a
hilar lymph node. There was a left lower paraesophageal lymph
node measuring 1.1 cm in short axis with SUV of 4.3. There was a
large lesion at the gastroesophageal junction with SUV of 24.6;
there were no abdominal, pelvic, or bone metastases.
PAST MEDICAL HISTORY:
Lung cancer s/p left lower lobectomy ___ years ago
COPD
Asthma
GERD
DM type 2 - diet controlled
PAST SURGICAL HISTORY:
Left lower lobectomy
Social History:
___
Family History:
Father died of cardiac dz in his ___. Mother died age ___ of
stomach cancer. She had one brother who was a "blue baby," born
with a cardiac defect. She had a brother with schizophrenia who
died of unclear cause, twin brothers that died at birth, a
sister who died of a ruptured brain aneurysm ___ years ago, 2
sisters who are healthy, and a brother who is deaf and
cognitively impaired (mother had
___ while pregnant). She has 3 children all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: Pain 0 T 97.9 HR 88 BP 149/68 RR 18 SAT 98% O2 on RA
GENERAL: Generally upset and frustrated but in NAD.
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress and is speaking
in full sentences, somewhat diminished breathsounds throughout
but no frank wheeze or rhonci
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding;
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM
=========================
VS: T:97.8 BP:158/77 HR:100 RR:18 POx:100% on Room Air
GENERAL: cachectic woman in NAD.
HEENT: Anicteric sclerea, PERLL, MMM, oropharynx clear without
lesions, no signs of thrush
CHEST: no TTP along costochrondral border
CARDS: RRR, S1 + S2 present, no mrg
PULM: CTAB, no rales/rhonchi, breathing comfortably on room air
without the use of accessory muscles.
GI: SNTND, +BS, no rebound/guarding
EXT: WWP, no ___ edema, clubbing, or cyanosis
SKIN: Stage I pressure ulcer on coccyx per nursing; No new
rashes
Access: PICC c/d/I, no drainage or erythema, no tenderness
surrounding site.
Pertinent Results:
ADMISSION LABS
===================
WBC-1.3* RBC-3.19* Hgb-8.0* Hct-27.5* MCV-86 MCH-25.1*
MCHC-29.1* RDW-16.1* RDWSD-45.1 Plt ___
Neuts-67.7 Lymphs-8.5* Monos-19.2* Eos-2.3 Baso-1.5* Im
___ AbsNeut-0.88* AbsLymp-0.11* AbsMono-0.25 AbsEos-0.03*
AbsBaso-0.02
Hypochr-2+* Anisocy-1+* Poiklo-2+* Macrocy-NORMAL Microcy-1+*
Polychr-1+* Ovalocy-2+* Target-OCCASIONAL Schisto-1+*
Burr-OCCASIONAL Stipple-1+* Tear ___
___
___ PTT-21.0* ___
Glucose-108* UreaN-12 Creat-0.5 Na-143 K-3.9 Cl-107 HCO3-18*
AnGap-18*
ALT-13 AST-17 AlkPhos-61 TotBili-0.3
Albumin-3.5 Calcium-8.3* Phos-3.4 Mg-1.5*
PERTINENT LABS
=========================
___: calTIBC-215* VitB12-631 ___ Ferritn-52 TRF-165*
___ 05:14AM BLOOD ALT-11 AST-11 LD(LDH)-180 AlkPhos-58
TotBili-0.2
___ 05:14AM BLOOD Triglyc-63
DISCHARGE LABS
========================
WBC-2.1* RBC-3.07* Hgb-8.4* Hct-27.2* MCV-89 MCH-27.4 MCHC-30.9*
RDW-19.9* RDWSD-62.7* Plt ___
Glucose-131* UreaN-29* Creat-0.3* Na-143 K-5.0 Cl-108 HCO3-22
AnGap-13
Calcium-8.3* Phos-4.0 Mg-2.0
MICROBIOLOGY
=====================
_______________________________________________________
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 12:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
================
___ CHEST PORTABLE PICC IMPRESSION:
The tip of a new right PICC line projects over the mid to distal
SVC. No pneumothorax is identified.
___ (PA & LAT) IMPRESSION:
No acute cardiopulmonary process.
___
IMPRESSION: In comparison with the study of ___, there
again is hyperexpansion of the lungs consistent with chronic
pulmonary disease. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a past medical history of
lung cancer status-post left lower lobe resction, chronic
obstructive pulmonary disease, and malignant esophageal tumor of
the gastro-esophageal junction, on cycle 1 of ___ and
concurrent radiation who was admitted with dyspnea and
persistent odynophagia.
ACUTE ISSUES:
=============
# Odynophagia.
This was most likely secondary to mucositis from chemotherapy
and radiation. esophagitis secondary to candidiasis was
considered, but low clinical suspicion given no evidence of
uncontrolled infection on exam. Her symptoms well controlled
with sucralfate, magic mouthwash, viscous lidocaine, daily
proton-pump inhibitor, and liquid oxycodone. She was given
fluconazole (end date ___, continued until recovery of ANC.
# Anemia
The patient was found to have asymptomatic anemia was likely
secondary to chemoradiation. During this admission pt was
transfused 1 unit of red blood cells. Hgb on discharge 8.4. Of
note, iron studies with TSat of 10%, can consider iron infusions
as an outpatient.
# Dyspnea
Initially there was concern for COPD exacerbation, however; the
patient appeared to be at her baseline on exam. Pneumonitis from
radiaiton and esophagitis was also considered. There was
clinical suspicion for pulmonary embolism, however; the patient
declined CTA and V/Q scan. Ms. ___ dyspnea was
symptomatically managed with duonebs Q6H as needed, albuterol,
and Fluticasone-Salmeterol 250/50 INH twice daily while
inpatient. Her home Spiriva was held during admission. Please
note that patient is known to intermittently refuse
inhalers/nebs, contributing to worsening dyspnea.
# Severe protein calorie malnutrition:
The patient was cachectic on admission, which was likely
secondary to decreased
oral intake in the setting of severe odynophagia. On ___, the
patient received a R PICC line and on ___, total parenteral
nutrition was started with plan to continue for the duration of
her radiation/chemo course, and continue until ___ for
total of 2 months. Enteral feeding options were discussed, but
patient strongly preferred TPN.
# Neutropenia
Most likely secondary to chemoradiaton. Pt remained afebrile and
HD stable. On discharge patient was no longer neutropenic, with
ANC of 1.77.
# GEJ adenocarcinoma:
T3N1M0. Not a good surgical candidate. The patient's outpatient
oncologist was consulted regarding her radiation therapy with
the plan to continue radiation in the setting of held
chemotherapy (___) during admission. Plan for total 28
fractions of radiation therapy for esophageal cancer. Last
treatment is planned for ___.
The patient was continued on Zofran/Compazine/Ativan as needed
for chemoradiation side effect management.
CHRONIC ISSUES:
===============
# Chronic Obstructive Pulmonary Disease:
- Continued treatment with inhalers/advair as above
# Gastro-esophageal Reflux Disease:
- Omeprazole 20 mg QD as above
TRANSITIONAL ISSUES:
=====================
[ ] Continue TPN until ___ for total of 2 months
[ ] Please monitor triglycerides and LFTs weekly while on TPN
[ ] Consider iron transfusions for anemia (TSat of 10%)
[ ] Patient with 2 more fractions of radiation planned, end date
___
[ ] Please continue to encourage use of home inhalers
#Code Status: FULL CODE
#Contact/HCP: ___ ___, ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Gabapentin 300 mg PO TID
5. LORazepam 0.5 mg PO PRIOR TO RADIATION, MAY RPT X1
6. Multivitamins 1 TAB PO DAILY
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn/epigastric pain
11. Omeprazole 20 mg PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation ___ puffs
Q4H:PRN
13. Glucerna (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 shake oral TID
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. Simethicone 40-80 mg PO QID:PRN gas
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Fluconazole 100 mg PO Q24H
18. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN mouth
pain
Discharge Medications:
1. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day Disp
#*1 Bottle Refills:*0
2. LORazepam 0.25 mg PO Q4H:PRN anxiety/nausea
3. OxycoDONE Liquid 2.5-5 mg PO Q8H:PRN Pain - Moderate
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. albuterol sulfate 90 mcg/actuation inhalation ___ puffs
Q4H:PRN
6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal pain
7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn/epigastric pain
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Gabapentin 100 mg PO TID
14. Glucerna (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose
intolerance,soy) 1 shake oral TID
15. Lidocaine Viscous 2% 5 mL PO Q4HR:PRN pain
16. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN mouth
pain
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Ondansetron ODT 8 mg PO Q8H:PRN nausea
20. Prochlorperazine 10 mg PO Q6H:PRN nausea
21. Tiotropium Bromide 1 CAP IH DAILY
22.Non standard TPN ___
Volume (ml/d):1300 Amino Acid (g/d):65 Dextrose (g/d):250 Fat
(g/d):___lements and Standard Adult Multivitamins
NaCL:60 NaAc:0 NaPO4:0 KCl:0 KAc:0 KPO4:5 MgSO4:16 CaGluc:10
Cycle over 12 hrs Start at 1800
Decrease rate to (ml/h) ___ at 0400 Stop at 0600
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
===================
Odynophagia
Anemia
Dyspnea
Severe Protein Calorie Malnutrion
Neutropenia
Gastroesophageal Junction Carcinoma
SECONDARY DIAGNOSIS:
====================
Chronic Obstructive Pulmonary Disease
Gastroesophageal Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you were short of
breath and having pain when you swallowed.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
While you were in the hospital you received nutrition through an
IV (TPN).
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with your Oncologist
3) Take your new medications as directed
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19615022-DS-10
| 19,615,022 | 23,010,510 |
DS
| 10 |
2114-07-06 00:00:00
|
2114-07-06 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain, fevers
Major Surgical or Invasive Procedure:
PICC Line insertion (___)
TEE (___)
History of Present Illness:
Mr. ___ is a ___ year old with a h/o Hepatitis C, IVDU (heroin)
transferred from ___ with fevers, back pain, and positive
blood cultures for gram positive cocci.
Patient began having severe ___ back pain earlier this week,
with reports of subjective fevers and presented to ___
___. He denies trauma. He does not have a history of
epidural abscesses, focal weakness, and an MRI showed "no
evidence of epidural or paraspinal fluid collection or abscess."
He reports pain with urination (no hesitation, no urgency, no
gross hematuria) and
pain with bowel movements (last bowel movement yesterday).
Denies
urinary/bowel incontinence/saddle anesthesia.
CT-abdomen / pelvis with contrast shows mild constipation, with
a
mildly thickened bladder wall.
Patient has chronic low back pain requiring steroid injections,
but this is far worse than his baseline pain.
In the ED, initial vitals: 99.6 89 130/84 20 98% RA
Exam was notable for lumbar paraspinal tenderness. Labs were
significant for WBC 16.2, negative UA, lactate 1.2.
MRI L spine showed no epidural abscess but a L4-L5 disc bulge
compressing the nerve roots.
In the ED, he received: 3 doses of IV hydromorphone, IM
ketorolac 30 mg, Lidocaine 5% Patches, 3 L NS, Diazepam 5 mg
(4:30 AM ___ IV Vancomycin 1000 mg, PO Acetaminophen 1000 mg,
and ibuprofen 800 mg
Vitals prior to transfer: 98.4 80 118/72 22 97% RA
Currently, he reports subjective fevers, back pain, and cough
productive of green sputum x 1 week. He reports numbness and
pain
along his left leg. He reports a pruritic rash on his legs. He
denies any pleuritic pain, palpitations, chest pain, dyspnea.
ROS: Positives as above. Otherwise, reports a history of
intermittent episodes of bright red blood mixed into his stool
every couple of weeks. He denies hard stools / straining.
Otherwise negative in remaining systems.
Past Medical History:
Chronic low back pain
Hepatitis C (not taking medications for it)
Social History:
___
Family History:
Adopted, with mixed heritage, and doesn't know
his birth mother / biological family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: T: 96.9, BP: 124/69, HR: 83, RR: 20; Os: 98% RA
GEN: Alert, not diaphoretic, lying in bed, not in acute distress
HEENT: Moist MM, pupils equal/reactive bilaterally, poor
dentition, no conjunctival pallor
NECK: Supple, left-sided tender cervical lymphadenopathy
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2, no m/r/g, distant heart sounds
ABD: Soft, non-distended, tenderness to palpation in left lower
quadrant and flank
MSK: Mild midline tenderness to palpation at L4-S1 area,
left-sided paraspinal tenderness to palpation
EXTREM: Warm, well-perfused, no edema
SKIN: dry skin, with irregular scabs along legs
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
===========================
PHYSICAL EXAM:
VS: T: 97.___.9, BP: 106-138/59-85, HR: 66-78, RR: ___ Os:
97-___-100% RA
GEN: Alert, not diaphoretic, lying in bed, not in acute
distress
HEENT: Moist MM, pupils equal/reactive bilaterally
PULM: coarse breath sounds in all lung fields bilaterally
COR: RRR (+)S1/S2, no m/r/g, distant heart sounds
ABD: Soft, non-distended, tenderness to palpation in left lower
quadrant and flank
MSK: Midline tenderness to palpation at L4-S1 area, left-sided
paraspinal tenderness to palpation, improved from previous exam
EXTREM: Warm, well-perfused, no edema. Tenderness and worsened
pins and needles sensation to palpation of left leg in L4-S1
distribution.
NEURO: Moves b/l upper extremities. ___ strength in right lower
extremity, ___ strength in left lower extremity limited by pain
Pertinent Results:
ADMISSION LABS:
=======================
___ 08:46PM BLOOD WBC-16.2* RBC-3.77* Hgb-11.8* Hct-36.2*
MCV-96 MCH-31.3 MCHC-32.6 RDW-13.0 RDWSD-46.3 Plt ___
___ 08:46PM BLOOD Neuts-72.2* Lymphs-15.7* Monos-11.2
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.69* AbsLymp-2.54
AbsMono-1.81* AbsEos-0.01* AbsBaso-0.03
___ 06:35AM BLOOD ___ PTT-29.9 ___
___ 08:46PM BLOOD Glucose-112* UreaN-6 Creat-0.7 Na-134
K-3.5 Cl-101 HCO3-23 AnGap-14
___ 06:35AM BLOOD ALT-22 AST-16 LD(LDH)-204 AlkPhos-54
TotBili-0.7
___ 06:35AM BLOOD Albumin-3.4* Calcium-9.0 Phos-2.2* Mg-2.2
___ 06:35AM BLOOD CRP-392.4*
___ 06:35AM BLOOD HIV Ab-Negative
___ 06:35AM BLOOD ASA-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
___ 08:57PM BLOOD Lactate-1.2
MICROBIOLOGY:
=======================
___ 8:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ AT 14:40 ON
___.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
STUDIES:
=======================
+ CXR ___: No acute cardiopulmonary process
+ MRI C/T/L spine ___:
Study is degraded by patient motion artifact.
1. No cord signal abnormality.
2. No evidence of epidural collection.
3. Multilevel degenerative changes, including a broad-based
disc
bulge atL4-5, which deforms the ventral thecal sac and contacts
the bilateral exiting nerve roots at the level.
+ TTE: The left atrial volume index is mildly increased. A small
secundum atrial septal defect is present. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and global systolic function (3D LVEF =
63 %). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. IMPRESSION: Normal
biventricular chamber size and systolic function. No 2D echo
evidence of endocarditis. No pathologic valvular flow. Small
secundum ASD.
+ TEE (___): A small secundum atrial septal defect is
present. Overall left ventricular systolic function is normal
(LVEF>55%). 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. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion. IMPRESSION: No vegetations/masses
visualized. Small secundum atrial septal defect.
DISCHARGE LABS:
=======================
___ 05:26AM BLOOD WBC-8.2 RBC-3.69* Hgb-11.4* Hct-36.1*
MCV-98 MCH-30.9 MCHC-31.6* RDW-12.9 RDWSD-46.4* Plt ___
___ 05:26AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-26 AnGap-13
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
44,400 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
Brief Hospital Course:
___ presenting with acute on chronic low back pain and gram
positive bacteremia in the setting of IV drug use.
# MSSA bacteremia: Patient presented with high grade bacteremia,
fevers and leukocytosis in setting of recent IV drug use. Fevers
and leukocytosis resolved with antibiotic therapy. Given
presence of Staph bacteremia, there was concern for possible
endocarditis vs. osteomyelitis / diskitis, though no evidence
for these complications were seen on TTE/TEE/MRI-Spine. Patient
did complain of back pain which could have been from developing
osteomyelitis, with markedly elevated CRP 392.4 on ___.
- ___ (Day 1): per ID recs: Nafcillin 2 gm q4 x 6 weeks;
follow-up in OPAT
- consider repeat spinal imaging in three weeks post discharge
if no improvement or worsening in back pain.
# Acute on chronic back pain, presumed osteomyelitis vs.
diskitis: Patient has chronic back pain requiring steroid
injections. He takes Percocet at home. His new left lower
extremity pain and numbness are likely secondary to known disc
herniation at that level. However, given his persistent leg
numbness, the long-interval of fevers + presumed bacteremia
until presentation to an outside hospital. Per patient report no
trauma; no saddle anesthesia, no weakness, no loss of
urinary/bowel incontinence concerning for spinal cord
compression. Imaging on ___ reassuring against absence of
abscess, but would not show developing osteomyelitis. Presumed
osteomyelitis vs. diskitis, though in the absence of another
foci of infection. Per ID recommendations, will treat with
nafcillin 2 gm x q4hr x 6 weeks. ___ consider week ___ MRI if
there continues to be weakness / numbness. Limit use of opioids.
Patient responded better to hydromorphone PO than oxycodone.
- Outpatient follow-up with ___ clinic, following PCP
___.
- Hydromorphone 2 mg PO Q8Hr:PRN
- Gabapentin 800 mg TID
- Acetaminophen 1000 mg PO/NG Q8H standing
- Ibuprofen 600 mg TID Q8H standing
- Lidocaine 5% Patch
# Dysuria: Clinical context of pain with urination, findings of
urobilinogen, as well as CT-AB findings of thickened bladder
wall concerning for cystitis. Improved during hospitalization
# LLQ Pain / Blood in stool: Per history, patient doesn't have
hard stools that require significant straining. Abdominal pain
is minimal. No evidence of anal fissures. History of several
years of presentation raises questions of inflammatory bowel
diseases, such as Crohn's or UC; possible diverticulosis (though
less likely given age); internal hemorrhoids. Patient has
asymptomatic anemia (as below). No episodes of blood in stool
during hospitalization.
- Consider additional follow-up as outpatient.
# Hepatitis C: Patient does not currently take medications for
it. Unclear viral load or progression of symptomology. HCV viral
load 44,400 IU/mL. LFTs unremarkable.
# History of IV heroin use: patient denies use in the past 2
weeks. Reports intermittent IV heroin use, with triggers being
his friends who use more regularly. He reports getting new
needles, but suspects his friends may also use his needles.
- Patient discharged with a prescription for Narcan.
- Coordinate follow-up in ___ clinic. Will need tapering
off other narcotics prior to discharge from ___.
=
=
=
=
================================================================
Transitional Issues:
1) Please follow-up in ___ clinic for follow-up of antibiotics
(CBC, LFTs) as well as arrangement to removal PICC line.
2) Follow-up Hepatitis C diagnosis with infectious disease
appointment following discharge from rehab facility.
3) Hematochezia - patient reports intermittent history of
hematochezia. Unclear etiology. ___ consider inflammatory bowel
diseases work-up as patient has never had a formal work-up.
4) Patient expressed an interest in utilizing suboxone, which he
has used before. He was connected to ___ in
___ on ___. He requires a PCP ___.
5) Patient was discharged with a prescription for narcan.
# CODE STATUS: Full
# CONTACT: ___ ___
___ INTAKE NOTE
======================================
OPAT Diagnosis: MSSA bloodstream infection and presumed
vertebral
osteomyelitis
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: nafcillin 2 g iv q4 hours
Start Date: ___
Projected End ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
NAFCILLIN: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY ESR/CRP for patients with bone/joint
infections and endocarditis or endovascular infections
FOLLOW UP APPOINTMENTS: Please contact ___ clinic at ___
to set up ID appointments for HCV care and OPAT as needed.
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Clinical Course:
Mr. ___ is a ___ year old male with history of HCV and IVDU who
presents from ___ for fevers, back pain, and bloodstream
infection with MSSA. Patient with history of chronic low back
pain requiring steroid injections in the past. However this
presentation was far worse than his baseline pain Endorsed some
subjective fevers and chills. Duration of bacteremia not known.
At ___, pt afebrile and hemodynamically stable. Labs
remarkable for WBC 14.2, UA negative, ESR 46, CRP 6.6. BCx x2
grew MSSA as did initial blood cx at ___. MRI L spine with
L4-L5 disc bulge compressing nerve roots, no evidence infection.
TTE and TEE negative for endocarditis. Patient was treated with
nafcillin after speciation obtained from ___. Plan is for
6
weeks of therapy for MSSA BSI with presumed vertebral
osteomyelitis or discitis based on his pain and possibility that
MRI may be insensitive to early osteomyelitis.
Essential Dates for OPAT therapy:
Start Date: ___ (last positive blood culture as of now)
Projected End ___
Plan for Transition to Oral Therapy: No
Plan for Future Imaging: No; if there is any compelling need to
end antibiotics earlier than 6 weeks, could repeat L spine MRI
___ weeks into course to help with decision making
Has the study been ordered/scheduled?
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Moderate
2. Gabapentin 800 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 200 mg PO BID
3. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
4. Ibuprofen 600 mg PO Q8H
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Nafcillin 2 g IV Q4H
7. Omeprazole 20 mg PO DAILY
8. Senna 17.2 mg PO BID
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Gabapentin 800 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
MSSA Septicemia
Secondary Diagnosis:
Acute on chronic back pain, presumed osteomyelitis vs. diskitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ on ___ for an infection of
your blood. It is likely this occurred due to your intra-venous
drug use of heroine, which introduced the bacteria into your
blood stream. Infection of the blood can often cause damage to
heart valves; we did an ultrasound of your heart which did not
show an infection of your heart. Upon discharge, your blood
cultures were negative for signs of infection of the blood.
However, given the long course of your blood infection and your
worsening back pain, we are treating you for 6 weeks of
antibiotics for possible infection of your spine. We did an MRI
to visualize your back which did not show signs of a collection
of fluid or infection, but since it was early in the course of
your illness, it cannot rule out an infection.
We treated your infection with IV antibiotics; in order to
facilitate this, we had you insert a PICC line. You will need to
continue the medications for 6 weeks, with follow-up in our
infectious diseases clinic, which will also arrange for removal
of your PICC line.
It was a pleasure taking care of you and we hope you feel
better.
Your ___ team
Followup Instructions:
___
|
19615022-DS-11
| 19,615,022 | 29,462,991 |
DS
| 11 |
2114-11-09 00:00:00
|
2114-11-09 14:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, left foot weakness
Major Surgical or Invasive Procedure:
___: L4-L5 laminectomy
History of Present Illness:
___ is a ___ male with a history of IV drug abuse and
Hepatitis C. He has a long history of back pain with multiple ER
visits. In ___, he was discharged from ___ to
___ on IV nafcillin for possible spinal
osteomyelitis vs discitis for back pain in the setting of MSSA
septicemia. In ___, he underwent an open biopsy of L4-5 for
questionable epidural abscess. The patient denies evidence of
infection at that time. He presents to ___ with ___ back
pain radiating to the left foot and new onset left foot
weakness. He denies insult or injury.
Past Medical History:
Chronic low back pain
Hepatitis C (not taking medications for it)
MSSA septicemia ___
Possible discitis vs. osteomyelitis
Social History:
___
Family History:
Adopted, with mixed heritage, and doesn't know his birth mother
/ biological family.
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilat EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 2 3 5
Sensation: Intact to light touch bilaterally. patient reports
decreased sensation over left foot.
Toes downgoing bilaterally
Rectal exam normal sphincter control
On discharge:
Awake and alert, cooperative with exam. Motor strength bilateral
upper extremities ___. Motor strength right lower extremity ___,
left lower extremity ___, except ___ ___. Sensation
intact to light touch bilaterally throughout all extremities.
Patient reports decreased sensation in left big toe. No clonus.
Pertinent Results:
Chest xray ___
IMPRESSION:
No acute cardiopulmonary process.
MR ___ W/O CONTRAST Study Date of ___ 2:37 AM
IMPRESSION:
1. At L4-L5 there is interval development of a small left
subarticular zone T2 intermediate intensity peripherally
enhancing focus, felt to most likely represent any new disc
extrusions/fragment. This severely crowds the left subarticular
zone, likely compressing the traversing left L5 nerve root. The
lack of adjacent abnormal enhancement or bone marrow edema makes
infectious process much less likely however given the patient's
clinical history, not entirely excluded. Would have low
threshold for reimaging if patient's symptoms progresses.
2. A nonenhancing fluid collection in the subcutaneous tissues
spanning the L3 through L5 levels posterior to the spinous
processes compatible with postoperative seroma from recent bone
biopsy described in clinical records.
3. There are no findings to suggest discitis osteomyelitis.
4. Degenerative changes are most prominent at L4-L5 where there
is moderate spinal canal and severe left and moderate right
neural foraminal narrowing.
5. Additional findings as described above.
L-SPINE (AP & LAT) Study Date of ___ 12:02 ___
IMPRESSION:
2 lateral views of the lumbar spine have been submitted for
dictation. On the initial image, there is a posterior marker at
the level of the superior endplate of L5. On the second image,
posterior marker is seen along the posterior cortex of L4.
Please refer to the operative note for additional details. There
are degenerative changes with mild loss of disc height at L4/L5
and anterior vertebral body spurring.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
10:28 AM
IMPRESSION:
Normal abdominal ultrasound.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of IV drug
abuse(heroin) who was admitted to ___ ___ months ago for back
pain concerning for discitis vs osteomyelitis and MSSA
bacteremia who was discharged on IV nafcillin ___ months ago. He
presented to ED with ___ back pain radiating to his L foot
with new onset L foot weakness.
#Osteomyelitis vs discitis: The patient went to the OR on ___
for L4-L5 laminectomy and decompression. The surgery was
complicated by a dural tear and was sealed with duraseal (no
abscess found). He was flat bedrest for 72 hour and needed
reminders for non-compliance. Post-operatively the patient
remained neurologically stable with some improvement in his LLE
weakness. The gram stain was negative as well as the wound and
anaerobic cultures. The pain service was consulted for
uncontrolled pain and the patient's medication regimen was
adjusted as recommended. His activity was liberalized after 72
hours. His foley was discontinued and a UA was sent for urinary
discomfort which was negative. His toradol was completed after 3
days and he was started on PRN Ibuprofen. At time of discharge,
his pain was well controlled. He was tolerating a diet and
ambulating independently. His vital signs were stable and he was
afebrile. He was discharged to home.
#ID: Blood cultures were drawn on admission and had no growth.
Infectious disease was consulted to assist with management of
possible infection given negative cultures. Pertinent labs for
hepatitis B were drawn. Liver function tests were obtained and
were remarkable only for AST 50. A RUQ ultrasound revealed a
normal abdomen. His ancef was discontinued on ___. He remained
afebrile with a negative infectious workup. ID will continue to
follow on an outpatient basis for re-evaluation and possible
treatment of chronic hepatitis C as well as if the patient
experiences recurrent fever. The patient will need to make a
follow up appointment in the Infectious Disease Clinic in ___
weeks.
#Suboxone treatment: Suboxone was held while he remained
inpatient. He is currently treated at ___ with plans to
attend his previously scheduled appointment on ___ for
refills.
#IV infiltration: Intra-operatively hand surgery was consulted
for IV propofol extravasation of the R antecubital fossa. Hand
surgery recommended elevating the extremity and no surgery was
indicated.
Medications on Admission:
gabapentin
buprenorphine-naloxone
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
5. Senna 17.2 mg PO QHS
6. Tizanidine ___ mg PO TID:PRN pain
RX *tizanidine 2 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
7. Gabapentin 300 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Back pain, left foot weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Spine Surgery without Fusion
Surgery
Your incision is closed with staples. You will need staple
removal. Please keep your incision dry until staple removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after staple removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You may take Ibuprofen/ Motrin for pain.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
19615440-DS-22
| 19,615,440 | 24,341,616 |
DS
| 22 |
2183-08-04 00:00:00
|
2183-08-04 19:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HEMATURIA, SOB, VOLUME OVERLOAD
Major Surgical or Invasive Procedure:
___ Revision of Sternotomy with wound vac placement
___ Cardiac Catheterization
___ removal of sternal hardware; bilateral pectoral
advancement flaps
___ PEG tube placement
History of Present Illness:
Mr. ___ is a ___ M hx dCHF (EF >55%) s/p pericardial stripping
in ___ for constrictive pericarditis, Cirrhosis likely due
to EtOH, new AFib(in the setting of pericardial stripping) on
coumadin who initially presented with hematuria in the setting
of an INR of 6.2 and was noted to be 50-60 pounds over dry
weight with pitting edema to mid-torso.
Hematuria resolved. On the ___ 2 floor, he was diuresed down 30
pounds with 100IV Lasix and metolazone 2.5mg. Further diuresis
was limited by blood pressures. As outpatient, the patient's
systolics tend to be in the ___ here, he has been more
consistently in the 80-90's. Creatinine has been stable around
1.4.
The patient also had erythema at the site of his sternotomy,
initially treated with Keflex, but progressed to serous
drainage. Surgery was consulted and went for cleanup and
excisions. Wires were also removed. The patient now has a wound
vac and is followed by Cardiac and Plastic Surgery.
On transfer to ___ floor, patient denied any chest pain or
dyspnea.
Past Medical History:
- Atrial Fib (Diagnosed on ___ admission): on coumadin at
home
- Constrictive pericarditis s/p pericardial stripping ___
- Cirrhosis, believed to be due to EtOH
- dCHF (LVEF >55% ___
- CKD Stage 3
- COPD
- Depression
- Lung cancer diagnosed ___ s/p radiation and chemo
Social History:
___
Family History:
Brother: ___, valve replacement
Daughter: CAD/PVD
Father: ___
Mother: ___, "heart problem"
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.4, 94/53, 104, 24, 100% on 2L
General: NAD, sitting up in bed in no acute events.
HEENT: MMM, EOMI, PERRLA
Neck: supple JVD elevated to the level of the jaw at 45degrees
CV: Irregularly irregular, no m/r/g
Lungs: decreased breathsounds bilaterally at the bases with
crackles half way up his back
Abdomen: +BS, soft, NT, distended
GU: Foley in place, no gross hematuria, extensive scrotal
swelling.
Ext: 3+ lower extermity pitting edema up to the mid back
Neuro: CN2-12 grossly intact
Skin: no rashes, midline sternotomy scar healing well without
exudate, mild erythema.
DISCHARGE PHYSICAL EXAM:
VS: 98.2/97.2 HR ___ RR 20 BP 86-101/57-61 O2 sat 95% RA
I/O:
24h: 1360/1300
8h: 240/300
weight: 79 (78)
Tele: AF 80-90's
.
Gen: elderly male, in NAD
HEENT: JVP 2cm above clavicle, oropharynx clear
CV: Irreg, nl S1/S2, ___ SEM @ LUSB
Resp: improved air movement right side, faint BB crackles.
Abd: soft, nt, nd, no organomegaly. JP drain out, PEG tube
seated well. Tegaderm over sternal incision site.
Ext: no edema.
Pertinent Results:
ADMISSION LABS:
___ 01:15PM BLOOD WBC-8.5 RBC-3.44* Hgb-8.8* Hct-28.8*
MCV-84 MCH-25.5* MCHC-30.5* RDW-18.5* Plt ___
___ 01:15PM BLOOD Neuts-85.2* Lymphs-6.0* Monos-7.0 Eos-0.9
Baso-0.8
___ 01:15PM BLOOD ___ PTT-47.6* ___
___ 01:15PM BLOOD Glucose-100 UreaN-31* Creat-1.2 Na-137
K-4.9 Cl-102 HCO3-27 AnGap-13
___ 06:55AM BLOOD ALT-12 AST-23 LD(LDH)-215 AlkPhos-136*
TotBili-0.6
___ 01:15PM BLOOD proBNP-3835*
___ 01:15PM BLOOD cTropnT-0.03*
___ 06:55AM BLOOD Albumin-2.7* Calcium-8.2* Phos-3.7 Mg-2.2
___ 01:15PM BLOOD Digoxin-1.7
___ 01:46PM BLOOD Lactate-1.9
___ 06:55AM BLOOD ___ PTT-45.1* ___
___ 01:30PM BLOOD ___ PTT-44.3* ___
___ 07:40AM BLOOD ___ PTT-38.2* ___
___ 01:00PM BLOOD ___
___ 05:34AM BLOOD ___
___ 04:52AM BLOOD ___
___ 06:15PM BLOOD ALT-12 AST-23 AlkPhos-114 TotBili-0.5
___ 04:45AM BLOOD Digoxin-1.7
___ 12:54PM BLOOD Type-ART Temp-36.7 pO2-74* pCO2-34*
pH-7.50* calTCO2-27 Base XS-3 Intubat-NOT INTUBA
___ 12:38PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
IMAGING:
ADMISSION CXR:
FINDINGS:
The cardiomediastinal silhouette and hilar contours are
unchanged with re
demonstration of paramediastinal fibrosis from prior radiation
therapy. Small bilateral pleural effusions are similar in
volume compared to ___. Again appreciated is mild central
vascular fullness compatible with volume overload. There is no
pneumothorax. Median sternotomy wires in are in place. The
osseous structures are grossly unremarkable.
IMPRESSION:
Similar appearance to ___ with redemonstration of small
bilateral pleural effusions, mild volume overload and
paramediastinal fibrosis.
___ CXR:
FINDINGS: Persistent cardiomegaly and upper zone vascular
redistribution, but decreased in extent of bilateral perihilar
haziness and bilateral septal thickening, suggesting improved
pulmonary edema in the setting of interval diuresis.
Geographically marginated opacities in left juxtahilar region
correspond to apparent post-radiation fibrosis on prior CT chest
of ___, and correlation with previous treatment
history would be helpful in this regard. Small-to-moderate
right pleural effusion has decreased in size and a small left
pleural effusion is similar to the prior study. Pericardial
calcifications are noted, best visualized on the lateral view,
and correlate to findings concerning for constrictive
pericarditis on prior CTA of the chest.
IMPRESSION:
1. Improving pulmonary edema. An underlying chronic
interstitial process cannot be excluded, and continued
radiographic followup may be helpful in this regard.
2. Improving right pleural effusion and persistent left pleural
effusion.
3. Post-treatment changes in left juxtahilar region.
4. Pericardial calcifications as described above.
___ ECHO:
The left atrium is dilated. The right atrium is markedly
dilated. The left ventricular cavity is unusually small. Left
ventricular systolic function is hyperdynamic (EF>75%).
Diastolic function could not be assessed. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is mild
pulmonary artery systolic hypertension.
IMPRESSION: Suboptimal image quality. Small, hyperdynamic left
ventricle. Unable to assess diastolic function. The right
ventricle is not well seen. Mild aortic regurgitation.
Pericardium not well seen.
___ CXR:
The patient continues to be in moderate-to-severe pulmonary
edema associated with bilateral, right more than left pleural
effusion. Cardiomediastinal silhouette is unchanged. No other
newly developed abnormality is demonstrated.
___ CARDIAC CATH:
COMMENTS:
1. Resting hemodynamics revealed elevated left and right heart
filling
pressures with equalization of diastolic pressures.
Interpretation was
limited by the patient's rhythm of atrial fibrillation.
Diastolic dip
and plateau were noted on ventricular pressures. Rapid y
descents were
also noted. There was moderate pulmonary arterial systolic
hypertension.
FINAL DIAGNOSIS:
1. Elevated left and right heart filling pressures with
equalization of
diastolic ventricular pressures and diastolic dip and plateau
and rapid
y descents, all suggestive of restriction versus constriction.
2. Moderate pulmonary artery hypertension.
3. No ventricular interdependence seen.
4. Unable to discriminate between restriction and constriction
however
the lack of ventricular interdependence and level of pulmonary
hypertension may favor restriction
___ CXR:
1. In comparison to ___ exam, there is interval
improvement in
pulmonary edema, which is now mild.
2. Small-to-moderate bilateral pleural effusions, right greater
than left,
slightly decreased in size since prior.
___ CXR:
In comparison with the study of ___, there is little overall
change. Again there is enlargement of the cardiac silhouette
with pulmonary
edema and bilateral pleural effusions with compressive
atelectasis at the
bases.
___ CXR:
Compared to the prior exam there is no significant interval
change.
___ CXR:
Chronic-appearing interstitial abnormality without radiographic
evidence for
acute change.
___ CXR:
Cardiac silhouette is enlarged, and is accompanied by pulmonary
vascular congestion and moderate pulmonary edema, the latter
likely
superimposed upon chronic underlying lung disease. Left hilum
appears
enlarged, with adjacent geographically marginated opacities
which may
correspond to previous history of radiation therapy for advanced
lung cancer.
Bilateral small pleural effusions appear similar to the prior
radiograph as
well as left apicolateral pleural thickening.
Consider a dedicated chest CT for more complete evaluation of
the left hilar
region to monitor the patient's lung cancer, particularly in the
absence of
more remote comparison radiographs.
CXR ___:
Unchanged evidence of
cardiac enlargement, pulmonary congestion and bilateral pleural
effusions. No
evidence of new discrete local parenchymal infiltrates and no
evidence of
pneumothorax.
IMPRESSION: Similar as on next preceding examination of ___, the portable
examination shows unchanged findings. Consider detailed chest
examinations in
this patient who allegedly has history of lung cancer.
Chest CT without contrast ___:
1. Right greater than left bibasilar consolidation and volume
loss with a
pattern of hypoenhancement compatible with pneumonia.
Associated mediastinal
and hilar lymphadenopathy is likely reactive. No current
evidence of lung
cancer recurrence although diffuse consolidation from existing
pneumonia may
mask underlying disease. Consider repeat imaging after
resolution.
2. Mild pulmonary edema.
3. Nonobstructing layering fluid in the trachea as well as a
focal area of
mucus plugging in the left lower lobar bronchus.
4. Diffuse bronchial wall thickening and innumerable 1-2 mm
nodules, likely
related to chronic small airways disease.
5. Stable left perihilar fibrosis representing post-radiation
change.
6. Foci of subcuteanous air in the upper abdomen and trace
peritoneal free
air is likely related to recent PEG placement.
DISCHARGE LABS:
___ 05:01AM BLOOD WBC-9.3 RBC-3.39* Hgb-8.6* Hct-29.0*
MCV-85 MCH-25.4* MCHC-29.7* RDW-19.8* Plt ___
___ 05:01AM BLOOD Glucose-126* UreaN-27* Creat-1.0 Na-137
K-5.1 Cl-99 HCO3-31 AnGap-12
___ 05:01AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.6
___ 05:36AM BLOOD FreeKap-56.9* FreeLam-36.2* Fr K/L-1.57
___ 05:36AM BLOOD Vanco-19.6
___ 03:02AM BLOOD Digoxin-1.5
___ 05:01AM BLOOD ___
Brief Hospital Course:
Pt is a ___ with new-onset afib (___) on coumadin, dCHF
(LVEF >75% ___, CKD stage 3, COPD, who p/w hematuria and
severe volume overload due to acute CHF exacerbation. Also had
surgical debridement and wound vac placed on sternotomy site.
#Acute CHF exacerbation:
Diastolic (EF>75%). History of pericardial stripping ___ for
constrictive pericarditis. Pt presented with worsening ___ edema,
50-60 pounds above dry weight, CXR consistent with acute CHF
exacerbation. ECHO ___ showed EF of >75%, pulmonary
hypertension. ADMISSION WEIGHT: 102.7 kg. Pt diuresed prior to
transfer with 100 mg IV lasix, metolazone 5mg PO BID. He was
transferred to ___ for further diuresis where he was started on
IV lasix ___ mg/hr drip. Prior to transfer, pt had lost more
than 10 kg (from 102.7), but further diuresis on ___ was
severely limited by blood pressure, which trended down from high
___ on admission to low ___. Lasix drip was held on ___ in
the setting of mental status change (see below). He was
transferred to the CCU for treatment with pressors and continued
diuresis. By ___ he was stable enough for transfer back to the
floor, but he returned to the CCU following removal of sternal
hardware on ___ (see below). At that point in time, blood
pressures remained on the low side but were mostly within
expected range (except temporarily after sternal closure, see
next paragraphs). He was started back on furosemide 40 mg daily
(home dose is 80 BID) and his weight is stable with I=O. He
appears mildly dry with dry mucous membranes, no peripheral
edema and faint BB crackles that are likely ___ pneumonia.
# Sternotomy site infection: Pt was seen by CT surgery who
recommended 1 week course of keflex on admission. Found to have
serous drainage at sternotomy site on ___. He went to the OR
with CT surgery and had cleanup of the surgical site, removal of
several of the wires, and placement of a wound vac. Culture grew
MRSA. He was placed on IV vanc per ID recommendations until, at
the earliest, ___. ID also to see pt after discharge.
Plastics took pt for I&D, removal of sternal hardware, and
bilateral pectoral advancement flaps on ___. Intra-operative
tissue culture from wound margin was positive for coag-positive
Staph aureus (pt already on appropriate abx). Abx coverage was
temporarily expanded post-operatively when pt was found to have
tachycardia and soft BPs, but with known MRSA infection abx was
again narrowed to vancomycin.
Cortisol was checked to r/o adrenal insufficiency; random
cortisol level came back elevated at 25.8. Last JP drain was
pulled ___. He will continue vancomycin until ___ when he
has an infectious disease f/u appt.
# Anemia: Pt had anemia after sternal closure and prior to PEG
tube placement. Received pRBC transfusion to buffer for PEG
placement. Hct low but sable at d/c.
#POOR NUTRITIONAL STATUS: Mr ___ had decreased appetite
throughout his stay. His albumin was also decreased. Nutrition
was consulted due to a concern regarding poor wound healing.
Ensure and multivitamins were added daily. The possibility of a
feeding tube was entertained prior to sternal wound closure, but
the need became more imperative post-operatively when PO intake
was very poor. Pt was started on mirtazapine to stimulate
appetite and to treat depression. Placement of NG tube was
attempted but pt was unable to tolerate procedure. After
considerable discussion with pt and family, a PEG tube was
placed ___. Pt was initially declined for surgery due to
low BP (though his baseline is low), so he was temporarily
placed on pressor in preparation for procedure. He returned
from OR on pressor, which was weaned. Tube feedings were
started ___. By ___, appetite was better and plans were
being made to administer tube feedings at night to promote
better PO intake during the day. Pt had bedside swallow eval
and per follow-up note on ___, RN did not have concern for
signs of aspiration and PO intake was improving.
# AFib: CHADS2 score of 2. New onset following pericardial
stripping in ___. Was on coumadin as an outpatient but
supratheraputic INR. Restarted coumadin on ___ at 4mg daily
(lower than home dose) since he was on antibiotics. INR became
supratherapeutic so his dose was initially decreased to 2mg
daily then held given his INR of 3.5 on ___. Anticoagulation
was temporarily subtherapeutic following sternal closure to
decrease risk of bleeding. INR at the time of discharge was 2.8
on a dosage of warfarin 5mg PO daily.
# Mental Status Change: Pt found to be somewhat somnolent and
confused in the afternoon of ___. Triggered for delirium.
No focal neurological deficits found on exam, toxic-metabolic
and infectious work up were negative, EKG nl, digoxin level also
wnl. He returned to his baseline toward the evening. Possibly
due to slight hypotension (bp ___ from diuresis earlier in
the day. Lasix ___ mg IV drip was held. Mental status change
resolved. He is now A/O and slighly grumpy with care but looking
forward to getting stronger and going home. Mirtazipine was
started for situational depression and appetite stimulation. He
continues on his home dose of SSRI.
#Hematuria: Resolved on admission. Likely due to indwelling
foley with supratheraputic INR of 6.2 on admission. He has no
signs or symptoms of active hematuria as the urine is clear. He
will need to keep the foley in for ___ more days with another
voiding trial on tamsulosin. (see "Urinary Retention" below).
# Urinary Retention: Voiding trial on ___ failed, then clean
Foley placed at that time. Per Urology, incomplete bladder
emptying with difficult catheterization due to penile edema.
Kept foley in. Held tamsulosin in the setting of hypotension.
Pt was still in house ___ and foley was removed in
anticipation of discharge. By nighttime he still had not
voided and required replacement of foley. Tamsulosin was
restarted and he should have another voiding trial in ___ days.
# Hemoptysis: On ___, pt had isolated episode of hemoptysis.
Obtained CXR and CT chest without contrast, and the CT showed
right greater than left bibasilar consolidation compatible with
pneumonia. Cefepime was added to antibiotic regimen ___ for
a seven-day course.
CHRONIC DIAGNOSES
#COPD: No PFTs availble for review. Does not appear to be an
acute exacerbation. No role for steroids or abx currently.
Continued spiriva and albuterol while in house.
#CKD: Admitted with creatinine of 1.2 from a baseline of 1.4.
Creatinine remained mostly stable during care by CCU, though
increased up to 1.4 on ___. His creatinine at discharge was
1.0.
# Cirrhosis: Likely due to EtOH. Did not appear decompensated.
LFT's stable.
TRANSITIONAL ISSUES
--ID to f/u outpatient on ___.
--outpatient Plastics f/u Dr. ___-- also on ___.
--consider urology appt if fails second voiding trial
--CT chest without contrast: "No current evidence of lung
cancer recurrence although diffuse consolidation from existing
pneumonia may
mask underlying disease. Consider repeat imaging after
resolution."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aspirin EC 81 mg PO DAILY
3. Digoxin 0.25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Warfarin 6 mg PO DAILY16
9. Tamsulosin 0.4 mg PO HS
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
11. Furosemide 80 mg PO BID
12. Spironolactone 25 mg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Potassium Chloride 40 mEq PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aspirin EC 81 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Digoxin 0.125 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
12. Bisacodyl 10 mg PR HS:PRN constipation
13. CefePIME 2 g IV Q8H Duration: 7 Days
first day ___. Docusate Sodium (Liquid) 100 mg NG BID
15. Guaifenesin ___ mL PO Q6H:PRN upper airway mucous
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
17. Tiotropium Bromide 1 CAP IH DAILY
18. Metoprolol Succinate XL 37.5 mg PO DAILY
19. Mirtazapine 15 mg PO HS depression, decreased appetite
20. Multivitamins 1 TAB PO DAILY
21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
22. Vancomycin 750 mg IV Q 24H
Pt has f/u with ID on ___ and will determine ABX course
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute decomponsated diastolic heart failure
Hematuria due to supratheraputic INR
Infected sternal wound with MRSA
Acute Kidney Injury
Secondary:
Atrial Fibrilation
Urinary Retention
Bilateral hospital acquired pneumonia
Hemopysis
Malnutrition requiring PEG tube
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You were admitted with blood in your urine in the setting of a
supratheraputic INR. Your coumadin was held and you improved.
You were also found to be massivly volume overloaded and we
agressively removed fluid with IV medication and you improved.
During the process of removing fluid, your blood pressure would
drop lower than is preferred. You were transferred to the
cardiac intensive care unit to continue removing fluid with a
closer monitoring of your blood pressure. We maintained your
blood pressure with the help of an IV medication.
You were also found to have an infection at the site of your
past heart surgery. We cleaned the infection, put a wound
vacuum on, and gave you IV antibiotics. You improved with this.
You also have an appointment with the Infectious Disease doctor
on ___, you will stay on antibiotics until then.
Please weigh yourself daily and if your weight goes up more than
3 pounds in 1 day or 5 pounds in 3 days, call Dr. ___.
Your weight on admission was 102.7 and weight on discharge was
79 kg.
Followup Instructions:
___
|
19615440-DS-23
| 19,615,440 | 20,514,577 |
DS
| 23 |
2183-08-19 00:00:00
|
2183-08-19 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension and altered mental status
Major Surgical or Invasive Procedure:
Intubation, ___, ED
Bedside bronchoscopy, MICU
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history
significant for CHF, recent constrictive pericarditis treated
with pericardial stripping c/b sternal osteomyelitis on
vanc/cefepime and afib on warfarin, and COPD who presents with
altered mental status. The patient was at rehab in ___ and
noted to be increasingly somnolent and delirious over the past
two days with occasional desats into the ___. He was brought to
___ for further evaluation.
On arrival to the ED, the patient was noted to have systolic
pressures in the 70's and was started on norepinephrine. Bedside
ultrasound was felt to reflect "poor squeeze" and dobutamine was
started as well. Zosyn was added to his current antibiotic
coverage. The patient was intubated for tachypnea and
respiratory distress and admitted to the MICU for further
management.
On arrival to the MICU, the patient was afebrile satting 98% on
CMV with an FiO2 of 40 with systolic in the 120s and HRs in the
___. He remained intubated and sedated
Past Medical History:
- Atrial Fib (Diagnosed on ___ admission): on coumadin at
home
- Constrictive pericarditis s/p pericardial stripping ___
- Cirrhosis, believed to be due to EtOH
- dCHF (LVEF >55% ___
- CKD Stage 3
- COPD
- Depression
- Lung cancer diagnosed ___ s/p radiation and chemo
Social History:
___
Family History:
Brother: ___, valve replacement
Daughter: CAD/PVD
Father: ___
Mother: ___, "heart problem"
Physical Exam:
Admission:
Vitals: T: 97.4 BP: 123/62 P:72 R:12 O2: 100% 40% fi02
(intubated)
General- Intubated and sedated
HEENT- Sclera anicteric, MMM
Lungs- Diffuse rhonchi, diminished breath sounds at bases
bilaterally
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, JVP elevated
Abdomen- soft, no frank ascites, bowel sounds present
GU- foley draining cloudy yellow fluid
Ext- cool, prolonged cap refill, clubbing noted, 2+ edema
Neuro- Unable to assess ___ sedation
Discharge:
Vitals: 97.9 96 108/57 18 96% NC
General: Patient sitting up in bed, awake, comfortable
HEENT: MM dry
Neck: JVP at earlobe while sitting up
CV: Harsh, cres/decres murmur appreciated at the heart base
Pulm: Coarse BS ___, sternal incision clean/dry/intact/nontender
Abd: Soft. NT/ND.
Ext: Upper extremities with ecchymoses present. Left upper
extremity greater than right upper extremity in diameter,
stable. No edema.
Neurological: A+0x2
Pertinent Results:
Admission labs:
___ 11:25AM ___ 11:25AM PLT COUNT-284
___ 11:25AM ___ PTT-43.8* ___
___ 11:25AM WBC-13.2* RBC-2.61* HGB-6.7* HCT-22.0* MCV-84
MCH-25.8* MCHC-30.7* RDW-19.8*
___ 11:25AM ALBUMIN-2.6*
___ 11:25AM proBNP-6154*
___ 11:25AM LIPASE-23
___ 11:25AM ALT(SGPT)-12 AST(SGOT)-20 ALK PHOS-108 TOT
BILI-0.3
___ 11:25AM estGFR-Using this
___ 11:25AM UREA N-46* CREAT-1.4*
___ 11:40AM GLUCOSE-97 LACTATE-1.2 NA+-135 K+-5.1 CL--101
TCO2-26
___ 11:40AM COMMENTS-GREEN TOP
___ 12:28PM TYPE-ART TEMP-37.7 ___ TIDAL VOL-550
O2 FLOW-100 PO2-329* PCO2-40 PH-7.39 TOTAL CO2-25 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED
___ 01:20PM URINE MUCOUS-OCC
___ 01:20PM URINE AMORPH-FEW
___ 01:20PM URINE GRANULAR-21* HYALINE-14*
___ 01:20PM URINE RBC-3* WBC-9* BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 01:20PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 01:20PM URINE GR HOLD-HOLD
___ 01:20PM URINE HOURS-RANDOM
___ 06:33PM OTHER BODY FLUID POLYS-36* LYMPHS-1* MONOS-0
MACROPHAG-60* OTHER-3*
___ 07:30PM PLT COUNT-248
___ 07:30PM WBC-9.3 RBC-3.09* HGB-8.2* HCT-25.8* MCV-84
MCH-26.4* MCHC-31.7 RDW-19.1*
___ 07:30PM CALCIUM-7.8* PHOSPHATE-4.2 MAGNESIUM-2.8*
___ 07:30PM cTropnT-0.04* proBNP-5981*
___ 07:30PM GLUCOSE-104* UREA N-50* CREAT-1.6* SODIUM-137
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-11
___ 07:40PM TYPE-ART TEMP-36.6 PEEP-5 O2-40 PO2-145*
PCO2-43 PH-7.36 TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED
___ 07:45PM ___ PTT-42.5* ___
Studies:
ECHO ___: The left atrium is dilated. The right atrium is
dilated. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is normal (LVEF>55%). There
is abnormal septal motion/position. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension.
IMPRESSION: Suboptimal image quality. Small, vigorous left
ventricle, with abnormal septal motion. Mild aortic
insufficiency. Mild mitral regurgitation. Moderate pulmonary
artery systolic hypertension.
-------------------
ECG ___: Sinus rhythm. Left atrial abnormality. Diffuse low
voltage. Right
ventricular conduction delay. Consider prior inferior wall
myocardial
infarction as recorded on ___. No diagnostic interim change
-------------------
Radiology Report CHEST (PORTABLE AP) Study Date of ___
11:35 AM
___ ___ 11:35 AM
CHEST (PORTABLE AP) Clip # ___
Reason: TRAUMA
Final Report
INDICATION: Altered mental status, hypotension, respiratory
failure.
COMPARISON: None.
TECHNIQUE: Supine AP view of the chest.
FINDINGS: Endotracheal tube tip terminates approximately 7 cm
from the
carina. The heart size is mild to moderately enlarged.
Perihilar haziness
with vascular indistinctness is compatible with
moderate-to-severe pulmonary
edema. Small bilateral pleural effusions are noted. No
pneumothorax is
identified. Right PICC tip terminates in the junction of the
SVC and right
atrium. No acute osseous abnormality is detected.
IMPRESSION: Moderate-to-severe pulmonary edema with small
bilateral pleural
effusions.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
11:39 AM
___ ___ 11:39 AM
CT HEAD W/O CONTRAST Clip # ___
Reason: R/O BLEED
Final Report
HISTORY: Altered mental status. Rule out bleed.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through
the brain
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
FINDINGS:
There is no acute intracerebral hemorrhage, major vascular
territory
infarction, edema, or shift of normally midline structures.
8-mm focal
hyperdensity in the foramen ___ is consistent with a
colloid cyst,
without evidence of hydrocephalus. Prominence of ventricles and
sulci is
consistent with age-related involutional changes. Hypodensity in
the left
lenitform nucleus could represent a dilated perivascular space
or an old
lacunar infarction. The basal cisterns appear patent and there
is preservation
of gray-white matter differentiation. There is calcification of
the carotid
siphons.
No fracture is identified. Secretions in the nasopharynx relate
to
endotracheal intubation. The visualized paranasal sinuses,
mastoid air cells
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: No acute intracranial findings. Colloid cyst within
the foramen of
___.
--------------------
Radiology Report CT CHEST W/O CONTRAST Study Date of ___
11:52 AM
___ ___ 11:___HEST W/O CONTRAST Clip # ___
Reason: HYPOTENSION, RESP FAILURE, RECENT CARDIAC SURG. ? FLUID
COLLECTION
Final Report
INDICATION: Hypotension, respiratory failure, recent cardiac
surgery.
Evaluate for fluid collection.
COMPARISON: Prior chest radiograph from ___ and chest
CT from ___.
TECHNIQUE: Volumetric, multidetector CT of the chest was
performed without
intravenous contrast. Images are presented in display in the
axial plane at
5-mm and 1.25-mm collimation. A series of multiplanar
reformation images were
submitted for review.
FINDINGS: The thyroid is unremarkable. Patient is intubated
with an
endotracheal tube seen in standard position. There is a small
amount of
secretions layering within the trachea. Remainder of the airways
are patent to
the subsegmental level. No new axillary, mediastinal or hilar
lymphadenopathy
is noted. Previously noted right hilar lymphadenopathy is better
seen on the
prior contrast enhanced CT exam. The heart is enlarged. Patient
is status post
pericardial stripping and there is redemonstration of dense
calcification on
the pericardium. Note is made of coronary artery and mitral
valve
calcifications. A right PICC line terminates in the distal SVC.
There is a
small pericardial effusion.
Consolidation of the right lower lobe has increased since prior
examination
and remains concerning for pneumonia. Patchy opacities in the
left lower lobe
are unchanged and likely reflect atelectasis. There are small
bilateral
pleural effusions, right greater than left. Diffuse bronchial
wall thickening
are suggestive of chronic small airways disease. Focus of left
perihilar
fibrosis relates to prior radiation changes and is unchanged
from prior.
There is diffuse smooth septal thickening with ground glass
opacification,
consistent with moderate to severe pulmonary edema. A 13-mm
ill-defined
lobulated nodular opacity in the right upper lobe is new since
prior and may
reflect focal mucous plugging or an area of infection or
inflammation (2:32).
There is an area of calcified pleural plaque in the lateral left
upper chest
wall (3:14). There is no pneumothorax. Mild paraseptal
emphysema is noted.
Although this study is not tailored for evaluation of
subdiaphragmatic organs,
imaged upper abdomen appears grossly intact.
OSSEOUS STRUCTURES: No blastic or lytic lesion concerning for
malignancy.
There are mild degenerative changes of the mid-to-lower thoracic
spine.
IMPRESSION:
1. Worsening right lower lobe opacity, concerning for
pneumonia.
2. Small bilateral pleural effusions, right worse than left.
3. Cardiomegaly and moderate-to-severe pulmonary edema.
4. Diffuse bronchial wall thickening likely related to chronic
small airways
disease.
5. 13-mm new lobulated nodular opacity in the right upper lobe
which may
reflect focal mucous plugging, or infection/inflammation.
Discharge labs:
___ 05:32AM BLOOD WBC-5.7 RBC-2.92* Hgb-7.8* Hct-24.8*
MCV-85 MCH-26.9* MCHC-31.6 RDW-19.9* Plt ___
___ 05:06AM BLOOD Glucose-129* UreaN-68* Creat-2.8* Na-143
K-4.2 Cl-94* HCO3-39* AnGap-14
___ 05:06AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.7*
___ 05:28AM BLOOD Vanco-25.4*
Brief Hospital Course:
Mr. ___ is a ___ M hx dCHF (EF >55%) s/p pericardial stripping
in ___ for constrictive pericarditis, Cirrhosis likely due
to EtOH, new AFib(in the setting of pericardial stripping) on
coumadin, CKD stage 3, COPD, lung ca s/p chemoRT in ___, and
cirhosis ___ ETOH who initially presented with AMS from rehab
found to be hypotensive likely ___ decompensated heart failure
with preserved EF in the setting of rising creatinine,
discharged home with hospice care.
# Hospice: During this admission the patient and his family
decided to make him DNR/DNI and transition him to hospice care.
As below, all aggressive interventions were withdrawn. His PICC
was taken out. He was transitioned to less frequent vitals and
blood draws, and off telemetry. His Remeron, Sertraline, and
tube feeds via PEG were continued. He was discharged home with
hospice care. His foley was left in because he has had urinary
retention in the past. He was given a bowel regimen. The
following medications were discontinued: simvastatin, coumadin,
digoxin, aspirin, omeprazole, spirinolactone, finasteride,
furosemide, metoprolol succinate, levothyroxine, Ultram, MVI,
trazodone.
# Decompensated heart failure with preserved EF/respiratory
failure: Mr. ___ was admitted on ___ from rehab with
hypotension and AMS. Baseline BPs in high ___ to ___ usually,
but when admitted SBPs were in the ___ systolic. Pt started on
levophed. Pt developed respiratory distress in the ED and was
intubated. Bedside ECHO showed poor squeeze, so dobutamine was
added. Pt also started on Zosyn and Vanc for possible PNA.
Bronch was negative and presentation was felt to be more
consistent with cardiogenic shock/decompensated heart failure.
His care was transferred to the CCU team given his primary
cardiac presentation. Dobutamine and levophed were weaned off
and he was started on neosynephrine for BP support, which was
able to be stopped before discharge with BPs at his baseline
(80s). Zosyn was discontinued and he completed his IV vancomycin
course. He was felt to be volume overloaded and was given a
lasix drip with adequate diuresis. This was transitioned to PO
torsemide. He was given a 2g sodium restriction and 2L fluid
restriction to help keep him euvolemic.
# Sternal wound infection: During previous admission he had
revision of sternotomy with wound vac placement on ___,
removal of sternal hardware and bilateral pectoral advancement
flaps on ___. He was discharged on an IV vancomycin course,
completed ___ his levels were 46.1 and it was held
given supratherapeutic. His wound did not appear infected to
complete his course.
# Anemia: Hematocrit of 22 and hemoglobin of 6.7 on presentation
with guiaic positive stool in ED. Unclear etiology w/ obvious
evidence of bleeding. He received 2 units of pRBCs prior to
transfer to the CCU. Hct was stable since transfer. At
discharge, his hematocrit was stable. Since he is now hospice
care, further workup was deferred.
# L arm pain/swelling: Unclear etiology but improved during
admission. Could have been secondary to a DVT but since he is
going to hospice care and did not desire systemic
anticoagulation (requested to stop coumadin as below) no
diagnostic studies were pursed.
# ___: Cr rose from 1.4 on admission to 2.8 at discharge. He
continued to have good urine output. Renal was consulted, who
felt that this was consistent with ATN (diffuse muddy brown
casts) in the setting of hypotension, supratherapeutic
vancomycin, possible infxn, diuresis, and baseline CKD III with
likely poor renal reserve. Was transitioned from lasix drip to
gentler PO torsemide. Serum creatinine was no longer followed as
patient was transitioned to hospice care.
# Hx of Atrial Fibrillation on Warfarin: Initially was
maintained on coumadin but family request that this be
discontinued. Warfarin was discontinued before discharge.
# Altered Mental Status: Patient presented with AMS. Several
potential etiologies are present, including hypotension,
infection, and respiratory distress. No asterixis to suggest
hepatic encephalopathy. This improved with optimization of his
respiratory/hemodynamic status.
# Cough: Has been aspirating per speech and swallow evaluation.
At discharge he was coughing, bringing up secretions, but has
not had evidence of pneumonia. He was given pureed (dysphagia)
diet with Nectar prethickened liquids. He was given Guiafenisin
for cough, albuterol, and famotidine.
# Cirrhosis (EtOH): Stable, MELD was 6 at last liver followup.
No esophageal varices. This was not an active issue during this
admission.
# Tube feeds: Were continued via PEG. At discharge: Two Cal HN
Full strength at 65 ml/hr for 14 hrs/day overnight.
Transition issues:
- Now DNR/DNI and hospice
- If not putting out good urine to torsemide and doesn't look
dry, can try 2.5 mg PO metolazone 30 min before the first
torsemide dose.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aspirin EC 81 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
10. Docusate Sodium (Liquid) 100 mg NG BID
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
12. Mirtazapine 15 mg PO HS depression, decreased appetite
13. Multivitamins 1 TAB PO DAILY
14. Warfarin 5 mg PO DAILY16
15. Vancomycin 750 mg IV Q 24H
Pt has f/u with ID on ___ and will determine ABX course
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
Do not take if you are having loose stools.
4. Mirtazapine 15 mg PO HS depression, decreased appetite
5. Sertraline 50 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Guaifenesin ___ mL PO Q6H:PRN cough
8. Torsemide 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Decompensated congestive heart failure with preserved EF
Cardiogenic shock
Atrial Fibrillation
Constrictive pericarditis
Sternal osteomyelitis
Cirrhosis
CKD Stage 3
COPD
- Depression
- Lung cancer diagnosed ___ s/p radiation and chemo
Discharge Condition:
Mental Status: Alert and oriented x2, gets confused at times.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with heart failure. You were given diuretics to remove extra
fluid and pressor medication to support your blood pressure. You
were intubated for respiratory support intially but at discharge
you were breathing well on your own. You completed the course of
vancomycin as planned. Your PICC was removed. Your foley was
left in at your request. Your tube feeds were continued.
You expressed desire to be DNR/DNI and transition to hospice
care. You were discharged home for this care.
Numerous medications were stopped during this admission
consonant to your goals of care.
Please take the remaining medications as prescribed.
Followup Instructions:
___
|
19615586-DS-15
| 19,615,586 | 20,287,453 |
DS
| 15 |
2200-03-21 00:00:00
|
2200-03-22 07:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Cephalexin Hcl / Azithromycin / Minocycline
Attending: ___.
Chief Complaint:
chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year-old woman, with a complicated surgical
history s/p R knee replacement ___ that was complicated by
ligamentous injury, prolonged recovery, with revision on ___
that was complicated knee infection requiring wash-out at the
end of ___, now presenting with chills and anemia.
Patient notes that she has been improving since her wash-out,
although she has been in and out of rehab. This past week, her
vanc trough has been supratherapeutic several times, requiring
adjustments of her dose. While at home on ___ at 8:20 am,
she started her vancomycin infusion (first time infusing it
herself). This continued while she was traveling in the car. She
became shaky and tremulous. She was evaluated in ___ clinic by
___, then became more shaky after her visit. When
she got up to use the bathroom, she also became lightheaded. She
needed to sit down, then was evaluated by Dr. ___
recommeded that she come to the ED for eval. At the time of his
evaluation, her T was 99.6 and FSBS 104.
She notes that her knee has not been painful or tender recently.
She has had intermittent constipation that is not new for her.
She deos note that she has had an area of "raw" skin at the top
of her buttocks. She notes that while at rehab and ___
___, she was recommended to have blood tranfusions a few
times, but was never given any.
She denies any fevers or chills at home. No known sick contacts
or travel (she's planning on going to ___ later this
___). She has no woodland exposures or known insect/tick
bites. No N/V/D, CP/SOB, cough, cold symptoms, headaches, night
sweats, weight loss, pruritus, jaundice, hematochezia,
hematemesis, melena, hematuria or dysuria. Her PICC has been in
good condition, without any erythema, drainage, swelling or
difficulty flushing. No lower extremity swelling or erythema.
Incision on right knee has not changed.
In the ED, initial vs were: 98.8 93 133/51 18 99%. Exam was
notable for PICC site without erythema or drainage; swollen
right knee with no tenderness and CDI incision; erythematous
groin rash; 2cm open shallow laceration in gluteal cleft 2
finger breadths above the anus with erythema and mild
tenderness, no fluctuance or pus drainage; Guaiac negative
rectal exam. Labs were remarkable for WBC 4.6 with 73%N, H/H
6.8/20.1 (baseline 7-8/mid ___, plt 677; BUN 23/Cr 1.2, glucose
105; lactate 1.7. UA without evidence of infection. Blood
cultures x2 were sent. CXR PA/lat showed no acute
cardiopulmonary process. Patient was seen by Orthopedics
consult, who believed that the knee was not infected. Patient
was not given anything in the ED. Vitals on transfer were: 99.6
88 113/58 18 97% RA .
On the floor, she was comfortable, with no complaints.
Past Medical History:
- transverse myelitis, not on immunosuppressants, diagnosed in
___ with multiple recurrences
- hypertension
- hyperlipidemia
- sciatica
- Right total knee replacement (___) c/b torn ligements
afterwards, requiring repair on ___. On ___, she
developed fevers/chills/diaporesis, and was found to have septic
knee, which was treated with surgical wash-out, temporary
antibiotic spacer, then new hardware
- fall with head trauma requiring 7 staples in ___
- baselin anemia with Hgbs ___ / Hct mid ___, not worked up
- Migraine headaches
- Chronic LBP
- MRSA infections, recurrent cellulitis RLE (Completed
decolonization ___
- Lumbo/sacral scoliosis
- s/p cataract surgery ___
- Urge incontinence
- Sinus bradycardia
- TIA ___
- Osteopenia
- GERD
- CKD (bl 1.2 -1.4)
- Status post full thickness skin graft dorsum of the right foot
___
- s/p R TKR ___
- s/p vastus medialis oblique repair ___
- s/p TAH/BSO
- s/p tonsillectomy
Social History:
___
Family History:
Mother- CAD, type II DM
Father - CAD
CAD: M, F, multiple siblings, paternal uncles and aunts, ___ DM:
M, brother Cancer: sister (pancreatic), brothers x 3 (prostate),
brother (___)
Physical Exam:
ADMISSION EXAM:
Vitals- 98.5 107/47 83 18 97%RA 68.8 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,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back- No CVA tenderness or spinous process TTP. Top of the
gluteal fold has a 1.5-cm skin tear down to subcutaneous layer
with mild erythma, but no bleeding, drainage or TTP.
GU- no foley. Mild erythema on upper/inner thighs.
Ext- Incision over the front of R knee CDI. R knee swollen,
without any TTP or erythema. Extr warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Neuro- Speech fluent. A,A+O x3. CNs2-12 intact, strength in UE
___ bilaterally. In feet ___ bilaterally. Strength in R leg
limited by healing knee. L thigh ___, R thigh ___.
Access- LUE PICC CDI without erythema, drainage or TTP.
DISCHARGE EXAM:
Vitals- Tm 98.8 Tc 94.4 BP 110/64 (98-109/46-64) HR ___ RR 18
Sat 99% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
CV- RRR, s1, s2, no m/r/g
Abdomen- S, ND, NT
Back- No CVA tenderness or spinous process TTP. 1.5cm skin
laceration midline in gluteal fold, no erythema or underlying
fluctuance, mildly tender to palpation.
GU- Deferred
Ext- R knee incision C/D/I. R knee non-tender. Extr warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro- AAOx3. CNs2-12 intact, strength in UE ___ bilaterally. In
feet ___ bilaterally. Strength in R leg limited by healing knee.
L thigh ___, R thigh ___.
Access- LUE PICC CDI without erythema or exudate.
Pertinent Results:
ADMIT LABS:
___ 03:48PM BLOOD WBC-4.6 RBC-2.30* Hgb-6.8* Hct-20.1*
MCV-87 MCH-29.5 MCHC-33.9 RDW-12.2 Plt ___
___ 03:48PM BLOOD Neuts-73.0* Lymphs-14.6* Monos-10.8
Eos-0.7 Baso-1.0
___ 03:48PM BLOOD Glucose-105* UreaN-23* Creat-1.2* Na-136
K-4.7 Cl-101 HCO3-26 AnGap-14
___ 10:10PM BLOOD Calcium-9.3 Mg-2.0 UricAcd-7.9*
VANCO LEVELS:
___ 06:55AM BLOOD Vanco-28.1*
___ 09:20AM BLOOD Vanco-22.8*
___ 05:31AM BLOOD Vanco-22.8*
ANEMIA EVALUATION:
___ 10:10PM BLOOD ___ 10:10PM BLOOD Ret Aut-0.1*
___ 10:10PM BLOOD ALT-14 AST-24 LD(LDH)-273* AlkPhos-97
TotBili-0.2 DirBili-0.1 IndBili-0.1
___ 10:10PM BLOOD Hapto-277*
IMAGING:
CHEST (PA & LAT) Study Date of ___ 3:18 ___
No acute cardiopulmonary process.
URINALYSIS:
___ 04:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 04:25PM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-6
MICRO:
___ 10:10 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce detectable levels of antibody. Patients with
clinical history and/or symptoms suggestive of lyme disease
should be retested in ___ weeks.
___ 8:00 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ BLOOD CULTURE -PENDING
___ BLOOD CULTURE-PENDING
DISCHARGE LABS:
___ 09:20AM BLOOD WBC-4.9 RBC-2.93* Hgb-8.6* Hct-25.5*
MCV-87 MCH-29.5 MCHC-33.9 RDW-12.2 Plt ___
___ 09:20AM BLOOD Plt ___
___ 09:20AM BLOOD Glucose-159* UreaN-22* Creat-1.4* Na-138
K-4.7 Cl-103 HCO3-25 AnGap-15
___ 09:20AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year-old lady, with a complicated surgical
history s/p R knee replacement ___ that was complicated by
ligamentous injury, prolonged recovery, with revision on ___
that was complicated knee infection requiring wash-out at the
end of ___, now presenting with chills and anemia.
ACTIVE ISSUES:
# Rigors: Unclear etiology with differential including
infection, hypoglycemia (FSBS was normal), malignancy and
possible med hypersensitivity effect from vancomycin. No
documented fevers. Possible portals of entry for infection
include R knee, PICC line (infused own vanco prior to admission,
but does not appear infected) and gluteal tear. Her knee was
evaluated by Orthopedic Surgery and was felt to be non-infected.
Urine culture was negative. CXR without e/o pneumonia. Given
anemia, thrombocytosis and some e/o hemolysis below, may
implicate viral etiology or tick-borne illness. Blood cultures,
urine culture, babesia smear and lyme/parvo serologies were sent
and are pending at discharge.
# Anemia: Her baseline hematocrit was in the mid-30___ but has
dropped to ___ over the last month, current hct 21. Her
reticulocyte count is low, suggesting insufficient bone marrow
response. The anemia may be secondary to post-surgical loss as
well as chronic infection given elevated ferritin. She received
1u pRBC and her hematocrit bumped appropriately. Her hematocrit
was monitored and remained stable during the admission. Patient
needs follow-up with an outpatient hematologist for work-up of
her anemia.
# Septic arthritis: Pt has been followed by ___ for recent
admission with septic arthritis. Her vancomycin was held given
high trough values (28.1 on admission, 22.8 on ___, 22.8 on
___. Her renal function has been stable with Cr at 1.2.
Discussed with ___ from Infectious Disease and it was decided
that her antibiotics will be switched to daptomycin at 6mg/kg
(400mg) once daily, given her fluctuating vancomycin levels. At
discharge, CPK was also drawn to establish baseline. On
discharge, her vitals are stable, she is afebrile and does not
have any complaints.
CHRONIC ISSUES
# Groin fungal rash - She was treated with topical antifungal
miconazole powder. The rash improved during the admission.
# CKD: Patient has CKD with baseline Cr of 1.2, which has been
stable through the hospitalization. Patient was encouraged to
maintain po hydration.
# Transverse myelitis: Patient was continued on tizanidine at
her home dose as needed for spasms.
TRANSITION ISSUES:
- f/u final blood cultures
- Vancomycin was not given during the admission as level was
supratherapeutic. Discussed with ___ and she was switched to
daptomycin 6mg/kg once daily.
- f/u baseline CPK level drawn at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. Senna 1 TAB PO BID
7. Simvastatin 20 mg PO DAILY
8. Tizanidine 2 mg PO BID
9. Tizanidine ___ mg PO HS
10. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
11. Enoxaparin Sodium 40 mg SC DAILY
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN severe
pain
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
14. Vancomycin 1000 mg IV Q 24H
15. Ditropan XL (oxybutynin chloride) 5 mg Oral DAILY
16. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
17. Vitamin D 50,000 UNIT PO EVERY OTHER WEEK
18. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN severe
pain
7. Senna 1 TAB PO BID
8. Simvastatin 20 mg PO DAILY
9. Tizanidine 2 mg PO BID
10. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
11. Ditropan XL (oxybutynin chloride) 5 mg Oral DAILY
12. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First
Dose: Next Routine Administration Time
13. Tizanidine ___ mg PO HS
14. Daptomycin 400 mg IV Q24H
RX *daptomycin [CUBICIN] 500 mg 400 mg IV q24 hr Disp #*4000
Milligram Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
17. Vitamin D 50,000 UNIT PO EVERY OTHER WEEK
18. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Rigors
anemia
SECONDARY DIAGNOSIS:
- s/p R TKR c/b multiple washouts and infection
- Anemia with H/H ___ at baseline)
- CKD (bl 1.2 -1.4)
- HTN
- HLD
- MRSA infections
- Transverse myelitis, not on immunosupressants
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were at the ___
___. You were admitted with shaking
chills and anemia. The etiology of the chills could be either
infectious or drug-related. You had normal labs and a chest
x-ray which did not show infections. Your knee was evaluated by
Orthopedic Surgery who did not see any evidence of infection.
You had blood and urine cultures drawn which are pending at
discharge. You also had blood drawn for testing viral and
tick-borne injections, the results of which are also pending.
For your anemia, we drew more labs for further characterization.
You should follow up with your PCP/hematologist to obtain
further work-up of your anemia and low reticulocyte count.
Your vancomycin was held during this admission because the level
was consistently above the desired therapeutic range. Your
outpatient infectious disease physician decided to switch you to
Daptomycin, the first dose was given before discharge. You will
continue to follow up with your ___ infectious disease doctor
for continued antibiotics.
Please keep your appointments listed below.
Wishing you all the best!
Followup Instructions:
___
|
19615696-DS-7
| 19,615,696 | 25,783,877 |
DS
| 7 |
2125-05-24 00:00:00
|
2125-05-25 22:32:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a past medical history significant for
coronary artery disease, heart failure, hypertension on Plavix
presenting after being found down. She was last seen in her
normal state of health last evening, but was found this morning
lying near the bathtub. Patient was unable to characterize the
fall or explain exactly how it happened. Per the EMS when
presenting to the ED, she had significant trauma with his left
arm trapped under her body, with bruising and dried blood on her
face, left arm, and left leg. On ROS, her family reports 2 days
of increased urinary frequency and foul smelling urine.
.
After a discussion with her sister, ___, it appears that
her symptoms are all acute. Her sister talks with her twice a
day and reports that she did not have any slurred speech until
the day of admission. Sister found her at 1pm on the bathroom
floor. Also, she was quite functional at home, going up and
down the stairs daily. She had been having global wekaness for
about ___ weeks but absolutely did not have left > right
weakness or difficulty moving. She does not even use a walker
or cane prior, last fall was ___ years ago.
.
In the ED, initial VS were: 96.7, 107, 163/79, 18 and 93% on RA.
Exam was notable for an initial GCS of 7 that quickly improved
to 14 as the ED team was preparing to intubate (later found out
that she was DNR/DNI). Her left arm had diffuse erythema but was
soft and had strong distal pulses, without concern for
compartment syndrome. She was noted to have decreased strength
in the left arm, with positive babinski on the left. Labs were
notable for a troponin elevation to 0.17 (unknown baseline) with
mildly elevated CKs to 1101, trending up from 1015 and a WBC of
11.9 with no bandemia and mild left shift. EKG showed
irregularly irregular rhythm at ~92bpm with LAD, Q waves in II,
III, as well as diffuse TWIs in II, III, aVF, V4-V6 and poor
R-wave progression. She was treated with ceftriaxone for a
presumed UTI with U/A showing 17 WBCs and few bacteria with
small leuk esterase. Imaging was remarkable for a CT head
showing an acute/subacute right MCA territory stroke and CT neck
with an old dens fx that is s/p surgical repair. CT torso with
bilateral pleural effusions, R>L.
.
Trauma cleared patient and Neuro noted dysarthria and mixed
aphasia (fluent non-sense speech, follows some simple commands,
but only intermittently), and extensive upper motor neuron signs
on the left. They planned to follow-up with further recs and
recommended goal SBPs 120-160. She received 2L NS in total and
was sent to the ICU.
.
Vitals on transfer: 97.7, 97, 157/71, 16 and 96% on 2L
.
On arrival to the MICU, she was lying in bed and still with
dysarthria but following simple commands. She did not move her
left side.
Past Medical History:
.
1. HTN
2. CAD s/p DES in ___ for angina
3. MI in ___ ?inferior or inferolateral, diagnosed with CHF
after this MI.
4. CHF, recently diagnosed and placed on diuretic
5. reportedly, no Neurologic/stroke history
6. Afib, not on anticoagulation per patient wishes
Social History:
___
Family History:
MI (father)
Physical Exam:
Vitals: T: 99.1, BP: 155/63, P: 88, R: 18, O2: 93% on 3L NC
General: Alert, not oriented to place, appears disheveled
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP elevated ~10cm, no LAD
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: bilateral arms with diffuse ecchymoses of different ages,
left arm is almost entirely ecchymotic. right knee with redness
and warmth. 2+ pulses in bilateral radial and DP. no clubbing,
trace peripehral edema
Neuro: CN not assessed because not following commands to open
eyes etc, ___ strength right arm, ___ strength right leg, ___
strength left arm and leg, complete loss of sensation on left
side, right-sided sensation intact arm and leg, hyperreflexic on
the left with + babinski, gait deferred
Pertinent Results:
ADMISSION
___ 01:39AM BLOOD WBC-9.2 RBC-4.19* Hgb-11.0* Hct-34.4*
MCV-82 MCH-26.2* MCHC-31.9 RDW-16.4* Plt ___
___ 05:00PM BLOOD WBC-11.9* RBC-4.68 Hgb-11.9* Hct-38.3
MCV-82 MCH-25.5* MCHC-31.1 RDW-16.4* Plt ___
___ 05:00PM BLOOD Neuts-88.7* Lymphs-6.3* Monos-4.5 Eos-0.3
Baso-0.2
___ 01:39AM BLOOD Glucose-112* UreaN-17 Creat-0.9 Na-144
K-3.2* Cl-108 HCO3-27 AnGap-12
___ 08:00PM BLOOD Glucose-117* UreaN-19 Creat-0.9 Na-141
K-3.3 Cl-107 HCO3-25 AnGap-12
___ 05:00PM BLOOD Glucose-124* UreaN-22* Creat-1.0 Na-144
K-3.5 Cl-107 HCO3-27 AnGap-14
.
PERTINENT
___ 08:09PM BLOOD Lactate-1.8
___ 05:14PM BLOOD Glucose-122* Lactate-2.2* K-3.5
___ 05:00PM BLOOD CK(CPK)-1015*
___ 08:00PM BLOOD CK(CPK)-1101*
___ 01:39AM BLOOD CK(CPK)-1217*
___ 10:04AM BLOOD CK(CPK)-815*
___ 04:34AM BLOOD ALT-36 AST-62* LD(LDH)-428* CK(CPK)-201
AlkPhos-86 TotBili-0.6
___ 07:40AM BLOOD CK(CPK)-235*
___ 05:00PM BLOOD cTropnT-0.17*
___ 08:00PM BLOOD CK-MB-40* MB Indx-3.6
___ 01:39AM BLOOD CK-MB-36* MB Indx-3.0 cTropnT-0.25*
___ 10:04AM BLOOD CK-MB-23* MB Indx-2.8 cTropnT-0.22*
___ 04:34AM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.27*
___ 07:40AM BLOOD CK-MB-9 cTropnT-0.50*
___ 08:58AM BLOOD CK-MB-6 cTropnT-0.41*
___ 06:20AM BLOOD CK-MB-5 cTropnT-0.33*
.
___ 08:58AM BLOOD %HbA1c- 5.5
___ 08:58AM BLOOD Triglyc-104 HDL-55 CHOL/HD-2.5 LDLcalc-59
.
___ 05:00PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 05:00PM URINE RBC-2 WBC-17* Bacteri-FEW Yeast-NONE
Epi-1
___ 05:00PM URINE CastGr-1* CastHy-6*
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp
.
DISCHARGE
___ 06:15AM BLOOD WBC-7.2 RBC-4.26 Hgb-11.3* Hct-35.1*
MCV-82 MCH-26.5* MCHC-32.1 RDW-16.3* Plt ___
___ 06:15AM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-143
K-3.9 Cl-106 HCO3-31 AnGap-10
___ 06:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
.
EKG ___
Atrial fibrillation with a controlled ventricular response. Left
axis
deviation. There is a late transition with small R waves in the
anterior leadsconsistent with possible myocardial infarction.
Non-specific ST-T wave changes.
No previous tracing available for comparison.
IntervalsAxes
___
___
.
EKG ___
Artifact is present. Atrial fibrillation with rapid ventricular
response. Left axis deviation. 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 ___ the rate is faster.
IntervalsAxes
___
___
.
CT CHEST ___
MPRESSION:
1. Mild to moderate congestive heart failure with moderate to
large bilateralpleural effusions.
2. There is no evidence of intra-abdominal or intra-pelvic
traumatic injury.Diffuse ecchymosis seen on the left side of the
body most prominent at theleft greater trochanter.
3. Fatty liver, without focal lesions.
4. Calcified lymphadenopathy in small bowel mesentery compatible
with prior
granulomatous infection.
.
CT ABD ___. Mild to moderate congestive heart failure with moderate to
large bilateral pleural effusions.
2. There is no evidence of intra-abdominal or intra-pelvic
traumatic injury. Diffuse ecchymosis seen on the left side of
the body most prominent at the left greater trochanter.
3. Fatty liver, without focal lesions.
4. Calcified lymphadenopathy in small bowel mesentery compatible
with prior
granulomatous infection.
.
CT C-SPINE ___. No acute fracture of the cervical spine.
2. Chronic dens fracture, with cerclage stabilization.
3. Right thyroid nodule.
.
CT HEAD ___. Acute/subacute right MCA territory infarction, without
intracranial
hemorrhage or mass effect.
2. Subgaleal hematoma and soft tissue swelling overlying the
left
frontoparietal region and midline forehead.
3. Age-indeterminate right nasal bone fracture.
.
ECHO ___
Poor image quality.The left atrium is mildly dilated. 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. There is probably mild regional left
ventricular systolic dysfunction with basal inferior and
infero-lateral hypokinesis. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade. EF 55%.
.
CT HEAD AND NECK ___. Acute/subacute infarct in right middle cerebral artery
territory.
2. No evidence of intracranial hemorrhage or new infarct.
3. 7.8 mm aneurysm in right middle cerebral artery bifurcation.
4. Calcified plaques in cavernous segments of bilateral internal
carotid
arteries causing mild narrowing.
5. Calcified plaques at the aortic arch, origin of great
vessels, origin of
right subclavian, and at bilateral carotid bifurcations without
significant
stenosis.
.
Brief Hospital Course:
___ with history of CAD/CHF, HTN, Afib (on ASA and plavix)
presenting after being found down at home with CT head showing a
subacute MCA infarct.
# Fall/Presyncope: Her differential diagnosis included stroke vs
delirium. Head CT showed "acute/subacute" stroke in the right
hemisphere which was consistent with new left sided neurologic
deficits and could have resulted in a fall. She received ___
during her inpatient course and was discharged to a
rehabilitation facility.
.
# Subacute MCA infarct/CVA: The patient suffered a right MCA
stroke with residual motor deficits include dysarthria,
dysphagia, and left upper extremity paralysis. This was felt to
be most likely cardioembolic in nature, given h/o atrial
fibrillation in a patient who was not anticoagulated. We
controlled her BP with SBP goals 120-160's. Her anticoagulation
status is complicated given both stroke history but also fall
risk. Furthermore, the patient has expressed the desire not to
be anticoagulated with warfarin. The patient was continued on
Aspirin and Plavix. The patient was also started on sertraline
25mg daily given evidence of improved functional recovery
post-stroke in patients started on SSRIs. The patient was
ultimately transfered to a rehabilitation facility for intensive
___ and OT.
The patient's stroke was complicated by dysphagia. The patient
was evaluated and cleared for ground solids. She was noted to
have some aspiration with thin liquids,however, the patient and
family have opted to continue with thin liquids understanding
the risk of aspiration. Additional recommendations include: 1:1
supervision for all PO intake and the following: a) single sips
only b) no mixed consistencies (liquids and solids together) c)
check for pocketing on the left- provide f/u sips or
suction/finger sweep as needed d). Meds crushed with purees e.
TID oral care. The patient will benefit from re-evaluation in
the future for likely advancement of solid diet.
.
# Atrial fibrillation, poorly controlled: Thought to be the
cause of her stroke. She was not started on anticoagulation due
to concern for hemorrhagic conversion of her stroke. She was
rate controlled with diltiazem drip until speech and swallow
cleared her to restart oral meds, after which she was given PO
diltiazem. She was ultimately rate controlled on metoprolol
succinate 150mg twice daily. She continued to have short bursts
of tachycardia to 120s but remained asymptomatic throughout.
Continued titration and monitoring will be necessary.
.
# UTI: Her UA was slightly positive with a few leukocytes and
as discussed above, she was covered with ceftriaxone during her
inpatient course. Her urine culture grew alpha strep, she
completed 3 days of ceftiaxone therapy.
# HTN, benign: Less likely that her BP dropped causing syncope
and fall.
Antihypertensives were held in the acute stroke setting with
goal SBP 120-160 to maintain perfusion of infarcted brain. The
patient would likely benefit from addition of an ace-inhibitor
given CAD once her av nodal blocking agents have been uptitrated
with goal BP of < 130/90.
.
# Elevated CK: She was found down at home and clearly could not
move at all. Her phosphorous and creatinine were normal
indicating that her muscle injury was not signficant enough to
cause rhabdomyolysis.
.
# h/o CAD native/ chronic systolic CHF: s/p MI in ___ for
which the patient was taking plavix at home. Patient was noted
to have uptrending troponins to peak of 0.5, with no associated
chest pain or other concerning symptoms. EKG did show
non-specific ST abnormalities suggestive of NSTEMI or demand
ischemia in the setting of Afib with RVR. Troponins trended down
progressively prior to discharge. She was continued on plavix
and ASA 325mg, her BP was controlled as discussed above. She was
given lasix prn, but did not develop decompensated CHF. She
remained hemodynamically stable throughout her hospital course.
Medications on Admission:
Lasix 20mg daily, atenolol ?mg, norvasc 2.5mg, plavix 75mg daily
-Lasix 20mg daily,
-atenolol ?mg,
-norvasc 2.5mg,
-plavix 75mg daily,
-ASA,
-lisinopril 10mg
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for sob/wheeze.
6. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain: do not exceed 4g in 24 hours.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Acute embolic stroke
SECONDARY DIAGNOSES: Atrial fibrillation, Non ST elevation
myocardial infarction, hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the hospital because you had fallen at
home. You were found to have a stroke which resulted in
weakness of your left side. We think the stroke was caused by a
clot coming from your heart. You have a condition called atrial
fibrillation which means that your heart does not contract in a
coordinated way and clots can form there.
.
The following changes were made to your medications:
START metoprolol
START sertraline
STOP atenolol
STOP norvasc
STOP lisinopril
STOP lasix
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
___
|
19616286-DS-20
| 19,616,286 | 27,276,761 |
DS
| 20 |
2187-01-12 00:00:00
|
2187-01-14 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain, difficulty breathing, difficulty swallowing
Major Surgical or Invasive Procedure:
Flexible Bronch, Rigid Bronch, Stent Placement (___)
Lymph Node Biopsy (___)
History of Present Illness:
Mr. ___ is a ___ y.o. obese male with no significant PMH who
presents with 3 days of worsening bilateral neck swelling. The
patient woke up three days ago with right neck stiffness, which
he attributes to sleeping in a strange position. As the day
progressed, he noted swelling on both sides of his neck and
attributed this to a virus. He was unable to swallow pills
yesterday and could only tolerate small sips of water, and he
then developed shortness of breath, resulting in him going to
___. He was administered empiric antibiotics and IV
Decadron and was transferred to ___ for further evaluation by
ENT.
Past Medical History:
Obesity
Social History:
___
Family History:
Father: pre-diabetes
Mother: healthy
Sister: autistic spectrum, epilepsy
No family history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
VITALS: Afebrile, HR ___, RR 18
GENERAL: Well appearing obese man, in no acute distress.
HEENT: Inspection of lids and conjuctivae normal. PERRL, no
pallor or icterus. Mucous membranes moist. Erythematous and
enlarged tonsils.
NECK: Supple, mild thyromegaly palpable, no hard nodule
appreciated.
LYMPH: Significant bilateral submandibular lymphadenopathy. No
axillary or inguinal lymphadenopathy.
LUNGS: Clear to auscultation bl.
HEART: RRR, normal S1, S2. No murmur, rubs or gallops.
ABD: Soft, NT/ND, normal bowel sounds.
EXTREMITIES: Warm and well perfused, no cyanosis, clubbing or
edema.
SKIN: No rashes or suspicious lesions.
NEURO: CN II-XII intact, normal movement and speech
DISCHARGE PHYSICAL EXAMINATION
24 HR Data (last updated ___ @ 1538)
Temp: 98.5 (Tm 99.4), BP: 132/87 (119-138/68-89), HR: 77
(72-86), RR: 16 (___), O2 sat: 96% (95-96), O2 delivery: Ra
GENERAL: Well appearing man, in no acute distress.
NECK: Supple, mild thyromegaly palpable. Left side is mildly
more
swollen than right.
LYMPH: Significant bilateral submandibular lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: RRR, normal S1, S2. No murmur, rubs or gallops.
ABD: Soft, NT/ND, normal bowel sounds.
EXTREMITIES: Warm and well perfused, no cyanosis, clubbing or
edema.
SKIN: No rashes or suspicious lesions.
NEURO: AO x 3
Pertinent Results:
ADMISSION LABS:
=================
___ 07:51AM BLOOD WBC-11.8* RBC-5.17 Hgb-15.4 Hct-45.5
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.3 RDWSD-46.3 Plt ___
___ 07:51AM BLOOD Neuts-86.8* Lymphs-9.6* Monos-2.9*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.27* AbsLymp-1.13*
AbsMono-0.34 AbsEos-0.00* AbsBaso-0.03
___ 07:51AM BLOOD ___ PTT-27.0 ___
___ 07:51AM BLOOD Plt ___
___ 07:51AM BLOOD Glucose-120* UreaN-6 Creat-0.8 Na-146
K-4.0 Cl-102 HCO3-25 AnGap-19*
___ 07:51AM BLOOD ALT-14 AST-18 LD(___)-255* AlkPhos-73
TotBili-2.2*
___ 02:47PM BLOOD LD(___)-281*
___ 07:51AM BLOOD Albumin-4.8 Calcium-9.1 Phos-3.1 Mg-2.0
UricAcd-3.7
___ 12:54AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 UricAcd-4.0
___ 07:51AM BLOOD TSH-83*
___ 08:50AM BLOOD antiTPO-17
___ 09:05AM BLOOD CEA-78.7*
___ 08:50AM BLOOD HIV Ab-NEG
___ 08:07AM BLOOD ___ pO2-46* pCO2-43 pH-7.40
calTCO2-28 Base XS-0
___ 08:07AM BLOOD Lactate-1.4
DISCHARGE LABS:
=================
___ 06:24AM BLOOD WBC-10.9* RBC-4.79 Hgb-14.2 Hct-42.6
MCV-89 MCH-29.6 MCHC-33.3 RDW-14.3 RDWSD-45.8 Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-81 UreaN-7 Creat-0.8 Na-139 K-3.6
Cl-100 HCO3-23 AnGap-16
___ 06:24AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.3
___ 06:24AM BLOOD TSH-87*
___ 09:05AM BLOOD PTH-57
___ 06:24AM BLOOD Free T4-0.7*
IMAGING:
========
___ Pathology Tissue: LYMPH NODE FOR HEME
Left neck lymph node, needle biopsy: Medullary thyroid
carcinoma, see note.
Note: The malignancy is positive for CK7, TTF-1, Chromogranin,
Synaptophysin, Calcitonin, and CEA. About ___ of cells are
MIB-1 positive. CK20 is negative. This case has been reviewed
with
Dr ___
___ Pathology Tissue: Immunophenotyping- left
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia/lymphoma
Approximately 8.2% of total acquired events are evaluable
non-debris events.
The viability of the analyzed non-debris events done by 7-AAD is
90%.
CD45-bright, low side-scattered gated lymphocytes comprise 4% of
total analyzed events.
B cells and T cells are scant in number precluding evaluation of
clonality/further evaluation.
INTERPRETATION
Nondiagnostic study. Cell marker analysis was attempted, but was
nondiagnostic in this case due to insufficient numbers of
cells/insufficient amount of tissue for analysis. Clonality
could not be assessed in this case due to insufficient numbers
of B cells. If clinically indicated, we recommend a repeat
specimen be submitted to the flow cytometry laboratory.
Correlation with clinical, morphologic (see separate pathology
and cytogenetics ___ and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
___ Cytogenetics Tissue: LYMPH NODE
CYTOGENETICS PROCEDURE: 3 day DSP30/IL2-stimulated culture for
Giemsa-banded chromosome analysis.
FINDINGS: No mitotic cells were found in the culture set up from
this sample.
CYTOGENETIC DIAGNOSIS: Undetermined.
INTERPRETATION/COMMENT: Chromosome analysis was not possible
because the culture set up from this left neck lymph node core
needle biopsy did not produce mitotic cells.
___ Imaging BX SUPERFISCAL CER,AXL
IMPRESSION:
1. Successful ultrasound-guided core-biopsy of a conglomeration
of markedly enlarged left neck nodes. A total of five core
biopsy specimens were obtained for histopathology, flow
cytometry and cytogenetics per lymphoma protocol.
2. No drainable fluid collections.
3. Small superficial post-biopsy hematoma
___HEST W/CONTRAST
IMPRESSION:
Diffuse heterogenous enlargement of the thyroid gland with
resultant tracheal narrowing at the trachea measuring 2-3 mm in
diameter, which appear similar as noted on prior neck CT done ___.
Supraclavicular and cervical adenopathy was better characterized
on prior CT neck study.
Correlation with cytology is advised to exclude metastatic
thyroid cancer. In the differential diagnosis consider
infective/inflammatory process, though this seems much less
likely than malignancy.
A couple of 13 mm superior mediastinal lymph nodes.
No mid to lower mediastinal or hilar adenopathy.
No suspicious pulmonary nodules or masses, only few very small
nodules.
Followup of these could be considered if needed clinically.
For neck findings reference is made to CT neck report of the
prior day.
For abdominal findings reference is made to CT abdomen report of
the same
date.
___BD & PELVIS WITH CO
IMPRESSION:
1. No intra-abdominal. No splenomegaly.
2. No acute intra-abdominal or pelvic pathology.
3. Degenerative changes at the L5-S1 level with bilateral
spondylolysis and grade 1 anterior spondylolisthesis of L5 on
S1.
4. For chest findings reference is made to CT chest report of
the same date.
___ Imaging CHEST (PORTABLE AP)
Status post upper tracheal stent placement. No evidence of
acute pulmonary disease.
___ Pulm/Sleep Pulmonary/Bronchoscopy
___ Pulm/Sleep Pulmonary/Bronchoscopy
Brief Hospital Course:
HOSPITAL COURSE:
Previously healthy ___ yo male presenting with shortness of
breath and neck pain found to have new diagnosis of medullary
thyroid cancer with severe stenosis of the trachea now s/p
tracheal stenting ___.
ACUTE ISSUES:
==============
# Medullary thyroid carcinoma:
New diagnosis, s/p tracheal stenting ___ given airway
compression and dysphagia with significant improvement in
symptoms. He will undergo outpatient planning of surgical
resection with oral surgery. He will likely require a total
thyroidectomy, bilateral neck dissection and tracheal resection.
For concern of MEN2 syndrome, we ordered labs for calcitonin,
CEA, plasma free metanephrines, 24 hr urine metanephrines, and
VMA. He will followed by numerous physicians including
___, Endocrinology, ENT, and
Hematology/Oncology. In addition he will likely need genetic
testing, so please ensure that he sets up and follow with
Genetics. In terms of his stent, he was discharged with a
nebulizer machine, Acetylcysteine 20% ___ mL NEB BID for a
total of 10 days, Albuterol 0.083% Neb Soln 1 NEB for a total of
10 days, Sodium Chloride 3% Inhalation Soln 5 mL NEB BID , and
Guaifenesin-CODEINE Phosphate ___ mL PO/NG Q6H:PRN COUGH.
Please follow up on his numerous laboratory workup for other
related malignancies and endocrine dysfunction.
# Hypothyroidism:
New diagnosis. Initial TSH 87 and T4 2.7 on ___. He was
started on 150mcg levothyroxine. Please follow up on his TSH and
free T4 outpatient and adjust the levothyroxine as medically
warranted. This is likely iso of his medullary thyroid
carcinoma.
TRANSITIONAL ISSUES:
====================
[ ] Please ensure that he followed up by his new PCP,
___, Endocrinology, ENT, and
Hematology/Oncology, Genetics, and Radiology/Oncology if
warranted.
[ ] Please recheck his TSH and T4 and adjust his levothyroxine
as medically warranted
[ ] Please follow up on his calcitonin, CEA, plasma free
metanephrines, 24 hr urine metanephrines, and VMA.
[ ] Please ensure that Mr. ___ has enough social support and
care in the setting of a new diagnosis of cancer
Medications on Admission:
None
Discharge Medications:
1. Acetylcysteine 20% ___ mL NEB BID Duration: 10 Days
RX *acetylcysteine 200 mg/mL (20 %) ___ mL nebulized twice a
day Disp #*210 Milliliter Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH BID Duration: 10 Days
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Neb INH twice a
day Disp ___ Milliliter Refills:*0
3. GuaiFENesin ER 1200 mg PO Q12H:PRN congestion
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN COUGH
RX *codeine-guaifenesin 10 mg-100 mg/5 mL ___ mL by mouth four
times a day Refills:*0
5. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. nebulizers 1 Unit miscellaneous ONCE
RX *nebulizers [VixOne Nebulizer-Adult Mask] 1 nebulizer with
supplies to be used daily as instructed Disp #*1 Each Refills:*0
7. Sodium Chloride 3% Inhalation Soln 5 mL NEB BID
RX *sodium chloride 3 % 5 mL INH twice a day Disp #*200
Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Medullary Thyroid Carcinoma
Discharge Condition:
Good
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you had worsening bilateral
neck swelling, difficulty swallowing, and difficulty breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you steroids to reduce inflammation of your neck which
would reduce the swelling.
- We put a stent in your neck to ensure that you would be able
to breathe in the setting of the swelling.
- Unfortunately, on imaging we discovered a mass on your
thyroid. We performed a biopsy which confirmed a cancer called
medullary thyroid carcinoma.
- As this cancer can be associated with other cancers and
endocrine dysfunction, we performed several laboratory blood
tests to ensure that we were are not missing anything.
- One of the things we found was that your body was not
producing enough thyroid hormones, so you were started on
supplements.
- You will be followed by numerous providers who will help you
manage this cancer and the process.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19616308-DS-16
| 19,616,308 | 28,924,001 |
DS
| 16 |
2163-10-27 00:00:00
|
2163-10-27 14:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old right handed man with a history
of TIA who presented to ___ with right-sided
weakness and left gaze deviation, and was found to have a left
MCA territory stroke.
He was found down by his family this morning. Last known normal
last night. He was taken to ___ and
subsequently transferred to ___. No records were provided with
transport. Here, the endovascular team was activated while
CTA/CTP were performed. This showed L MCA territory infarct in
progress, and it was the assessment of both the stroke and
neurosurgical teams that the risk of intervention was high given
the CTP findings and infarct core size. This was discussed with
his wife, ___, who was in agreement.
He has a history of TIA for which he was seen at ___ ___
years ago. He presented at that time for disorientation. His
wife recalls no other details. He was not started on any
medications.
She does not believe he has any medical conditions, but says he
takes "some pills" but does not know what they are. The
medication history request in OMR did not yield any filled
prescriptions. His PCP is ___ at ___.
Past Medical History:
None
Social History:
Works as ___. Married to wife ___
(___). Has two young boys ages ___ and ___. Never smoker.
Drinks ___ alcoholic drinks on the weekend.
Physical Exam:
Admission
PHYSICAL EXAMINATION
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND.
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Required moderate stimulation to remain alert
and answer questions. Oriented to month, year, and age. Unable
to
participate in attention and further language testing. Followed
commands on the left side and midline.
- Cranial Nerves: PERRL 3->2 brisk. No BTT bilaterally. Left
gaze
deviation. Bifacial weakness. Hearing intact to speech.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 5 5 5 5
R Right arm flaccid Right leg purposeful withdrawl
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc] [Toe
L 2+ 2+ 2+ 1 Mute
R 2+ 2+ 2+ 1 Up
- Sensory: No sensation on right vs neglect. Did not apply
noxious stimulus to right.
- Coordination: Unable to assess due to increasing somnolence.
- Gait: Unable
Discharge
PHYSICAL EXAMINATION
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND.
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake and alerted. Answering questions.
Followed
commands on the left side and midline. Difficulty comprehending
commands.
- Cranial Nerves: PERRL 3->2 brisk. Right facial drop.
- Motor/Sensory: RUE plegic, RLE antigravity, moves left side
spontaneously with
full strength. Decrease sensation in RUE and RLE.
- Gait: Deferred
Pertinent Results:
Admission
___ 08:38AM BLOOD WBC-10.2* RBC-4.84 Hgb-14.5 Hct-42.8
MCV-88 MCH-30.0 MCHC-33.9 RDW-13.5 RDWSD-43.0 Plt ___
___ 08:38AM BLOOD ___ PTT-26.4 ___
Stroke Labs
___ 09:15AM BLOOD Triglyc-110 HDL-51 CHOL/HD-3.9
LDLcalc-126
___ 09:15AM BLOOD TSH-1.0
CTA/CTP Head ___. Left extracranial and intracranial internal carotid artery
occlusion, and occlusion of the left M1 segment. There is mild
collateral flow within the vascular territory of the left middle
cerebral artery. Loss of gray-white matter differentiation and
sulcal effacement within the left parietal lobe is consistent
with a large acute to subacute infarct. No evidence of
hemorrhagic transformation. Please note that the CT perfusion
images are nondiagnostic due to suboptimal bolus timing.
2. Moderate intracranial atherosclerosis.
3. Moderate extracranial atherosclerosis, with less than 50%
stenosis within the right internal carotid artery. The left
internal carotid artery cannot be evaluated with NASCET criteria
due to the proximal occlusion. The vertebral arteries are
patent.
ECHO ___
Normal biventricular cavity sizes with preserved regional and
global biventricular systolic function. Mildly dilated thoracic
aorta. Ttrace aortic regurgitation with mild aortic valve
sclerosos. Mild pulmonary artery systolic hypertension.
Increased PCWP. No definite structural cardiac source of
embolism identified.
VIDEO OROPHARYNGEAL SWALLOW ___
There is consistent aspiration with thin consistency barium.
There is 1 time
aspiration with nectar consistency barium. Otherwise no
aspiration or
penetration. There is increased residue after swallowing of
solid consistency
barium.
IMPRESSION:
Aspiration with thin liquids.
Brief Hospital Course:
Mr. ___ is a ___ right-handed man with a history
of TIA who presented to ___ with right-sided
weakness, aphasia, and left gaze deviation, and he was found to
have a left MCA territory stroke. He was last known well the
evening prior to presentation, so he was outside of the window
for tPA. He was transferred to ___ for possible endovascular
clot retrieval; however, the CTP demonstrated a large infarct in
progress with high chance of hemorrhagic conversion and further
injury should flow be restored. Given timeframe and large
hypodensity, we did not pursue endovascular thrombectomy as the
perceived benefit would be negligible and the risk high. CT head
demonstrated a large hypodensity occupying at least 50% of the
left MCA territory. CT perfusion scan was technically not
feasible due to patient motion. CTA with left proximal ICA
occlusion extending intracranially. The etiology may be
atheroembolus. An echo ruled out thrombus and PFO. His video
swallow evaluation demonstrated aspiration with thin liquids.
However, per speech and swallow team, he is ok to take PO with
ground solids, nectar thick liquids with 1:1 supervision during
meals. He was able to meet nutritional needs with PO intake. LDL
126, TSH 1.0 HbA1c 5.4. ___ recommended acute rehab. He failed a
voiding trial after a foley was discontinued, so this was
replaced.
New medications:
-Atorvastatin 40 mg
-Aspirin 81 mg
-Clopidogrel 75mg
Transitional issues:
-Mildly dilated aorta on Echo, will require repeat echo in ___
years
-Outpatient ___ (order is attached)
-Foley voiding trial
-Continued physical therapy and occupational therapy; continued
evaluation by swallow team; speech therapy
- Obtain 3x/week weights
- Add MVI with minerals
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*3
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*3
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: language and comprehension deficits
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right-sided weakness
and language difficulty 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 such as those listed
below.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
Your risks include atherosclerosis (narrowing of the blood
vessls leading to the brain) and high cholesterol.
In order to prevent future strokes, we plan to give you new
medications:
-We started you on aspirin 81mg to prevent your risk of
strokes. You should take this medication indefinitely.
-We started you on clopidogrel 75 mg to prevent your risk of
strokes. You should take this medication for 3 months. (For 3
months, you will take both aspirin and clopidogrel.)
-We started you on atorvastatin 80 mg daily to treat your high
cholesterol.
We are providing you with an order for an exam called ___ of
Hearts," which is a monitor to look for an abnormal heart rhythm
called atrial fibrillation that can put you at risk for strokes
and will require treatment if identified. Please follow the
instructions below in the order to make the appointment.
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:
___
|
19616308-DS-17
| 19,616,308 | 20,262,456 |
DS
| 17 |
2163-11-02 00:00:00
|
2163-11-02 13:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RLE DVT
Major Surgical or Invasive Procedure:
IVC Filter Placement (___)
History of Present Illness:
Mr. ___ is ___ male with a history of TIA who was
discharged from the neurology service ___ after being diagnosed
with a large left MCA stroke is transferred from ___
after he was found to have a DVT. The patient denied chest pain
or shortness breath, dizziness, fever, chills or cough.
In the ED, initial VS were: 97.7 55 130/69 20 95% RA
Exam notable for:
- CTAB
- RRR
- No calf pain or swelling
Labs showed: ___: 12.5 PTT: 26.7 INR: 1.2
Imaging showed:
US- Deep vein thrombosis in the distal right femoral vein with
possible extension into the proximal popliteal and left
posterior tibial vein.
Patient received: atorva
Neuro was consulted:
Patient with recent (___) large L MCA territory infarct.
Returns now with DVT. Please clarify extent and clinical
significance of DVT (i.e. does it extend into the pelvis? is
there a high risk for PE?). There are no rigorous clinical
guidelines addressing the safety of starting A/C after a large
territory infarct. If clinically warranted, we would agree with
anticoagulation for DVT
treatment (lovenox bridge to Coumadin), with the caveat that he
is certainly at increased risk of bleeding and should return to
the ED ASAP if any s/s of ICH (increased L sided weakness,
speech difficulty, somnolence, etc) occur.
Transfer VS were: 61 152/69 20 93% RA
Notably, he was admitted to neuro from ___ after
presenting w/ right-sided weakness and left gaze deviation, TPA
was not given since he was out the window. Per ___ d/c summary
"CTA demonstrated a large infarct in progress with high chance
of hemorrhagic conversion and further injury should flow be
restored". CTA showed a left proximal ICA occlusion extending
intracranially. Endovascular thrombectomy was not pursued since
the perceived benefit would be negligible and it would be the
risk high. CT head demonstrated a large hypodensity occupying at
least 50% of the left MCA territory. CT perfusion scan was
technically not feasible due to patient motion. An echo ruled
out thrombus and PFO. His video swallow evaluation demonstrated
aspiration with thin liquids. However, per speech and swallow
team, he is ok to take PO with ground solids, nectar thick
liquids with 1:1 supervision during meals.
On arrival to the floor, patient reported that he was feeling
okay and denied CP, SOB, abdominal pain, nausea, vomiting, and
diarrhea. He did endorse leg pain.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
TIA
L MCA Stroke
Social History:
___
Family History:
Brother - MI at age ___
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 97.3 PO 168 / 85 56 20 96 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI,
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, RLE >LLE, no TTP
of calves, no palpable cord
PULSES: 2+ DP pulses bilaterally
NEURO: Sensation to light touch is intact throughout his left
upper and lower extremities, he does not have sensation to light
touch over his right upper lower extremities , he is unable to
hold his right upper extremity against gravity is not able to
voluntarily move his right lower extremity
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL
==================
PHYSICAL EXAMINATION
Tm: 99.1, HR 69, BP 133/68, RR 18, 96% on RA
General: awake, in NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND.
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, place, full
date. Follows single-step commands with intermittent attention.
Cannot perform multi-step commands (performs incorrect sequence
of actions). Cannot follow written commands. However, he is able
to read slowly without problems. ___ object recall immediately,
and ___ recall after 5 minutes. Able to name high frequency
objects, but difficulty with low frequency objects. Was not able
to describe pictoral representation of a scene. No dysarthria,
but speech is slowed.
- Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Right
visual field deficit in right eye. Right facial droop (reduced
smile and reduced eyebrow raise). Altered sensation on right
side of face, but unable to describe sensation. Bilateral
hearing loss grossly (baseline for patient). Tongue protrusion
midline.
- Motor/Sensory: RUE plegic with extensor response to noxious,
RLE withdrawal to noxious, moves left side (LUE and LLE)
spontaneously with
full strength. Altered sensation in RUE and RLE (patient unable
to describe alteration).
- Reflexes: 2+ in bilateral brachioradialis, biceps, triceps,
and patellar. 1+ Achilles bilaterally. Toes downgoing on left,
upgoing on right plantar reflex.
- Cerebellum: Unable to assess finger-nose-finger test (patient
could not identify nose and some other parts of body, given
naming difficulties).
- Gait: Deferred
Pertinent Results:
ADMISSION LABS
==============
___ 06:08AM BLOOD WBC-9.3 RBC-4.68 Hgb-13.4* Hct-40.1
MCV-86 MCH-28.6 MCHC-33.4 RDW-13.1 RDWSD-40.2 Plt ___
___ 03:27PM BLOOD Neuts-68.5 Lymphs-14.2* Monos-14.4*
Eos-1.4 Baso-0.7 Im ___ AbsNeut-5.89 AbsLymp-1.22
AbsMono-1.24* AbsEos-0.12 AbsBaso-0.06
___ 03:27PM BLOOD ___ PTT-26.7 ___
___ 06:08AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-103 HCO3-26 AnGap-11
___ 06:08AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.4
HYPERCOAGULATION TESTS
=======================
___ 05:20PM BLOOD AT: 105 ProtCFn: 127 ProtSFn: 100
___ 05:20PM BLOOD VitB12: 496
___ 05:20PM BLOOD FacVIII: 217*
MICRO
=====
None
IMAGING
=======
US RLE ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral veins. Normal compressibility and flow of the
left femoral and popliteal veins. Normal color flow and
compressibility are demonstrated in the left posterior tibial
and peroneal veins. There is a occlusive thrombus in the right
mid to distal femoral vein. There is possible extension into the
proximal popliteal vein, however compressible. One of the left
posterior tibial veins is noncompressible. There is normal
respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Deep vein thrombosis in the mid to distal right femoral vein
with possible
extension into the proximal popliteal and left posterior tibial
vein.
CT CHEST W/CONTRAST ___
No evidence of intrathoracic malignancy or infection.
CT ABD & PELVIS WITH CO ___. No evidence of malignancy in the abdomen or pelvis, as
clinically
questioned.
2. There is prominent posterior osteophytes at the level of
T9-T10, causing moderate spinal canal narrowing. Recommend
correlation for potential symptoms.
3. There is a 0.4 cm hypodensity in the pancreatic uncinate
process, which is nonspecific, but likely represents a side
branch IPMN. Consider MRI of the pancreas in one year for
further evaluation.
4. Rounded hypodensity in the IVC inferior to the IVC filter,
possibly representing a nonocclusive thrombus. The common
femoral veins are patent.
DISCHARGE LABS
==============
___ 05:15AM BLOOD WBC-10.2* RBC-4.53* Hgb-13.2* Hct-39.4*
MCV-87 MCH-29.1 MCHC-33.5 RDW-13.0 RDWSD-40.5 Plt ___
___ 05:15AM BLOOD ___ PTT-30.0 ___
___ 05:15AM BLOOD Glucose-109* UreaN-17 Creat-0.5 Na-140
K-4.4 Cl-100 HCO3-24 AnGap-16
___ 05:15AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ year-old-male with a past medical history of
TIA and a recent discharge from the neurology service on ___
s/p large left MCA stroke who was transferred from ___
___ after he was found to have a RLE DVT for further
management.
# Distal right femoral DVT in the setting of recent large L MCA
stroke
A Doppler ultrasound of his right lower extremity on ___
revealed deep vein thrombosis in the mid to distal right femoral
vein with possible extension into the proximal popliteal and
left posterior tibial vein. There is an extensive conversation
that was had between medicine, neurology, and the patient's wife
about the risks and benefits of starting therapeutic
anticoagulation so soon after his recent left MCA CVA on ___.
A consensus decision was made to place an IVC filter in the
interim while the risk of hemorrhagic transformation of his
recent infarct would decrease. Was the risk had diminished, the
plan was to retrieve the IVC filter and start the patient on
therapeutic anticoagulation. The neurology/stroke team was
involved in guidance of determining when the transition point
would be. On ___, the patient had an IVC filter placed by ___
without complications.
# L MCA stroke
The patient had been recently admitted from ___ and was
found to have a large left MCA infarct with motor and sensory
deficits in the right half of his body. At that time, no tPA
administered as he was outside the window for treatment. His
neurologic status was closely monitored during this admission.
He was continued on aspirin, Plavix, atorvastatin. Neurology
was consulted to comment on whether he would require continued
triple therapy after initiation of anticoagulation or whether
aspirin or Plavix could be discontinued at that point. It was
decided that patient would be started on enoxaparin and
warfarin. A Ct torso was done that rule out malignancy or
infectious processes. Hypercoagulation work up was also ordered.
35 minutes were spent on discharge.
TRANSITIONAL ISSUES
===================
[] Will need ___ monitor at discharge for outpatient evaluation
[] Will need to be ordered for homocysteine, anti-phospholipid,
antithrombin III and prothrombin as outpatient.
[] Will need to follow final results of inpatient
hypercoagulation work-up
[] Will need to continue enoxaparin 90mg SC until INR
therapeutic for 24 hours. Then continue Warfarin daily dosing
based on INR.
CODE STATUS: Full (confirmed)
HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 90 mg SC BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Warfarin 5 mg PO DAILY16
Please monitor daily INR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Right lower extremity DVT (distal femoral to posterior tibial)
Secondary Diagnoses
===================
Complete Left MCA stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was pleasure taking care of you in the hospital!
Why was I admitted?
-Your admitted to the hospital from ___ rehab because of
concerns of a blood clot in your right leg
What happened while I was in the hospital?
-The risks and benefits of starting a blood thinner so soon
after your recent stroke were discussed in depth with the
neurology doctors as ___ as your wife
-A consensus decision was made to place an IVC filter in your
vein to prevent the clot in the leg from going to your lung
-You will be started on a blood thinner after the risk of
bleeding in the area of your stroke decreases and the IVC filter
will be removed by the interventional radiologists at a later
point
-You were seen and evaluated by physical therapy and
occupational therapy to help rescreen for rehab
-We did a scan of your thorax, abdomen and pelvis. We did not
find any evidence of malignancy or infection. We also did some
blood work to look for conditions that predispose to the
formation of clots. You need to follow up theses results as an
outpatient.
What should I do after I get discharged from the hospital?
-Continue to take all of her medications as prescribed, details
below
-Keep all of your appointments as scheduled
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
19616427-DS-2
| 19,616,427 | 26,566,148 |
DS
| 2 |
2177-11-29 00:00:00
|
2177-11-29 13:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
1. Open reduction, internal fixation of left periprosthetic hip
fracture; ___ ___
History of Present Illness:
___ female presents with the above fracture s/p and
unwitnessed fall at her nursing facility earlier today. The
patient was found down at her nursing facility with left hip
pain
and inability to weight-bear. Unclear HS/LOC. She denies any
other injuries. She presented to ___ where work-up
was remarkable for L hip periprosthetic fracture and she was
transferred to ___ for further care.
Past Medical History:
Dementia
HTN
HLD
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on Discharge
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
dressing clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Left lower extremity fires ___
Left lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Left lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
noncontributory
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of left periprosthetic hip 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 her nursing facility
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
touch down weight bearing in the left lower extremity with no
hip precautions, and will be discharged on enoxaparin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
I provided an opioid prescription with a notation that it can be
filled at a lower amount. I discussed with the patient regarding
the quantity of the opioid prescribed and the option to fill the
prescription in a lesser quantity. I also discussed the risks
associated with the opioid prescribed. Prior to prescribing the
opioid, I utilized the ___ Prescription
Awareness Tool) to review the patients previous prescriptions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X DAILY
2. Docusate Sodium 100 mg PO BID
use while taking narcotic pain medication.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 30 mg SC Q24H
RX *enoxaparin 30 mg/0.3 mL 1 injection subcutaneously daily
Disp #*28 Syringe Refills:*0
4. OLANZapine 2.5 mg PO QHS:PRN Confusion or agitation
RX *olanzapine 2.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
OK to request partial fill. wean as tolerated
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*28 Tablet Refills:*0
6. Senna 8.6 mg PO BID
use while taking narcotic pain medication.
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth daily Disp #*30 Tablet Refills:*12
8. amLODIPine 10 mg PO DAILY
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. Hydrochlorothiazide 12.5 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left hip periprothestic fracture, closed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing on the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take <<<<<>>>> 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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
touch down weight bearing on the left lower extremity. Hip range
of motion as tolerated with no precautions.
Treatments Frequency:
Dressing can be left open until visibly soiled or falling off.
If it becomes soaked it can be redressed as needing for
drainage. If the incision is dry it may be left open to air.
Followup Instructions:
___
|
19616513-DS-18
| 19,616,513 | 27,415,535 |
DS
| 18 |
2143-03-29 00:00:00
|
2143-03-30 11:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUE thrombosed fistula
Major Surgical or Invasive Procedure:
S/p RUE fistula thrombectomy on ___ by Interventional
Radiology
S/p Angioplasty and dilation of SVC on ___ by Interventional
Radiology
History of Present Illness:
Mr. ___ is a ___ year old male with a PMHx notable for HIV
(last CD4 count 369, undetectable viral load in ___ and ESRD
on HD with a fistula (MWF) ___ to BK infection s/p kidney
transplant ___ c/b chronic allograft nephropathy who
presents with failed access to his right upper extremity
fistula. Yesterday, the patient went for dialysis but could not
get access. At the time, he denied any pain, but notes some
increased sensitivity to touch near the fistula site. The
fistula was created in ___ and he has had no problems with it
until yesterday. Of note, the patient says over the last week,
he also has maybe had increased swelling of his neck, face, and
eyelids although earlier in the evening he expressly denied
this. At baseline he makes no urine. Currently, he is listed a
deceased donor kidney. He has accumulated over 1300 waiting
days.
In the ED, initial vitals: 98.2 86 179/111 16 100% room air. Was
hypertensive and got hydral 20 mg. Labs showed stable Hct. U/s
today shows extensive thrombosis of the right upper extremity
fistula on wet read. Vitals prior to transfer: 97.9 77 184/83 20
99% RA. Transplant surgery saw patient, and of note, their note
says "recent symptoms of SVC syndrome and pulsatility of fistula
suggesting central outflow stenosis. Pt will be seen in AV Care
for thrombectomy and likely angioplasty of outflow lesions.
Follow-up plan to be determined after today's procedure. Case
will be discussed at our weekly multidisciplinary access
meeting."
Currently, on the floor, patient endorses mild arm pain, R
lateral neck stiffness, and increased difficulty breathing as if
throat is swelling up. Is not wheezing. He says that his lower
neck is acutely swelling and he has not noticed his eyes
swelling before. He also says that his tongue is not swelling,
however, he does think that his voice is changing and becoming
more hoarse.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
- ESRD (HIV nephropathy, ESRD s/p cadaveric transplant ___
complicated by allograft nephropathy, BK/polyoma virus
nephropathy in ___
- HIV on HAART and currently on the transplant list
- Secondary hyperparathyroidectomy
- Hypertension
- neuropathy from HIV
- History of anaphylaxis to ___ grapes in ___
- History of Right IJ clot s/p coumadin for 3 months which
presented with neck swelling (f/u imaging shows recanalization
of the right internal jugular vein with chronic non-occlusive
thrombus)
- anal condylomata
SURGICAL HX:
- RUE AVF (___)
- Right brachiocephalic AVF (___)
- Right radiocephalic ___
- Ligation LUE AV fistula (___)
- Modified uvulopalatopharyngoplasty ___
- Subtotal parathyroidectomy (___)
- Anterior cervical corpectomy C4/C5, arthrodesis C3-C6
Social History:
___
Family History:
No history of renal disorders or coagulopathy in the family.
Physical Exam:
Admission:
Vitals- 98 151/84 98 18 92 RA
General- Somnolent and snoring loudly; obese black male. No
acute distress. Speaking in short sentences with ___ word
answers.
HEENT- Sclera anicteric, MMM, oropharynx clear, no uvula
swelling, no macroglossia; no scalloping; back of airway not
visualized well. Periorbital edema.
Neck- obese, short, JVP not elevated, no LAD. Anterior neck
edema.
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, with systolic murmur heard throughout
precordium
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema,
Palpable thrill, audible bruit over right upper extremity
fistula, distal pulses and sensation intact. Dressing c/d/i.
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
speaking in full sentences. anterior neck edema improved. left
upper arm swelling with stitches in the fistula.
Pertinent Results:
Admission labs:
---------------
___ 08:00PM ___ PTT-30.6 ___
___ 04:40AM GLUCOSE-79 UREA N-70* CREAT-18.3*# SODIUM-141
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-22 ANION GAP-25*
___ 04:40AM CALCIUM-9.7 PHOSPHATE-8.0*# MAGNESIUM-2.4
___ 04:40AM WBC-3.3* RBC-3.93* HGB-12.4*# HCT-39.5*#
MCV-100* MCH-31.6 MCHC-31.5 RDW-14.9
___ 04:40AM NEUTS-62.8 ___ MONOS-8.0 EOS-2.4
BASOS-0.6
___ 04:40AM PLT COUNT-109*
Discharge labs:
----------------
___ 02:30PM BLOOD WBC-6.0 RBC-3.93* Hgb-12.3* Hct-39.4*
MCV-100* MCH-31.3 MCHC-31.1 RDW-15.3 Plt Ct-98*
___ 02:30PM BLOOD Glucose-119* UreaN-61* Creat-16.6* Na-135
K-4.2 Cl-92* HCO3-24 AnGap-23*
___ 02:30PM BLOOD Calcium-8.6 Phos-7.2* Mg-2.3
Imaging:
--------
CHEST (PA & LAT) Study Date of ___
No acute cardiopulmonary abnormality.
UNILAT UP EXT VEINS US RIGHT ___
There is extensive echogenic thrombus distending the right upper
extremity fistula. No flow is detected by color Doppler.
CHEST (PORTABLE AP) Study Date of ___ 5:43 ___ (post
procedure)
No subcutaneous air. No other acute change
DIALYSIS ACCESS ANGIOGRAM on ___
80% stenosis at mid-fistula, 80% stenosis at basilic vein, and
70% stenosis at SVC. A post angioplasty angiogram then revealed
no residual stenosis.
Brief Hospital Course:
___ year old male with a PMHx notable for HIV (last CD4 count
369, undetectable viral load in ___ and HIV-associated ESRD
on HD with a fistula (MWF) ___ to HIV/BK virus s/p failed kidney
transplant in ___ who presents with failed access to his right
upper extremity fistula found to have thrombed RUE fistula as
well as face and neck swelling.
Active issues:
# Neck, face, eyelid edema: Etiology unclear, though given acute
presentation, likely SVC syndrome in setting of known SVC
stenosis and revascularization and normalization of blood flow
from RUE. However, differential also included angioedema
(though unlikely to present for first time at this age and no
involvement of tongue) and so for this reason he was empirically
treated with hydrocortisone and benadryl. Ultimately, SVC
syndrome is the likely etiology. He had angioplasty and partial
dilation of SVC by ___ on ___ with good effect. He did
receive a heparin gtt prior to the ___ angioplasty but it was
stopped after angioplasty as no clot had been visualized.
- follow up with interventional radiology as outpatient for
additional dilation of SVC after discharge from hospital
# OSA: Known severe sleep apnea by previous sleep studies, which
have led to palate biopsies. Continuous O2 monitoring showed
sats >92% on RA. Prior sleep clinic notes indicate that he has
had poor compliance with CPAP.
- consider again attempting CPAP as outpatient
# Thrombosed RUE fistula: No clear etiology. Has history of
Internal Jugular Vein thrombosis. S/p ___ thrombectomy on ___
with good effect. Per reports, entire clot removed by ___ today.
___ be related to chronic SVC stenosis and sluggish flow.
Completed HD without events.
Chronic issues:
---------------
# HIV: Last CD4 count 300s, viral load undetectable. Continued
kaletra, viread
# HTN: Continue home meds.
# ESRD: M, W, F. S/p failed kidney transplant. Continued
calcitriol, tacrolimus, prednisone, bactrim ppx (changed from DS
to SS)
# GERD: Continued omeprazole
Transitional issues:
--------------------
# CODE STATUS: Presumed Full
- f/u with outpatient ___ for possible additional dilation of SVC
(see discharge instructions to call Dr. ___ at ___- also had stitch in place over fistula and was asked to
f/u with AV care regarding this.
- f/u for evaluation for CPAP because of severe OSA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Abacavir Sulfate 300 mg PO BID
3. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (FR)
4. Lopinavir-Ritonavir 2 TAB PO BID
5. Tacrolimus 0.5 mg PO 1X/WEEK (MO)
6. Omeprazole 40 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 300 mg PO BID
2. Calcitriol 0.25 mcg PO DAILY
3. Lopinavir-Ritonavir 2 TAB PO BID
4. Omeprazole 40 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Tacrolimus 0.5 mg PO 1X/WEEK (MO)
7. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (FR)
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Thrombosed RUE Fistula
SVC Syndrome
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 were admitted for a thrombosed hemodialysis
fistula and were found to have stenosis of one of the major
veins draining to your heart. You were treated by Interventional
Radiology with removal of the clot in your arm and then with
dilation of the area of stricture in your large vein, called the
Superior Vena Cava. You then got dialysis. It is important that
you follow up with the Interventional Radiology doctors after
___ for additional evaluation for further dilation of the
stricture of your vein. Please also continue to follow up for
evaluation of your fistula as recommended.
We wish you the best and take care.
Sincerely,
SIRS Medical Service
___
Followup Instructions:
___
|
19616513-DS-21
| 19,616,513 | 28,341,957 |
DS
| 21 |
2143-09-17 00:00:00
|
2143-09-17 18:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ ESRD ___ HIV nephropathy, s/p DCD kidney transplant ___ c/b
allograft nephropathy ___ BK polyomavirus in ___ s/p SCD kidney
transplant on ___ c/b DGF & urinary retention s/p ureteral
stent removal ___ presenting with fevers 102 and dysuria.
After stent removal, he began having mild dysuria that has
progressively become worse. He also endorses dysuria, frequency
and urgency. He had a fever 102 on satuarday, took some tylenol
later for HA (subsided) but then had another low grade fever to
100.2 with chills at home on ___.
He was recently admitted to the Transplant surgery service
___ after presenting with fevers 102. Fever work up was
unrevealing, with lactococcus grown in the blood cx, which was
thought to be a contaminant by ID. He was initially started on
empiric antibiotics (vanc x5days) but was not disharged home on
any antibiotics. A f/u BK urine smaple was negative on ___.
Last ___ was 136.
Past Medical History:
- ESRD (HIV nephropathy, ESRD s/p cadaveric transplant ___
complicated by allograft nephropathy, BK/polyoma virus
nephropathy in ___
- HIV on HAART and currently on the transplant list
- Secondary hyperparathyroidectomy
- Hypertension
- neuropathy from HIV
- History of anaphylaxis to ___ in ___
- History of Right IJ clot s/p coumadin for 3 months which
presented with neck swelling (f/u imaging shows recanalization
of the right internal jugular vein with chronic non-occlusive
thrombus)
- anal condylomata
SURGICAL HX:
- RUE AVF (___)
- Right brachiocephalic AVF (___)
- Right radiocephalic ___
- Ligation LUE AV fistula (___)
- Modified uvulopalatopharyngoplasty ___
- Subtotal parathyroidectomy (___)
- Anterior cervical corpectomy C4/C5, arthrodesis C3-C6
Social History:
___
Family History:
No history of renal disorders or coagulopathy in the family.
Father with diabetes
Physical Exam:
Admission Physical Exam:
Vitals: 101.2 119 138/72 18 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,graft
non-tender
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
99.3/97.7 89 134/72 18 100RA
Gen: AOx3, sitting in chair, NAD
HEENT: sclera nonicteric, MMM, EMOI
CV: RRR, S1/S2
Pulm: CTAB/L, no respiratory distress
Abd: soft, nontender, no rebound, no guarding
Ext: warm, well perfused, no edema or evidence of cyanosis
Pertinent Results:
Labs:
___ 06:50AM BLOOD WBC-2.5* RBC-3.26* Hgb-10.4* Hct-29.7*
MCV-91 MCH-32.0 MCHC-35.0 RDW-14.6 Plt ___
___ 06:50AM BLOOD Glucose-116* UreaN-20 Creat-2.2* Na-138
K-3.7 Cl-105 HCO3-23 AnGap-14
___ 06:50AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.6
Tacrolimus Level:
___ 06:50AM BLOOD tacroFK-9.6
___ 07:22AM BLOOD tacroFK-9.0
___ 08:35AM BLOOD tacroFK-5.0
Microbiology
___ 8:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
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---- =>16 R
Imaging:
RENAL TRANSPLANT U.S. ___: Normal renal transplant
ultrasound
CXR ___: No acute intrathoracic process
Brief Hospital Course:
Mr. ___ UA was positive for UTI. He was subsequently
admitted to the transplant surgery service for further
management. He was initially started on vancomycin and
ceftriaxone for emperic coverage. He underwent a renal
transplant ultrasound which revealed normal findings with
adequate arterial waveformes and velocities. The infectious
disease team was consulted and recommended Ciprofloxacin until
___ for Citrobacter Freundii Complex infection, per urine
culture sensitivities. Daily blood cultures were drawn and at
time of discharge, all blood cultures were no growth to date.
Mr. ___ WBC was <3 during this admission. Valcyte dose was
decreased from 450 Q24 to 250 Q48. MMF dose was also decreased
from 500PO QID to ___ PO BID. Additionally, calcitriol was
increased from 0.5mcg to 0.75mcg QD per nephrology. At time of
discharge, patient was afebrile for >24 hours, tolerating a
regular diet, having adequate urine output, and ambulating
without difficulty. Discharge teaching was completed and he
voiced verbal agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Calcium Carbonate ___ mg PO BID
4. Dolutegravir 50 mg PO DAILY
5. Emtricitabine 200 mg PO EVERY OTHER DAY
6. Maraviroc 300 mg PO BID
7. Mycophenolate Mofetil 500 mg PO QID
8. Omeprazole 40 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. PredniSONE 15 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Tacrolimus 7 mg PO Q12H
13. Tamsulosin 0.4 mg PO QHS
14. Tenofovir Disoproxil (Viread) 300 mg PO Q48H
15. ValGANCIclovir 450 mg PO Q24H
16. Acetaminophen 1000 mg PO Q8H:PRN pain
17. Docusate Sodium 100 mg PO BID
18. Sodium Polystyrene Sulfonate 15 gm PO ASDIR
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Calcitriol 0.75 mcg PO DAILY
3. Calcium Carbonate ___ mg PO BID
Take separate from meals and mycophenolate/other meds
4. Docusate Sodium 100 mg PO BID
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine 200 mg PO EVERY OTHER DAY
7. Maraviroc 300 mg PO BID
8. Mycophenolate Mofetil 500 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
No driving if taking this medication
11. PredniSONE 10 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 8 mg PO Q12H
Level and Labs ___. Tamsulosin 0.4 mg PO QHS
15. Tenofovir Disoproxil (Viread) 300 mg PO Q48H
16. ValGANCIclovir 450 mg PO Q48H
17. Acetaminophen 1000 mg PO Q8H:PRN pain
Maximum 3 grams daily
18. Azithromycin 1200 mg PO 1X/WEEK (SA)
19. Sodium Polystyrene Sulfonate 15 gm PO ASDIR
Take only as directed by the transplant clinic for high
potassium level in your blood work
20. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
End date ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Leukopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, yellowing of skin or
eyes, increased abdominal pain, dizziness or weakness, decreased
urine output or dark, cloudy urine, difficulty with voiding
urine, swelling of abdomen or ankles, or any other concerning
symptoms.
You will have labwork drawn as arranged by the transplant
clinic, with results to the transplant clinic (Fax ___
. CBC, Chem 10, AST,T Bili, Urinalysis, Trough Tacro level.
On the days you have your labs drawn, do not take your Tacro
until your labs are drawn. Bring your Tacro with you so you may
take your medication as soon as your labwork has been drawn.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. No driving if taking narcotic pain medications
Drink enough fluids to keep your urine light in color.
Check your blood pressure at home. Report consistently elevated
values to the transplant clinic
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
Continue Cipro, antibiotic for your urinary tract infection
through ___
Followup Instructions:
___
|
19616613-DS-10
| 19,616,613 | 28,808,756 |
DS
| 10 |
2159-04-08 00:00:00
|
2159-04-10 14:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion, abdominal pain
Major Surgical or Invasive Procedure:
ERCP
- The plastic stent was removed using a polypectomy snare.
- Patency of the metalic stent was noted.
- A 3mm long stricture was seen above the stent in the proximal
CHD with mild post-obstructive dilation - likely from
porta-hepatis lymph nodes.
- A ___ X 5cm double pig tailed plastic stent was placed
successfully traversing the proximal stricture.
History of Present Illness:
The majority of the history is from chart review as patient is
altered and could not provide adequate history.
Mr. ___ is a ___ year old gentleman with a history of hepatitis
C cirrhosis, alcohol abuse, and obesity who was discharged from
the hospital 5 days ago for a biliary duct obstruction s/p
stenting in the setting of a pancreatic mass that is now
confirmed as pancreatic adenocarcinoma. He presets today with
fevers, confusion, lethargey, tremulousness, and persistent
abdominal pain.
Last week at an OSH, the patient had a CT A/P, MRCP, and ERCP
showing biliary ductal prominence with abnormal proliferation of
peripancreatic and retorperitoneal lymph nodes as well focal
hypoattentuation in the pancreatic head concerning for neoplasm.
His MRCP was significant for a intra-pancreatic CBD stricture
concerning for malignancy. He then underwent an ERCP which again
demonstrated a malignant-appearing CBD stricture and a
pancreatic and CBD duct stents were placed. Cytology was
positive adenocarcinoma. At ___, patient underwent repeat ERCP
with the placement of a metal stent in the CBD and FNA with
showed adenocarcinoma.
Per the ED note the patient was seen in clinic yesterday where
labs were notable for TBili 6.5, AST 225, ALT 116, AP 243 which
were elevated from prior. Patient's brother spoke with the
surgery service day prior to admission and said the patient had
continued abdominal pain which he has had for more than a month,
but was starting to have cold sweats without fevers. Today he is
fevers, confusion, lethargey and continued abdominal pain.
The patient himself says his abdominal pain has been on going
for ___ months, he is not sure if it's changed. He says he has
had fevers on and off for a while. He describes dysuria.
Otherwise no nausea, emesis, diarrhea, constipation, melena,
BRBR, cough, headache, chest pain, palpitations.
In the ED, initial vital signs were: T 97.7 Tm 101.3 BP 157/86 R
20 O2Sat 9% RA. Tmax in the ED was 101.3. His ED exam was
notable for scleral icterus, asterixis, and tenderness to
palpation in the epigastrium. He was alert to his name, the
city, and the president, but not to the date or the hosital.
Labs were notable for a wbc 4.5, H/H 12.1/35.0, Plt 166, AST
218, ALT 123, AP 218, T bili 7.3, INR 1.2, K 2.9. The patient
was initially started on cefepime which was changed to zosyn,
and given IVF.
Of note, just prior to coming to the floor, the patient was
noted to be "somnolent" but arouable to voice by his nurse.
Therefore, additional dilaudid was held given concerns for
somnolence.
On the floor, patient was awake and alert, continues to have
right upper quadrant pain.
Past Medical History:
- Pancreatic adenocarcinoma
* Presented to ___ ___ with obstructive
jaundice.
* CTA (___) showed 4.2 x 2.9 cm "hypoenhancing
pancreatic head/neck mass concerning for adenocarcinoma" and
results in "encasement of celiac axis" and liver lesions
"concerning but not diagnostic for metastases"
* FNA (___) confirms adenocarcinoma
- Hepatitis C/EtOH cirrhosis
* Previously on ledipasvir-sofosbuvir
- Morbid obesity
- Obstructive sleep apnea: On CPAP
- Bipolar disorder
- Anxiety disorder
- History of alcohol abuse
- Hypertension
Social History:
___
Family History:
No history of pancreatic cancer, maternal grandfather died of
cancer but patient does not know what type.
Physical Exam:
ADMISSION:
==========
Vitals - 97.9 133/77 72 20 98% 3L
___: obese male, lying in bed in no acute distress
HEENT: icteric sclera, MM dry
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese abdomen, soft, mildly distended with tenderness
over upper quadrants, no rebound or guarding
EXTREMITIES: pitting edema to the knee bilaterally
NEURO: A&Ox1 to person. Moving all extremities purposfully.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
==========
Vitals: 97.9, 147/88, 93, 18, 93% 3LNC
___: AAOx3, comfortable appearing, in NAD, sitting on edge
of bed
HEENT: NCAT, Scleral icterus. MMM. OP clear.
Neck: supple, No JVD
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: BS+, obese, soft, nondistended, tender to palpation
diffusely without rebound or guarding No HSM, improved from
previous exams
Ext: WWP. trace edema bilaterally
Neuro: moves all extremities grossly
Pertinent Results:
ADMISSION:
==========
___ 05:07PM LACTATE-1.9
___ 04:55PM GLUCOSE-187* UREA N-7 CREAT-0.8 SODIUM-135
POTASSIUM-2.9* CHLORIDE-92* TOTAL CO2-33* ANION GAP-13
___ 04:55PM estGFR-Using this
___ 04:55PM ALT(SGPT)-123* AST(SGOT)-218* ALK PHOS-218*
TOT BILI-7.3*
___ 04:55PM LIPASE-13
___ 04:55PM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-2.0*
MAGNESIUM-2.4
___ 04:55PM WBC-4.5 RBC-3.75* HGB-12.1* HCT-35.0* MCV-93
MCH-32.2* MCHC-34.5 RDW-16.8*
___ 04:55PM NEUTS-71.8* LYMPHS-15.3* MONOS-8.9 EOS-3.5
BASOS-0.5
___ 04:55PM PLT COUNT-166
___ 04:55PM ___ PTT-27.0 ___
OTHER LABS:
===========
___ 04:55PM BLOOD ALT-123* AST-218* AlkPhos-218*
TotBili-7.3*
___ 07:15AM BLOOD ALT-119* AST-198* AlkPhos-219*
TotBili-9.2*
___ 06:50AM BLOOD ALT-105* AST-165* LD(___)-287*
AlkPhos-213* TotBili-9.1*
___ 06:36AM BLOOD ALT-106* AST-174* LD(___)-284*
AlkPhos-223* TotBili-8.0*
DISCHARGE:
==========
___ 06:36AM BLOOD WBC-4.5 RBC-3.71* Hgb-11.7* Hct-34.7*
MCV-94 MCH-31.6 MCHC-33.8 RDW-16.8* Plt ___
___ 06:36AM BLOOD ___ PTT-26.1 ___
___ 06:36AM BLOOD Glucose-127* UreaN-8 Creat-0.7 Na-140
K-3.5 Cl-99 HCO3-30 AnGap-15
___ 06:36AM BLOOD ALT-106* AST-174* LD(LDH)-284*
AlkPhos-223* TotBili-8.0*
___ 06:36AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.5
IMAGING:
========
___ ERCP:
Impression: The scout film revealed a plastic and a metalic
biliary stent in place.
The plastic stent was removed using a polypectomy snare.
Contrast extended to the CBD and CHD and left IHD. Patency of
the metalic stent was noted.
A 3mm long stricture was seen above the stent in the proximal
CHD with mild post-obstructive dilation - likely from
porta-hepatis lymph nodes.
A 4mm Hurricane balloon was introduced through the guidewire for
dilation under flouroscopy successfully.
A ___ X 9cm double pig tailed plastic stent was placed
successfully traversing the proximal stricture.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum.
___ CXR:
IMPRESSION:
In comparison with the study of ___, there is continued
enlargement of the cardiac silhouette with opacification at the
left base consistent with volume loss in the lower lobe and
pleural effusion. No acute focal pneumonia or definite vascular
congestion.
___ CT Abd/Pelvis
IMPRESSION:
1. Ill-defined hypoenhancing pancreatic head/ neck mass with
upstream ductal dilatation and gland atrophy, concerning for
adenocarcinoma. The mass occludes the portosplenic confluence
and results in encasement of celiac axis branches as noted
above. Plastic CBD stent in place.
2. Incompletely characterized hypodense liver lesions as
detailed above, concerning but not diagnostic for metastases.
One of the liver lesions is somewhat linear and may represent a
right anterior portal venous thrombus.
3. Porta hepatis, mesenteric, and retroperitoneal
lymphadenopathy concerning for tumor involvement.
4. Small amount of abdominopelvic ascites has increased from
recent CT scan.
5. Splenomegaly.
6. Please refer to chest CT for thoracic details.
MICROBIOLOGY:
=============
Blood and urine cultures negative to date
Brief Hospital Course:
___ yo M with pancreatic adenocarcinoma, HTN, bipolar disorder
here with fever and fatigue and rising LFTs.
# Fever/LFT abnormalities. Given rebounding LFTs, fever, and
abominal pain and recent instrumentation concerning for possible
ascending cholangitis. His LFTs are not far from his baseline
though they were declining after the stent was placed. Other
causes of his fever include his underlying malignancy. Blood
cultures were sent and he was started on zosyn empirically. He
was treated with morphine for pain which was later changed to
dilaudid due to concern for altered mental status. ERCP was
performed to examine the stents. Plastic stent was removed and a
new stent was placed to the proximal stricture. LFTs were
downtrending by discharge and abdominal pain improved. He was
transitioned from zosyn to oral ciprofloxacin which will be
continued for a 5 day course.
# Obesity hypoventilation: Patient was found to have O2
saturation <89% on RA at rest and ambulation, likely related to
obesity hypoventilation and obstructive sleep apnea. He was
discharged with home oxygen therapy in addition to his CPAP at
night.
# Pancreatic Adenocarcinoma. Pathology was consistent with
adenocarcinoma.
Patient was previously scheduled to follow up with oncology on
___ and will follow up with them as an outpatient.
# Delirium: Patient was A&Ox1. Per his brother, baseline is very
flat due to his psychiatric medications. He was acutely confused
on arrival likely secondary to infection and use of morphine for
pain relief which his brother said he tolerates poorly. He was
changed to dilaudid and his mental status improved.
# Hypertension: Continued on amlodipine 2.5 mg PO DAILY
# Obstructive sleep apnea: CPAP
# Bipolar disorder/Anxiety: Continued ARIPiprazole 30 mg PO
DAILY, Citalopram 40 mg PO DAILY, ClonazePAM 2 mg PO BID,
QUEtiapine Fumarate 100mg BID and Venlafaxine 100 mg PO BID
# History of alcohol abuse. Patient states last drink was
several months ago. He was continued on Acamprosate 666 mg PO
TID
# Chronic pain: continued on Gabapentin 800 mg PO TID
# GERD: Famotidine 20 mg BID
# COPD/asthma: Fluticasone-Salmeterol Diskus (250/50) 1 INH IH
BID
# Tobacco abuse: Nicotine Patch 14 mg TD DAILY
TRANSITIONAL ISSUES:
-will need oncology follow up for new diagnosis
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acamprosate 666 mg PO TID
2. Amlodipine 2.5 mg PO DAILY
3. ARIPiprazole 30 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. ClonazePAM 2 mg PO BID
6. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Gabapentin 800 mg PO TID
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
12. Nicotine Patch 14 mg TD DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. QUEtiapine Fumarate 100 mg PO QAM
15. QUEtiapine Fumarate 100 mg PO QHS
16. Senna 8.6 mg PO BID
17. Venlafaxine 100 mg PO BID
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
19. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Oxygen
Dx: Hypoventilation secondary to obesity
Home O2
concentration and portable
3L O2 via nasal cannula
Rest sat on RA 84%, ambulatory 84% on RA, ambulatory on 3L
90-91%
Length of need: 99
2. Acamprosate 666 mg PO TID
3. Amlodipine 2.5 mg PO DAILY
4. ARIPiprazole 30 mg PO DAILY
5. Citalopram 40 mg PO DAILY
6. ClonazePAM 2 mg PO BID
7. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
8. Famotidine 20 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Gabapentin 800 mg PO TID
11. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch transdermally daily Disp #*7
Patch Refills:*0
12. QUEtiapine Fumarate 100 mg PO QAM
13. Venlafaxine 100 mg PO BID
14. Docusate Sodium 100 mg PO BID
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
16. Polyethylene Glycol 17 g PO DAILY
17. QUEtiapine Fumarate 100 mg PO QHS
18. Senna 8.6 mg PO BID
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*72 Tablet Refills:*0
20. Ciprofloxacin HCl 750 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Recurrent biliary obstruction
- metabolic encephalopathy
Secondary:
- Pancreatic adenocarcinoma
- Hypertension
- Morbid obesity
- OSA on CPAP
- Bipolar disorder
- Anxiety
- ETOH abuse in remission
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with abdominal pain due to a
blocked stent near your pancreas. This was fixed with a
procedure and the blockage was removed. Your liver tests
improved and your pain did as well. Your appointment with
oncology was rescheduled to next week. You should follow up with
your primary care doctor to have labs checked to make sure your
liver tests are going in the right direction.
You were started on an antibiotic to prevent infection after the
stent and you should keep taking this through ___. You were
also given pain medication and oxygen as you were found to have
low numbers while walking and at rest. You should continue to
wear your CPAP at night. It is very important that you NOT smoke
while on oxygen as this can cause a fire.
Your ___ Care Team
Followup Instructions:
___
|
19616613-DS-11
| 19,616,613 | 28,204,724 |
DS
| 11 |
2159-04-24 00:00:00
|
2159-04-25 07:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ M with DM2, obesity, HCV/EtOH cirrhosis with a
recent diagnosis of pancreatic adenocarcinoma who presents with
fever, chills, confusion and malaise.
He was recently admitted on ___ ___ Surgical
Service) after being transferred from ___
due to ___ for pancreatic malignancy. He underwent EGD/EUS
on ___ with biopsies which confirmed the diagnosis of
adenocarcinoma. He was subsequently discharged home with
oncology follow-up but was readmitted on ___ (Medicine)
for cholangitis. On that admission ERCP was performed (___)
with stent placement and dilation of malignant-appearing
stricture. He subsequently followed-up with oncology as an
outpatient on ___ at which time treatment options were
discussed, although his hepatic function was cited as a concern.
In the last several days since that appointment he has been
living with his brother who is his HCP and primary caregiver.
Unfortunately he has developed worsening abdominal pain ___
in severity), nausea, poor PO intake, jaundice. He has also
noted chills but has not measured any fevers. He denies any
diarrhea and has been moving his bowels. He has also been
sleepy but ___ states this is his recent baseline.
In the ED, initial vitals: 96.0 102 148/86 26 94% 2L Nasal
Cannula
- ERCP was consulted and recommended NPO @ MN for possible ERCP
in AM
- Labs notable for T-bili 10.3 (8.2 two days ago), ALT 141, AST
307, Alk-phos 328, lipase 27, lactate 1.5
- Diagnostic paracentesis was performed showing 1425 WBCs (15%
PMNs) but was noted to be cloudy appearing
- He was given 4.5g IV pipercillin-tazobactam
Vitals prior to transfer: 99 158/90 20 93% Nasal Cannula
Currently, he is sleepy but endorses mild ___ abdominal pain
radiating to his back. ___ reports ___ has had no EtOH to
drink in several weeks. In the ED it was noted that the patient
was hallucinating that he was seeing spiders, but he currently
denies this. ___ states he has had these type of
hallucinations previously. He denies any history of EtOH
withdrawal.
Past Medical History:
- Pancreatic adenocarcinoma
* Presented to ___ ___ with obstructive
jaundice.
* CTA (___) showed 4.2 x 2.9 cm "hypoenhancing
pancreatic head/neck mass concerning for adenocarcinoma" and
results in "encasement of celiac axis" and liver lesions
"concerning but not diagnostic for metastases"
* FNA (___) confirms adenocarcinoma
- Hepatitis C/EtOH cirrhosis
* Previously on ledipasvir-sofosbuvir
- Morbid obesity
- Obstructive sleep apnea: On CPAP
- Bipolar disorder
- Anxiety disorder
- History of alcohol abuse
- Hypertension
Social History:
___
___ History:
No history of pancreatic cancer, maternal grandfather died of
cancer but patient does not know what type.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 BP 135/84 HR 97 RR 18 SpO2 98% on RA
___: Sleepy but rouses to voice
HEENT: Conjunctival icterus present
RESP: CTAB, distant breath sounds
CV: RRR, distant heart sounds, no m/r/g
ABD: Distended, obese, tense, +fluid wave
GU: No foley
EXT: 3+ edema R=L
NEURO: Sleepy, rouses to voice, oriented x 3. +Asterixis
SKIN: Mild jaundice appreciated
DISCHARGE PHYSICAL EXAM:
GEN: disheveled male in no acute distress
HEENT: tacky mucous membranes
PULM: coarse breath sounds without distress
COR: RRR (+)S1/S2
ABD: Obese, diffuse mild tenderness
EXTREM: Warm, well-perfused
NEURO: AOx1-2, difficult to understand speech
Pertinent Results:
ADMISSION LABS
___ 10:55AM BLOOD WBC-9.1# RBC-3.91* Hgb-12.1* Hct-37.3*
MCV-95 MCH-30.9 MCHC-32.4 RDW-16.9* Plt ___
___ 10:55AM BLOOD Neuts-82.1* Lymphs-10.7* Monos-5.8
Eos-0.9 Baso-0.6
___ 04:57PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 10:55AM BLOOD ___ PTT-26.4 ___
___ 10:55AM BLOOD Plt ___
___ 04:57PM BLOOD ___
___ 12:05AM BLOOD ___
___ 10:55AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 10:55AM BLOOD ALT-141* AST-307* AlkPhos-328*
TotBili-10.3* DirBili-6.5* IndBili-3.8
___ 10:55AM BLOOD Lipase-27
___ 10:55AM BLOOD Albumin-3.1* Calcium-9.0 Phos-2.3* Mg-2.3
___ 10:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
TROPONIN TREND
___ 10:55AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD cTropnT-<0.01
LACTATE TREND
___ 11:11AM BLOOD Lactate-1.5
___ 05:43PM BLOOD Lactate-4.2*
___ 12:15AM BLOOD Lactate-5.7*
___ 05:01AM BLOOD Lactate-7.0*
___ 11:24AM BLOOD freeCa-1.10*
URINE
___ 03:15PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-8* pH-6.5 Leuks-NEG
___ 03:15PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
ASCITIC FLUID
___ 11:38AM ASCITES WBC-1425* RBC-2200* Polys-15*
Lymphs-66* Monos-0 Eos-1* Atyps-1* Plasma-1* Mesothe-2*
Macroph-12* Other-2*
___ 11:38AM OTHER BODY FLUID TotProt-1.7 Glucose-155
LD(LDH)-124 Albumin-LESS THAN
MICROBIOLOGY
MICROBIOLOGY DATA:
__________________________________________________________
___ 4:57 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): gram negative rods
__________________________________________________________
___ 4:57 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): gram negative rods
__________________________________________________________
___ 4:57 pm URINE Source: Catheter.
URINE CULTURE: negative
__________________________________________________________
___ 10:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:45 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:40 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:40 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G---------- 0.5 I
VANCOMYCIN------------ 0.25 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0631 ON ___ - ___.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 11:38 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 10:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ - ___.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 6:36 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:01 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:02 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
CTA chest (___):
1. Limited exam due to suboptimal opacification of the pulmonary
arteries
however acute pulmonary emboli are noted bilaterally including
lobar and
segmental branches on the right and segmental branches on the
left. No
evidence of right heart strain.
2. Small left pleural effusion with bibasilar consolidations may
reflect
atelectasis or aspiration.
3. Pneumobilia status post stent placement which is in
appropriate position.
4. Heterogeneous attenuation of the liver with new vague
hypodensity within
segment 6 of the liver is noted and given the short-term
development is
unlikely to represent metastases and may be perfusion
abnormality. Portal
veins are not assessed on this exam but the prior study
mentioned a possible
right portal venous thrombus.
5. Unchanged pancreatic head and neck mass with lymphadenopathy
in the
periportal, retroperitoneal and mesenteric stations.
6. Increasing moderate ascites.
EKG (___): Sinus tachycardia with prolonged QTc
CXR (___): Bibasilar opacities, likely representing
atelectasis on the right, however the opacities in the left
lower lung are slightly more confluent and may represent
atelectasis or pneumonia. Mild to moderate cardiomegaly.
LIVER U/S (___): Limited exam. Irregular liver suggesting
background cirrhosis. No focal defect identified but this is
not excluded
ERCP (___):
Scout film was showed a previously placed metal stent. No
plastic stent was seen. The common bile duct, common hepatic
duct, right and left hepatic ducts, and biliary radicles were
not filled with contrast. Only a few scattered intrahepatic
radicals were opacified after full injection cholangiography. A
single irregular stricture that was 2.5 cm long was seen from
the proximal end of the metal stent to the bifurcation extending
to both the R and L hepatic ducts. These findings are consistent
with a Bismuth type IV lesion. Scant biliary drainage was seen
endoscopically.
Radiologic interpretation:
I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good.
Impression:
No plastic stent was seen.
The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were not filled with
contrast.
Only a few scattered intrahepatic radicals were opacified after
full injection cholangiography.
A single irregular stricture that was 2.5 cm long was seen from
the proximal end of the metal stent to the bifurcation extending
to both the R and L hepatic ducts.
These findings are consistent with a Bismuth type IV lesion.
Scant biliary drainage was seen endoscopically.
ERCP (___):
Impression: The scout film revealed a plastic and a metalic
biliary stent in place.
The plastic stent was removed using a polypectomy snare.
Contrast extended to the CBD and CHD and left IHD. Patency of
the metalic stent was noted.
A 3mm long stricture was seen above the stent in the proximal
CHD with mild post-obstructive dilation - likely from
porta-hepatis lymph nodes.
A 4mm Hurricane balloon was introduced through the guidewire for
dilation under flouroscopy successfully.
A ___ X 9cm double pig tailed plastic stent was placed
successfully traversing the proximal stricture.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum.
Brief Hospital Course:
___ M with DM2, obesity, OSA, HCV/EtOH cirrhosis, recent
diagnosis of pancreatic adenocarcenoma (___) and cholangitis
s/p ERCP (___) with stent placement found to have presumed
cholangitis and multisystem organ failure in the setting of
overwhelming sepsis. Given his poor prognosis, the patient was
transitioned to comfort measure and discharged on hospice.
#) PANCREATIC ADENOCARCINOMA: Stage III/IV based on T4 tumor
size (tumor encases celiac vessels and is >4cm) and +LNs seen on
imaging, but full formal staging has not yet taken place. When
it became clear that PTBD would not be placed due to patient's
persistent decompensation, patient and family decided to
transition to hospice.
#) SEPSIS: Patient was admitted with chills, confusion and
malaise along with worsening abdominal pain ___ in
severity), nausea, poor PO intake and jaundice concerning for
cholangitis. He was started on IV vancomycin and pip/tazo upon
admission. ERCP was significant for malignant-appearing
strictures as well- unfortunately ERCP revealed blockage of
biliary drainage with no possible endoscopic intervention. PTBD
scheduled ___ was deferred in the setting of continued
decompensation. Pip/tazo was d/c on ___. Of note, blood
cultures from admission were consistent with strep viridans and
subsequent blood cultures from ___ were consistent with gram
negative rods, presumably from GI source. Patient was started on
meropenem on ___ for concern of sepsis in the setting of
fever, tachycardia, and respiratory distress while awaiting
PTBD. Interventional radiology subsequently concluded that
patient is longer candidate for PTBD due to respiratory issues
and concern for instability under anesthesia. Antibiotics were
discontinued upon transitioned to comfort measures.
#) RESPIRATORY DISTRESS: While in the PACU awaiting PTBD on
___, patient developed tachycardia and increasing respiratory
distress with increasing O2 requirements to 10L facemask. The
operation was held and he transferred to the MICU. Symptoms were
presumably from sepsis and PE. Patient was initially restarted
on heparin gtt at lower goal but this was discontinued within
___ given worsening coagulopathy.
#) PULMONARY EMBOLUS: On ___ CTA C/A/P showed acute PE
bilaterally in lobar and segmental branches for which patient
was started on heparin gtt. Heparin gtt was discontinued
midnight prior to anticipated PTBD on ___. Heparin gtt was
briefly restarted on heparin gtt at lower goal the evening that
procedure was deferred but this was again within 12h given
worsening coagulopathy.
#) HEPATITIS C/ETOH CIRRHOSIS: Peritoneal fluid studies are not
consistent with SBP. Scheduled for liver bx with ___ but
deferring in setting of acute illness. SAAG>1.1 suggesting
likely secondary to portal hypertension.
# Communication: HCP:Brother/HCP ___ (___)
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acamprosate 666 mg PO TID
2. Amlodipine 2.5 mg PO DAILY
3. ARIPiprazole 30 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. ClonazePAM 2 mg PO BID
6. DiphenhydrAMINE 25 mg PO Q8H:PRN itching
7. Famotidine 20 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Gabapentin 800 mg PO TID
10. Nicotine Patch 14 mg TD DAILY
11. QUEtiapine Fumarate 100 mg PO QAM
12. Venlafaxine 100 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Polyethylene Glycol 17 g PO DAILY
16. QUEtiapine Fumarate 100 mg PO QHS
17. Senna 8.6 mg PO BID
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
19. Ciprofloxacin HCl 750 mg PO Q12H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Milk of Magnesia 30 mL PO Q6H:PRN constipation
3. Nicotine Patch 14 mg TD DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID
6. Lorazepam 0.5-1 mg PO Q4H:PRN dyspnea, anxiety
RX *lorazepam 2 mg/mL 0.5-1 mg by mouth every four (4) hours
Refills:*0
7. Morphine Sulfate (Concentrated Oral Soln) 20 mg PO Q4H
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 20 mg by mouth
every four (4) hours Refills:*0
8. Morphine Sulfate (Concentrated Oral Soln) 10 mg PO Q1H:PRN
pain, dyspnea
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10 mg by mouth
q1h Refills:*0
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Dyspnea/wheezing
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY: metastatic pancreatic adenocarcinoma, cholangitis
Secondary: Hepatitis C, Alcoholic Cirrhosis, OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure treating you at ___
___. You were admitted with concern for recent fevers and
abdominal pain in the setting of your known pancreatic cancer.
Your abdominal pain was evaluated via an endoscopic procedure
which unfortunately showed advancement of your cancer. After
discussion with you, your family, and your outpatient provider,
the decision was made to admit you to hospice care at a
rehabilitation facility.
We wish you the best going forward,
Your ___ team
Followup Instructions:
___
|
19617689-DS-6
| 19,617,689 | 27,298,390 |
DS
| 6 |
2187-04-16 00:00:00
|
2187-04-24 11:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Augmentin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/ history of depression here c/o cough for the last two
weeks, but worse since yesterday. Was seen by her PCP 3 days ago
for this and diagnosed with viral bronchitis. Endorses chills
earlier today. Has been taking good PO and keeping hydrates.
Endorses improvement with benzonatate and Robitussin. Denies
chest pain (except with coughing), SOB.
In the ED, initial vitals were: 99.2 95 141/77 20 92% RA
- Exam: Well-appearing middle aged woman in NAD, althought
somewhat anxious. Lungs CTAB, RRR w/o m/r/g, no edema in LEs.
- Imaging showed LLL infiltrate c/w pneumonia.
- Labs showed WBC 18k.
Patient was started on doxycyline for community acquired
pneumonia.
She was observed overnight in the ED and late became hypoxic to
80% on RA with respiratory rates in the ___. She was then
admitted to medicine for pneumonia.
On the floor, the patient says that she is not feeling well, is
coughing, has mild-moderate SOB since yesterday, endorses
constipation, and says that when she gets a coughing fit she
becomes incontinent.
Past Medical History:
Patient says that she has "something in her brain" that was
diagnosed on ___, is apparently scheduled for an EEG on ___.
Neurologist told her it was most likely nothing to worry about.
Couldn't give me any more detail than this
-Hearing loss
-Ovarian cyst ___ years ago and again in ___
-Hx of psychosis, hears voices in head
-Depression
Social History:
___
Family History:
* father with alcohol abuse
* grandmother hospitalized with "hearing voices"
* mother with hx of depression per patient
* brother with depression and one brother who is socially
isolative
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 98.7 139/59 103 25 97% RA
General: Alert, oriented, appears anxious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Wheezing and coarse rhonchi throughout, moving good air
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE EXAM
==============
Vitals: 98.3 ___ 92-96% RA seated/91-92% RA with
ambulation
General: Breathing comfortably, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple
Lungs: decreased breath sounds in posterior lung fields, diffuse
upper airway sounds R>L
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: no rash
Neuro: CN ___ grossly intact, moving all extremities
spontaneously
Psych: AAOx3, answers questions appropriately
Pertinent Results:
ADMISSION LABS
==============
___ 08:45PM GLUCOSE-123* UREA N-10 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-21* ANION GAP-18
___ 08:45PM WBC-18.4*# RBC-4.63 HGB-13.8 HCT-41.2 MCV-89
MCH-29.8 MCHC-33.5 RDW-13.4 RDWSD-43.7
___ 08:45PM NEUTS-83.1* LYMPHS-8.8* MONOS-5.9 EOS-1.4
BASOS-0.5 IM ___ AbsNeut-15.24*# AbsLymp-1.62 AbsMono-1.09*
AbsEos-0.26 AbsBaso-0.10*
___ 11:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 11:00PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:00PM URINE MUCOUS-RARE
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-9.1 RBC-4.67 Hgb-13.6 Hct-42.8 MCV-92
MCH-29.1 MCHC-31.8* RDW-14.6 RDWSD-48.7* Plt ___
___ 07:20AM BLOOD Glucose-106* UreaN-11 Creat-0.8 Na-143
K-4.0 Cl-102 HCO3-30 AnGap-15
___ 07:20AM BLOOD Calcium-9.8 Phos-4.7* Mg-1.9
IMAGING
=======
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Patchy left base opacity, in a relative linear configuration on
the frontal view, may be due to platelike atelectasis, but
underlying infection is not excluded in the appropriate clinical
setting.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Increasing patchy bilateral opacities suggestive of atelectasis;
however,
pneumonia is not excluded given the appropriate clinical
setting.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
In comparison with the study of ___, there again is
increased
opacification in the retrocardiac region. Although this could
merely
represent atelectasis, in view of the clinical findings
superimposed pneumonia must be considered. If the condition of
the patient permits, a lateral view could be helpful.
CTA Chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bibasilar consolidations may reflect pneumonia in the
correct clinical
setting.
3. Bilateral hilar lymphadenopathy.
4. Bowing of the posterior wall of the trachea, suggestive of
tracheobronchomalacia.
Video Swallow ___
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of
obstruction. There is evidence of penetration without evidence
of gross
aspiration.
IMPRESSION:
Penetration without evidence of gross aspiration.
Barium Swallow ___
Transient holdup of the barium tablet in the oropharynx.
Tertiary contractions may reflect esophageal dysmotility.
No esophageal stricture.
MICROBIOLOGY
============
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ 11:00 pm URINE OLD ___ ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 1:50 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a past medical history of
depression and psychosis who presented with cough x 2 weeks and
worsened one day prior to admission, SOB/wheezing, and malaise.
Imaging and labs showed a leukocytosis of 18k and abnormal CXR
concerning for pneumonia. The patient was found to have
extensive history of dysphagia, thus was treated for aspiration
pneumonia and evaluated with swallowing studies.
#Pneumonia: Ms ___ presented with cough x 2 weeks, which had
worsened prior to admission associated with wheezing and SOB.
Lab evaluation showed leukocytosis, contaminated sputum culture,
negative legionella antigen. CXR showed bilateral opacities
suggestive of atelectasis vs. pneumonia. The patient was
initially treated empirically for CAP with levofloxacin, which
was broadened to vancomycin and cefepime due to increasing
oxygen requirement. The patient was evaluated with a CTA of her
chest which showed no pulmonary embolism and bibasilar
consolidations. During her hospital course, the patient was
witnessed by nursing to have difficutly swallowing and managing
her secretions. With this historical detail, her pneumonia was
suspected to be related to aspiration and she was transitionned
to unasyn then augmentin, treated with a 7 day course through
___. The patient's dysphagia and secretions were managed as
below. She was treated with benzonatate 200mg PO TID for cough
and duonebs with improvement in her symptoms.
#Dysphagia: The patient reported a history of dysphagia over the
past ___ years, which she had never brought to the attention of
her outpatient PCP. She noted to have some difficulty swallowing
pills and managing her secretions, thus her pneumonia was
suspected to be caused by aspiration and treated as such as
above. The patient was evaluated by speech and swallow who found
her to have coughing with solids and liquids. The patient was
evaluated with video swallow which suggested some oropharyngeal
weakness. The patient was evaluated with barium swallow which
showed possible esophageal dysmotility. The patient was
encouraged to chew your food well, take two swallows per bite,
alternate bites and sipping fluids and eat and drink slowly. The
patient will follow up with GI after discharge for further
evaluation.
#Depression/psychosis: Patient remained stable. She was
continued on her home medications of Geodon, Clozapine, and
nortriptyline.
#Neuropathic pain: patient was continued on her home gabapentin
300 mg QAM
# Mental Status changes: The patient had some fluctuations in
her mental status when she was having increased oxygen
requirement. ABG did not show hypercarbia. Differential
diagnosis included delirium vs. toxic metabolic encephalopathy.
The patient was treated as above for pneumonia and her mental
status improved.
# Anion Gap Acidemia: The patient was found to have an anion gap
of 24 ___. Lactate at that time was 2.1. The patient had no
evidence of uremia, ketonemia, DKA. The patient's osmolar gap
the next day was found to be 2.7 and her gap closed
spontaneously.
TRANSITIONAL ISSUES
====================
- continue augmentin through ___
- please consider restarting glycopyrrolate for control of
secretions
- GI follow-up for evaluation of esophageal dysmotility
- Full code
- contact: ___, sister, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 50 mg PO QHS
2. Clozapine 200 mg PO QHS
3. ZIPRASidone Hydrochloride 80 mg PO BID
4. Gabapentin 300 mg PO QAM
5. Gabapentin 100 mg PO QPM
6. Benzonatate 100 mg PO TID
7. Glycopyrrolate 2 mg PO DAILY
8. Benztropine Mesylate 1 mg PO QPM
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID
2. Clozapine 200 mg PO QHS
3. Gabapentin 100 mg PO QPM
4. Nortriptyline 50 mg PO QHS
5. ZIPRASidone Hydrochloride 80 mg PO BID
6. Gabapentin 300 mg PO QAM
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*5 Tablet Refills:*0
9. Benzonatate 200 mg PO TID:PRN cough
RX *benzonatate 200 mg 1 capsule(s) by mouth three times per day
Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
aspriation pneumonia
dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with cough and shortness of
breath. We believe this was caused by aspiration pneumonia. You
were treated wtih antibiotics, cough medicine and inhalers and
your symptoms improved. While in the hospital you also told us
that you were having some difficulty swallowing. You were
evaluated with a video swallowing study and a xray of your
esophagus which showed some possible problems with the movement
of the muscles in your esophagus. After discharge, you should
follow up with the gastroenterologist to further evaluate your
swallowing. You should continue taking augmentin through
___.
To help prevent further choking and coughing when you eat,
please remember to eat chew your food well, take two swallows
per bite, alternating bites and sipping fluids as well as
eating/drinking slowly.
We wish you the best!
- Your ___ Care Team
Followup Instructions:
___
|
19618591-DS-20
| 19,618,591 | 29,731,314 |
DS
| 20 |
2202-05-09 00:00:00
|
2202-05-09 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
================================
Hospital Medicine Admission Note
================================
cc: knee pain/edema
Major Surgical or Invasive Procedure:
Arthrocentesis
History of Present Illness:
This is a ___ y/o M with history of RA and gout who presents with
right knee pain. He reports his knee pain started yesterday
morning and prevented him from walking. He also complains of
ankle pain which started at around the same time. He was seen by
his PCP recently for lower extremity edema. As part of this work
up, he had an ECHO which was unchanged. He was started on Lasix
which he started taking 4 days prior to admission. He says his
___ edema improved transiently and then recurred with the
development of his knee pain. His pain has been so bad that he
has been unable to walk. He denies fever or chills. Does have a
history of gout which he says has effected all of his joints. He
denies fever or chills.
In the ED: Arthrocentesis attempted per patient. Given
Prednisone 20mg x1 for presumed gout and admitted for futher
management.
On arrival to the floor, he continues to complain of ___ right
knee pain.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No dysuria. Ten point review of systems is
otherwise negative.
Past Medical History:
MI in 1980s (cocaine induced)
HTN
Hypercholesterolemia
Gastritis- recent EGD
Gout
Polysubstance abuse: Alcohol- history of DTs no seizures
Social History:
___
Family History:
+family history of hypertension, coronary disease
Physical Exam:
VS: T: 97.9 BP: 154/94 P: 96 R:18 O2: 97% RA
Laying in bed in NAD.
HEENT: MMM, EOMI, Tongue midline
Lungs: Clear B/L on auscultation
___: RRR S1, S2 present
Abd: Soft, Obese, Nontender nondistended. BS+
EXT: + pain on palpation of right knee and ankle. No significant
effusion noted. ROM limited secondary to pain. +2 edema R/L. No
erythema or warmpth of knee joint. No other joint involvement.
Neuro/Psych: AAOx3, alert but vague in answers
Pertinent Results:
___ 07:00PM GLUCOSE-126* UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
___ 07:00PM WBC-7.7# RBC-4.57* HGB-13.9* HCT-41.7 MCV-91
MCH-30.4 MCHC-33.2 RDW-13.1
___ 07:00PM NEUTS-79.8* LYMPHS-14.1* MONOS-3.3 EOS-2.6
BASOS-0.3
___ 07:00PM PLT COUNT-231
Lower extremity duplex:
Negative
Joint fluid analysis
Source: Knee
ANALYSIS
WBC, Joint Fluid ___ 0 - 150 #/uL
Hematocrit, Joint Fluid 3.5* 0 - 0 %
SPUN HEMATOCRIT PERFORMED
Polys 66* 0 - 25 %
Lymphocytes 25 0 - 75 %
Monocytes 6 0 - 70 %
Eosinophils 3* 0 - 0 %
Joint Crystals, Number NONE
Brief Hospital Course:
___ with HTN, HL, alcohol and polysubstance abuse, and
seropositive RA who presented with ___ days of worsening R knee
pain and inability to walk.
Right knee pain.
He denied any trauma to the joint. He was seen by Rheum,
arthorocentesis performed without crystals. Pain likely due to
RA vs OA. Steroid injection done at bedside with excellent
symptom relief. He will follow up with his rheumatologist and
PCP.
___ Edema:
THe patient reports 1 month of increasing lower extremity
swelling. He has undergone outpt eval for this with normal BNP,
normal EF. LENIs negative for DVT.
-Lasix started as outpt, continued
-Exam and history concerning for liver disease. Plan to check
outpatient ultrasound for signs of ascites and/or cirrhosis and
refer to hepatology if appropriate. Continue lasix.
-Amlodipine discontinued as this was started concurrently with
development of symptoms.
#Alcohol abuse
Patient with significant alchohol abuse. last drink ___.
Trying to get into detox. Has history of DTs but not seizures
per patient. Did not score on CIWA. Seen by social work.
#Hypertension, Benign. BP improved with treatemnt of pain.
- Amlodipine discontinued given ___ edema as above. Lisinpril
dose increased to 20 daily. Follow up as outpt in 1 week for
labs and BP check.
#Gastritis
Continue Omeprazole/Sucrafate.
#Hyperlipidemia
Continue gemfibrazole
TRANSITIONAL ISSUES:
Needs BP check, K+ / Cr check and lisinopril dose adjustment at
follow up visit
OUtpt abd US to eval liver, potential referral to hepatology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Cyclobenzaprine 10 mg PO TID:PRN back pain
3. Furosemide 40 mg PO DAILY
4. Gemfibrozil 600 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
8. Sucralfate 1 gm PO Q6H:PRN abdominal pain
9. SulfaSALAzine ___ 500 mg PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Cyclobenzaprine 10 mg PO TID:PRN back pain
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Gemfibrozil 600 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
10. Sucralfate 1 gm PO Q6H:PRN abdominal pain
11. SulfaSALAzine ___ 500 mg PO BID
12. Thiamine 100 mg PO DAILY
13. Acetaminophen 1000 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Osteoarthritis
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with knee pain. THis improved with a steroid
injection.
We stopped your amlodipine in case this was contributing to your
legs swelling. You also need an evaluation of your liver to see
if liver disease is causing you to retain fluid - you are
scheduled for an ultrasound on ___ as noted below. Please
follow up with your doctors as ___ below.
Followup Instructions:
___
|
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2202-11-18 00:00:00
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2202-11-18 23:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of hypertension, hyperlipidemia,
rheumatoid arthritis, alcoholism, and polysubstance abuse, who
was referred to ED by his primary care physician for orthostasis
and acute kidney injury.
Patient reports having lightheadedness with standing associated
with posterior headache for the past one to 2 months. His
symptoms resolve when he sits or lies down. He is not
vertiginous. He has no associated neurologic symptoms such as
weakness, numbness, visual changes. In addition, he notes a
chronic cough and chills.
Above symptoms occurred in the setting of changes in pt's
antihypertensives. On ___, his Lasix was discontinued and he
was started on hydrochlorothiazide. Lisinopril was maintained 40
mg per day. He had to follow up with his PCP yesterday and had a
creatinine of 3.0 from baseline of 1.0. He also had orthostatic
vital signs. He was urged to present to the emergency
department, but declined.
Today, he continued to feel lightheaded with position changes,
so decided to come to the emergency department. He denies any
abdominal pain, nausea, vomiting, dysuria, hematuria. He does
have some discomfort in his left lower back that has been
present for several weeks. He continues to make a normal amount
of urine.
In the ED intial vitals were: 98.2 120 137/82 20 100%. Labs were
significant for Cr 2.9, HCO3 20, HCT 33, UA negative. He was
admitted for further management of ___.
On the floor, he reported several episodes of syncope preceded
by dizziness and reports a h/o posterior head strike.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Alcohol dependence and polysubstance abuse.
4. Cocaine induced myocardial infarction, remote.
5. Rheumatoid arthritis.
6. Hemorrhoids.
7. Lower extremity edema.
8. Back pain after a car accident in ___.
9. History of colonic AVMs grade III internal hemorrhoids and
diverticulosis.
Social History:
___
Family History:
+family history of hypertension, coronary disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
PHYSICAL EXAM:
Vitals - 98.1, 127/82, 105, 18, 100*RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: Tachycardic, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +RUQ ttp; no HSM; +NABS
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in UE and ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
BACK: +Left CVAT
LABS: see below
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.3 125/80 83 20 96/RA
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclera, MMM, nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Obese, NT/ND, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in UE and ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS:
=====
___ 11:55PM BLOOD WBC-7.7 RBC-3.59* Hgb-11.1* Hct-33.3*
MCV-93 MCH-30.9 MCHC-33.3 RDW-13.5 Plt ___
___ 08:15AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.9* Hct-30.3*
MCV-94 MCH-30.6 MCHC-32.7 RDW-13.5 Plt ___
___ 01:50PM BLOOD WBC-6.3 RBC-3.35* Hgb-9.9* Hct-31.7*
MCV-95 MCH-29.6 MCHC-31.2 RDW-13.1 Plt ___
___ 06:40AM BLOOD WBC-5.1 RBC-3.24* Hgb-9.9* Hct-30.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.9 Plt ___
___ 11:55PM BLOOD Glucose-93 UreaN-52* Creat-2.9* Na-141
K-5.0 Cl-106 HCO3-20* AnGap-20
___ 08:15AM BLOOD Glucose-85 UreaN-46* Creat-2.3* Na-141
K-5.1 Cl-108 HCO3-21* AnGap-17
___ 07:20PM BLOOD Glucose-107* UreaN-35* Creat-1.7* Na-136
K-4.3 Cl-104 HCO3-21* AnGap-15
___ 06:40AM BLOOD Glucose-98 UreaN-28* Creat-1.6* Na-138
K-4.6 Cl-106 HCO3-22 AnGap-15
___ 11:55PM BLOOD ALT-19 AST-20 AlkPhos-79 TotBili-0.2
___ 11:55PM BLOOD CK-MB-2 proBNP-15
___ 11:55PM BLOOD cTropnT-<0.01
___ 11:55PM BLOOD Calcium-9.4 Phos-4.1 Mg-1.6
___ 08:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.5*
___ 07:20PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.5
___ 06:40AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
___ 11:55PM BLOOD VitB___-___*
IMAGING:
=========
CXR (___)
IMPRESSION: Compared to prior study of ___, the appearance
of the lower
lobes is worse and it is unclear if this is due to volume loss
or new
infiltrate.
Renal US (___)
IMPRESSION:
1. No evidence of hydronephrosis or concerning lesions.
2. Right renal cyst, unchanged from the prior exam.
CT Chest (___)
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
___ y/o M with a PMHx of hypertension, hyperlipidemia, rheumatoid
arthritis, alcoholism, and polysubstance abuse, who was referred
to ED by his primary care physician for orthostasis and acute
kidney injury.
ACTIVE ISSUES:
===============
# ___
Based on urine lytes, appeared to be pre-renal in etiology with
significant improvement noted s/p fluid boluses. Likely due to
dehydration from poor PO intake that may be multifactorial in
etiology from social situation to history of alcohol use. Renal
US was performed on admission that was stable. No evidence of
infectious process leading to renal injury. No culprit meds. On
admission, Cr of 3 improved to 1.6 with good UOP and stable
lytes. Recommended continued PO intake of water and f/u with PCP
upon discharge.
# Orthostasis
Likely due to hypovolemic state as above leading to ___. After
fluid boluses pt had negative orthostatics with significant
improvement in his symptoms. Potentially also may have ETOH
induced autonomic dysfunction leading to orthostasis. Continued
monitoring recommended upon discharge. Consider wearing support
stalkings.
# Reported Cough
Not a prominent feature while here on admission but CXR was
performed with question of reduced chronic lower lobe volumes.
As such a CT scan was performed that showed no acute
cardiopulmonary process with reduced volumes likely due to
atelectasis.
# Normocytic Anemia
Chronic with drop during admission diultional from fluid boluses
and stable throughout admission with no e/o bleeding. Reportedly
had colonscopy recently without significant findings. Warrants
continued f/u on outpatient basis.
# Alcohol abuse
No evidence of withdrawal while here. Not scoring on CIWA.
Alcohol resources provided. Continue evaluation on outpt basis.
TRANSITIONAL ISSUES:
====================
- Please setup with social work (alcohol use, housing,
resources)
- Continue to monitor renal function
- Continue work-up of anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ammonium lactate 12 % topical daily to feet
2. Cyclobenzaprine 10 mg PO TID:PRN pain
3. lisinopril-hydrochlorothiazide ___ mg oral 2 tabs daily
4. SulfaSALAzine ___ 1500 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. SulfaSALAzine ___ 1500 mg PO BID
4. Thiamine 100 mg PO DAILY
5. ammonium lactate 12 % topical daily to feet
6. Cyclobenzaprine 10 mg PO TID:PRN pain
7. lisinopril-hydrochlorothiazide ___ mg oral 2 tabs daily
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostasis
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for acute renal failure
(injury to your kidney) likely because of dehydration. This also
is likely why you felt dizzy. Both improved after giving you
fluids.
Please continue to drink plenty of water after leaving the
hospital to stay well hydrated. Avoid drinks with caffeine that
can lead to dehydration.
Also it is important to seek assistance for alcohol use to
prevent further health injury and may be causing your feelings
of lightheadness too. There are a number of resources that can
help. You can also talk to the social workers at Healthcare
Associates who can connect and provide you with resources.
Please continue to take your home medications.
Please make sure to follow-up with your primary care doctor in
the next week.
Take care.
- Your ___ Team
Followup Instructions:
___
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| 22 |
2205-05-02 00:00:00
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2205-05-03 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
Penicillins / ibuprofen
Attending: ___
Chief Complaint:
Acute on chronic back ___
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ with h/o pinched nerve in his back (managed by PCP),
polyarthralgias, RA gout, HTN, previous substance abuse on
naloxone, who is presenting with acute on chronic back ___ x 4
days. Ran out of ___ medications 4 days ago. Currently, he
denies trauma, heavy lifting, fever/chills, saddle anesthesia,
weakness, bowel/bladder incontinence.
He has a history of chronic ___, ___ to multiple car collisions
as a pedestrian. His typical ___ involves sharp ___, radiation
to both legs/hells, exacerbated by sitting, with no clear
alleviating factors elicited. Last MRI: ___ showing
degenerative changes with canal narrowing. He's seen by
rheumatology (Dr. ___ Dr. ___ / Dr. ___
___ previously managed with tiazanide (TID PRN),
Gabapentin 300 MG, with a previous consideration of spinal
injection (he's previously received injections in his hips).
There have been changes to his tizanidine prescription (he has
run out and needs follow-up with his PCP before renewal); his
nightly dose of oxycodone 5 mg nightly has been discontinued in
the last 3 months. His housing situation is also more unstable:
he was rejected from ___ (a sober house?)in ___ and ___
been living with his daughter for the past month.
Past Medical History:
Anxiety
Colonoic AVMs grade III w/ internal hemorrhoids + diverticulosis
L maxillary fracture with surrounding hematoma s/p drainage
Gastritis
Gout
Hemorrhoids
Hypertension
Hyperlipidemia
Polyarthralgias
Rheumatoid arthritis
Substance abuse - alcohol and cocaine
Remote history of cocaine induced myocardial infarction
B12 deficiency
Antral intestinal metaplasia
Social History:
___
Family History:
+family history of hypertension, coronary disease
Physical Exam:
ADMISSION PHYSICAL EXAM
PHYSICAL EXAM:
VS:97.7, PO 108 / 65, 88 19 98 RA
GEN: Alert, lying in bed, appears in ___
HEENT: PERRL, Moist MM, anicteric sclerae, no conjunctival
pallor
NECK: Supple without LAD
PULM: CTAB
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema, tender to light touch
diffusely
NEURO: CN II-XII grossly intact, inability to raise left or
right leg off bed > 10 degreees ___ ___ in lower back. Spinous
process tenderness at L5/S1 region, otherwise no other focal
neuro tenderness. gati not assessed. subjective decreased
sensation in right lower extremity at baseline.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4/97.9, 88-98, 116-153/67-88, 16 100%
General: alert, oriented, no acute distress, sitting in chair,
able to ambulate independently with aid of walker
HEENT: sclera anicteric, MMM
Neck: Supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: Moves all four extremities; Full strength bilaterally in
biceps/triceps, in quadriceps, in plantar/dorsiflexion.
Sensation in tact to light touch in ___ bilaterally.
Pertinent Results:
Admission Labs:
___ 08:23PM GLUCOSE-118* UREA N-14 CREAT-1.1 SODIUM-132*
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-24 ANION GAP-14
___ 08:23PM WBC-5.6 RBC-3.85* HGB-11.5* HCT-36.8* MCV-96
MCH-29.9 MCHC-31.3* RDW-14.2 RDWSD-50.1*
Discharge Labs:
___ 05:58AM BLOOD WBC-5.2 RBC-3.97* Hgb-12.0* Hct-37.3*
MCV-94 MCH-30.2 MCHC-32.2 RDW-13.6 RDWSD-46.4* Plt ___
___ 05:58AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-135
K-3.8 Cl-99 HCO3-25 AnGap-15
___ 05:58AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6
In-Patient Imaging:
CT L-SPINE W/O CONTRAST ___ 12:22 ___
IMPRESSION:
1. No acute fracture or traumatic dislocation.
2. Slight interval increase in size of a posterior disc bulge at
the L3-L4
level, resulting in mild canal narrowing.
3. No significant change in degenerative disc disease at the
L4-L5 level, with
diffuse disc bulge and prominent epidural fat causing severe
canal narrowing.
4. Diffuse disc bulge at L5-S1 is unchanged.
Brief Hospital Course:
___ with h/o pinched nerve in his back (managed by PCP), who is
presenting with acute on chronic back ___ x 7 days I/s/o not
having / not taking his ___ medications. At the time of
discharge, his back ___ was controlled.
# Back ___
Patient has a long history of multifactorial back ___,
complicated by rheumatologic causes, as well as mechanical
injuries. Patient had a L3-L4 CT, which as well as ___ evaluation
in the ED. On CT, he was found to have no acute fracture or
traumatic dislocation; a slight interval increase in size of a
posterior disc bulge at the L3-L4 level, resulting in mild canal
narrowing; and unchanged disk bulges at L5. Patient was resumed
on home regimen of medications, with an increase of his home
dose of 4 mg to tizanidine to 6 mg TID PRN.
He was evaluated by ___ and deemed safe for discharge with
follow-up out-patient ___.
TRANSITIONAL ISSUES
===========================================
1) Pt's home dose of tizanidine increased from 4 mg to 6 mg TID
PRN. Follow-up with primary care provider, chronic ___ clinic,
and rheumatology regarding appropriate ___ medication regimen
for patient's likely multi-factorial back ___.
2) Follow-up out-patient ___ to help with patient's baseline
limited ability to ambulate.
#Code: Full
#Communication: ___ - ___ (Sister); Daughter - ___
___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 100 mg PO QHS
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. lisinopril-hydrochlorothiazide ___ mg oral 2 tabs daily
5. Methotrexate 2.5 mg PO 1X/WEEK (MO)
6. Naltrexone 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. SulfaSALAzine ___ 500 mg PO UP TO 3 TABS BID
9. Tizanidine 4 mg PO TID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN ___ - Mild
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*90 Tablet
Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QPM:PRN back ___
RX *lidocaine [Lidoderm] 5 % Please apply to area of back ___
once a day Disp #*30 Patch Refills:*0
3. Tizanidine 6 mg PO TID
RX *tizanidine 6 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*90 Capsule Refills:*0
4. Amitriptyline 100 mg PO QHS
5. Cyanocobalamin 1000 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
8. lisinopril-hydrochlorothiazide ___ mg oral 2 tabs daily
9. Methotrexate 2.5 mg PO 1X/WEEK (MO)
10. Multivitamins 1 TAB PO DAILY
11. Naltrexone 50 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. SulfaSALAzine ___ 500 mg PO UP TO 3 TABS BID
14. Thiamine 100 mg PO DAILY
15. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic back ___
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with use of cane.
Discharge Instructions:
Dear Mr. ___:
It was a pleasure taking care of you while you were hospitalized
at ___. As you know, you were
admitted for worsening back ___. You were given your home
medicines to help you control your ___. You were seen by our
in-patient physical therapists who determined that you could
walk safely. We coordinated your follow-up appointments with
your primary care doctor and your physical therapist so that you
could address your back ___ and continue to improve your
baseline function.
Ultimately, we felt you were well enough to go home. Thank you
so much for letting us be a part of your care. We hope you're
feeling much better.
Your ___ Care Team
Followup Instructions:
___
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2206-06-06 00:00:00
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2206-06-06 13:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / ibuprofen
Attending: ___.
Chief Complaint:
L Groin Pain
Major Surgical or Invasive Procedure:
left hip arthrocentesis
History of Present Illness:
Of note, patient is somewhat of a vague historian. Pt is a ___
y/o M with PMHx HTN, gastritis, gout, prior polysubstance abuse,
as well as RA on MTX, who presented with L groin / LLE pain
since ___ (2 days 2 days ago). Pt describes pain as
"stinging" radiating from the L groin, around the anterior L
thigh, and then down the posterior aspect of the LLE. He reports
that there was some associated numbness but that this has
resolved. He endorses injury to the LLE ___ MVC several years
ago but states that this primary involved the L knee cap. He has
never had pain like this before. He denies any recent trauma to
the L leg or any heavy lifting. He denies any back pain or bowel
/ bladder incontinence. Per ED notes, he denies any IVDU.
Of note, per ED notes, he did have a pin recently removed from
this R knee and has been bearing more weight on the L leg
recently. He also endorses chronic numbness of the lateral RLE
related to another injury sustained from a MVC; however, he
states that this has not changed recently.
ED Course:
Initial VS: 98.8 98 151/85 16 98% RA Pain ___
Labs significant for CRP 118.3.
Imaging: ___ without evidence of DVT. CT A/P with no acute
process but did show evidence of degenerative disc disease.
Meds given:
___ 08:46 IV Morphine Sulfate 4 mg
___ 11:08 PO Oxycodone-Acetaminophen (5mg-325mg) 2 TAB
___ 19:56 IV Morphine Sulfate 4 mg
VS prior to transfer: 99.1 109 135/86 16 97% RA Pain ___
PVR was recorded as 0 in the ED. Given concern for inguinal
hernia on CT scan, surgery was consulted, who felt that the
patient's exam was not consistent with this.
On arrival to the floor, he confirmed the above history. He
reports that his pain is somewhat improved currently. He denies
any current back pain or numbness/tingling in the L leg.
However, he does report ongoing difficulty moving the LLE ___
pain. He is asking for a box lunch.
Past Medical History:
Anxiety
Colonoic AVMs grade III w/ internal hemorrhoids + diverticulosis
L maxillary fracture with surrounding hematoma s/p drainage
Gastritis
Gout
Hemorrhoids
Hypertension
Hyperlipidemia
Polyarthralgias
Rheumatoid arthritis
Substance abuse - alcohol and cocaine
Remote history of cocaine induced myocardial infarction
B12 deficiency
Antral intestinal metaplasia
Social History:
___
Family History:
Endorses FHx of CAD and EtOH abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 100.0 145 / 90 100 20 96 RA
GEN - alert, uncomfortable
HEENT - NC/AT, face symmetric
NECK - Supple
CV - Faint HS but appears RRR, no m/r/g appreaciated
RESP - CTA anteriorly, breathing comfortably
ABD - Obese, soft, NT, BS present
EXT - No calf tenderness ___ edema; pt with severely limited
ability to move the L leg ___ pain which extends from the groin,
around the L hip, and down the posterior aspect of the L leg; he
is tender to palpation on the anterior and lateral aspects of
the
L thigh; he does not have any appreciable pain, swelling, or
warmth over the L hip itself
BACK - no spinal tenderness noted
GU - no L sided inguinal hernia appreciated
SKIN - No apparent rashes
NEURO - Face symmetric; ___ strength in the BUE's; ___ strength
on RLE hip flexion and ankle dorsi/plantarflexion; unable to do
strength testing in the LLE ___ pain aside from L ankle
plantarflexion (___)
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM
Vitals: T 98.0 BP 139/84 HR 108 RR 18 O2: 94% on RA
Gen: Lying in bed in no distress, appears comfortable, awake and
alert
HEENT: AT, NC, PERRL, EOMI, MMM, hearing grossly intact
CV: tachycardic, regular rhythm, no mrg
Pulm: CTAB
GI: soft, obese, NT, ND, no HSM
MSK: No edema, L groin moderate pain with palpation - L hip
nontender, able to lift both legs off bed and 45 degrees at hip
Neuro: A+O x4, speech fluent, face symmetric, strength ___ in
all
extremities. Sensation intact.
Psych: calm mood, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 08:45AM BLOOD WBC-8.6 RBC-4.09* Hgb-12.0* Hct-37.3*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.9 RDWSD-46.1 Plt ___
___ 08:45AM BLOOD Neuts-66.8 Lymphs-18.1* Monos-13.0
Eos-1.4 Baso-0.2 Im ___ AbsNeut-5.74# AbsLymp-1.56
AbsMono-1.12* AbsEos-0.12 AbsBaso-0.02
___ 08:45AM BLOOD Glucose-129* UreaN-7 Creat-0.7 Na-141
K-3.8 Cl-103 HCO3-23 AnGap-15
___ 08:45AM BLOOD ALT-11 AST-13 AlkPhos-85 TotBili-0.6
___ 08:45AM BLOOD Albumin-3.7
___ 08:45AM BLOOD CRP-118.3*
___ 08:45AM BLOOD SED RATE-43
LLE DUPLEX
IMPRESSION:
Peroneal veins were not visualized. No evidence of deep venous
thrombosis in the remaining left lower extremity veins.
L HIP XR
IMPRESSION:
no fracture or dislocation. Minimal degenerative change.
MRI L-SPINE
IMPRESSION:
IMPRESSION:
1. No evidence for diskitis, osteomyelitis, epidural collection,
or
paravertebral collection. No abnormal intrathecal contrast
enhancement.
2. Epidural lipomatosis and multilevel degenerative disease
appear unchanged compared to the ___ MRI, as
detailed above. The thecal sac is severely narrowed at L4-L5
and L5-S1 with crowding of the intrathecal nerve roots.
Traversing L5 nerve roots are abutted and may be impinged at
L4-L5. Traversing right S1 nerve root is flattened at L5-S1.
MRI LEFT HIP
IMPRESSION:
1. Moderate left hip joint effusion and synovitis with
associated reactive
marrow edema in the adjacent acetabulum and proximal femur is
nonspecific and could be due to infectious or inflammatory
arthropathy. Correlation with recent arthrocentesis results is
recommended.
2. Mild nonspecific edema enhancement in the musculature about
the left hip may be due to strain or altered weight-bearing.
3. Increased signal at the insertion of the hamstring tendons
onto the left ischial tuberosity likely represents a partial
tear.
4. Linear focus of edema and enhancement in the right vastus
lateralis muscle could be seen in the setting of strain.
However, if there is clinical suspicion for a neoplastic
process, dedicated imaging of the right hip should be
considered.
L HIP ARTHROCENTESIS
IMPRESSION:
1. Imaging Findings: As above.
2. Procedure: Successful aspiration of 15 cc of yellowish
cloudy left hip
joint fluid. Samples were sent for cell count, differential,
and
microbiologic analysis.
Discharge Labs
___ 08:25AM BLOOD WBC-9.0 RBC-4.30* Hgb-12.7* Hct-38.9*
MCV-91 MCH-29.5 MCHC-32.6 RDW-13.5 RDWSD-44.3 Plt ___
___ 08:25AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-139
K-5.0 Cl-99 HCO3-28 AnGap-12
___ 08:45AM BLOOD ALT-11 AST-13 AlkPhos-85 TotBili-0.6
No labs done on ___ or ___
Brief Hospital Course:
___ y/o M with PMHx HTN, gastritis, gout,
prior polysubstance abuse, as well as RA on MTX, who presented
with L groin / LLE pain and pain-limited movements found to have
L hip inflammatory arthritis.
Active Issues
# L hip inflammatory arthritis
Pt presented with 2 days of persistent L groin and LLE pain in
the setting of known lumbar spinal stenosis. MRI L-spine was
stable compared to ___. NSGY consulted and reiterated that
none of the MRI findings explained his current presentation. CRP
and
ESR elevated, > 110 and > 40, respectively. Given his history of
gout and seropositive RA, c/f inflammatory process of the L hip
became the primary concern. Rheumatology consulted. MRI L hip
(+)
effusion and synovitis. ___ performed L hip tap which was c/w
inflammation but unlikely septic. Gram stain negative. He
started
on a prednisone taper for presumed RA flare of the L hip. His
symptoms improved. He is scheduled to follow-up with
rheumatology
as an outpatient.
- prednisone 40 mg po qday for 3 days (___), followed 30 mg
for 3 days (___), 20 mg (___), 10 mg (___)
- Tylenol ___ mg q8h as needed and oxycodone 5 mg q6h as needed
for pain control x 5 more days at discharge
- blood cultures neg x 2
- L hip aspirate culture neg so far
#Sinus tachycardia - intermittently tachycardic to ___
while hospitalized with no e/o pain. ___ have underlying OSA/OH.
# RA: Followed by Dr. ___.
- continued home MTX 10 mg every ___
- continued home sulfasalazine 500 mg PO BID
#Peripheral Neuropathy
-continued home gabapentin 400 mg PO TID
-continued amitriptyline 100 mg PO qHS
# H/O ETOH ABUSE: Pt denies any recent use (states last use was
4
months ago). No concern for withdrawal during this
hospitalization.
- continue MV, folate
# HTN: Elevated BP's in the ED likely ___ pain. Initially his
home HCTZ/Lisinopril was held given lower blood pressures with
opioids. At discharge HCTZ 12.5 mg daily was started and patient
counseled to restart combination pill with lisinopril at home
after discharge. He should follow up with his PCP this week to
have his blood pressure re-checked.
#TRANSITIONAL ISSUES
-complete prednisone taper on ___
-f/u with PCP this week for BP check as patient restarting his
home BP medications
-f/u with outpatient physical therapy
-f/u final joint culture (so far negative)
-continue w/u for sinus tachycardia - patient asymptomatic. ___
need sleep study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 975 mg PO Q8H:PRN Pain - Mild
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. Gabapentin 300 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO BID
6. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
7. SulfaSALAzine ___ 500 mg PO BID
8. Amitriptyline 100 mg PO QHS
9. FoLIC Acid 1 mg PO DAILY
10. Methotrexate 10 mg PO QMON
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*20
Capsule Refills:*0
3. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablets(s) by mouth daily Disp #*15 Dose
Pack Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [Senexon] 8.6 mg 1 tab by mouth every 12 hours as
needed Disp #*30 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Amitriptyline 100 mg PO QHS
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. Methotrexate 10 mg PO QMON
13. Multivitamins 1 TAB PO DAILY
14. SulfaSALAzine ___ 500 mg PO BID
15.Outpatient Physical Therapy
Physical Therapy Evaluation and Treatment for L hip rheumatoid
arthritis
3 days/week x 1 hour x 4 weeks
Please go to local ___
Discharge Disposition:
Home
Discharge Diagnosis:
# L hip inflammatory arthritis
# Rheumatoid arthritis flare
# L partial proximal hamstring tear
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 ___,
You were admitted to the hospital for left hip pain and left leg
weakness. You had an MRI of your left hip and fluid drained from
the joint space. You were seen by your rheumatologist, Dr.
___ diagnosed you with a rheumatoid arthritis flare of
your left hip. You were started on a steroid taper and your
symptoms improved. You have a scheduled appointment to follow-up
with your rheumatologist. Please continue to attend physical
therapy as an outpatient
It was a pleasure taking care of you,
-___ Team
Followup Instructions:
___
|
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2207-02-07 00:00:00
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2207-02-07 18:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / ibuprofen
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M with PMHx EtOH use disorder, HTN, gastritis, gout,
rheumatoid arthritis, lumbar spinal stenosis, ocular migraines,
s/p remote MVA and multiple surgeries on right leg who presents
with chills and diarrhea.
The patient reports he first began having shaking chills and
watery diarrhea on ___. The symptoms have persisted and
finally prompted him to seek help. He reports ~ 4 liquid,
non-bloody bowel movements per day. He is not experiencing
cramping or abdominal pain. He denies recent antibiotic use or
hospitalization but does live in a shelter. He is prescribed
Antabuse but says he has not been able to get his medications
recently. He saw his PCP at the beginning of the month and at
that time said he had attempted to drink alcohol. Today,
however,
he says he has not had a drink in a month but then also said he
felt like having a beer today but did not feel well enough. He
has also been experiencing cough productive of white sputum and
sore throat. He has a headache but says it is actually less
intense than some of the recurrent headaches he gets.
Of note, per ED notes, he did have a pin recently removed from
this R knee and has been bearing more weight on the L leg
recently. He also endorses chronic numbness of the lateral RLE
related to another injury sustained from a MVC; however, he
states that this has not changed recently.
In the ED he had a temperature of 100.8 but without a 1-hr
recheck. Other VS WNL but lactate was 3.1 without leukocytosis
or
abnormal Cr. U/A showed only few bacteria, flu negative.
ROS: A 10-point review of systems was obtained and was otherwise
negative except as per HPI.
Past Medical History:
ANIXETY D/O
AVM DISTAL TRANSVERSE COLON
L MAXILLARY FRX ___ C/B HEMATOMA AND INFX
GASTRITIS, H.PYLORI
GOUT
HEMORRHOIDS
HX GI BLEED
HYPERTENSION
IMPULSE CONTROL D/O
? MYOCARDIAL INFARCTION
POLYARTHRALGIAS ___
RHEUMATOID ARTHRITIS
POLYSUBSTANCE ABUSE
NASAL VESTIBULITIS
ALCOHOLISM
B12 DEFICIENCY
HEADACHE
ANTRAL INTESTINAL METAPLASIA
Social History:
___
Family History:
Endorses FHx of CAD and EtOH abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS - Temp of 100.8, reviewed in ED dash
GEN - alert, lying in bed
HEENT - NC/AT, face symmetric, no oropharynx edema
CV - RRR, no m/r/g appreaciated
RESP - Sounds of secretions in large airways but no wheezing,
crackles
ABD - Soft, NT, BS present, tympanic
EXT - RLE surgical scars, knees without warmth or swelling
SKIN - No new rashes
NEURO - Face symmetric, speech fluent
PSYCH - Calm, appropriate
DISCHARGE PHYSICAL EXAM:
===========================
VITALS: 97.8 124 / 79 90 18 98 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation in all
quadrants.
EXT: Warm and well perfused. No ___ edema.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs. ___ strength in all extremities
bilaterally
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 03:23PM BLOOD WBC-8.5 RBC-4.38* Hgb-13.8 Hct-42.0
MCV-96 MCH-31.5 MCHC-32.9 RDW-13.3 RDWSD-47.0* Plt ___
___ 03:23PM BLOOD WBC-8.5 RBC-4.38* Hgb-13.8 Hct-42.0
MCV-96 MCH-31.5 MCHC-32.9 RDW-13.3 RDWSD-47.0* Plt ___
___ 03:23PM BLOOD Glucose-111* UreaN-11 Creat-1.0 Na-140
K-4.2 Cl-101 HCO3-21* AnGap-18
___ 03:26PM BLOOD Lactate-3.1*
IMAGING:
==========
___ CXR:
Low lung volumes with probable bibasilar atelectasis.
DISCHARGE LABS:
=================
___ 05:26AM BLOOD WBC-4.5 RBC-4.09* Hgb-12.9* Hct-38.4*
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.7 RDWSD-43.5 Plt ___
___ 05:26AM BLOOD Glucose-101* UreaN-8 Creat-0.8 Na-138
K-4.4 Cl-100 HCO3-23 AnGap-15
___ 05:26AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.5*
Brief Hospital Course:
___ y/o M with PMHx EtOH use disorder, HTN,
gastritis, gout, rheumatoid arthritis, lumbar spinal stenosis,
ocular migraines, s/p remote MVA and multiple surgeries on right
leg who presents with chills and diarrhea. C diff was negative
and pt's symptoms improved with conservative care.
# Gastroenteritis: Pt presented with reports of chills, elevated
temperature. Lactate of 3.1 but no other signs of
organ dysfunction. Elevated lactate, diarrhea, and dizziness all
resolved during admission. C diff and norovirus PCR were neg.
Overall, presetnation was felt to be due to viral
gastroenteritis.
# RA: Followed by Dr. ___: continued home MTX 15 mg on
___, sulfasalazine,
hydroxychloroquine. may need to re-evaluate use if ongoing
alcohol use.
# H/O ETOH ABUSE: Pt with variable reports of last use, states
he had a "taste" on ___. Patient was monitored for signs of
withdrawal. Continued disulfiram, MV, folate.
# GERD:
- continued home PPI
# HTN:
- Held home lisinopril-HCTZ on admission given dizziness and
ongoing diarrhea; resumed at discharge
#Lumbar spinal stenosis: No further back pain off medications.
#Possible DMII: HA1C 6.7% ___. PCP monitoring off of
medications
#Headaches/ocular migraines:
- Continued tylenol
TRANSITIONAL ISSUES:
[]f/u pending BCx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Methotrexate 15 mg PO QMON
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. SulfaSALAzine ___ 1500 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID
9. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
10. lisinopril-hydrochlorothiazide ___ mg oral DAILY
11. Hydroxychloroquine Sulfate 200 mg PO BID
12. Disulfiram 250 mg PO DAILY
13. Lidocaine 5% Ointment 1 Appl TP DAILY
14. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
3. Disulfiram 250 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Lidocaine 5% Ointment 1 Appl TP DAILY
9. lisinopril-hydrochlorothiazide ___ mg oral DAILY
10. Methotrexate 15 mg PO QMON
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO BID
14. SulfaSALAzine ___ 1500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
viral gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with diarrhea. We think this was due
to a viral illness. Your symptoms improved during your
hospitalization and your testing was reassuring. Please take
your medications and follow up with your doctors as directed. We
wish you all the best.
Your ___ Care Team
Followup Instructions:
___
|
19618753-DS-5
| 19,618,753 | 24,471,920 |
DS
| 5 |
2156-11-13 00:00:00
|
2156-11-13 09:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fluconazole
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Incision & drainage left hip ___ ___
Repeat left hip washout (___)
Repeat left hip washout (___)
Repeat left hip washout (___)
Repeat left hip washout (___)
Left Hip wound closure (___)
History of Present Illness:
___ male with a history of IV drug use reporting history for ___
year, transferred from outside hospital with concern for left
septic hip. Patient reports that for 1 week prior to
presentation he had increasing pain ___ left hip with any range
of motion and with ambulation. Denied fever and chills until
day of presentation when he began to feel subjectively feverish
and chills. Patient reported that he relapsed 5 days ago on
fentanyl and heroin due to the pain from the hip, denied any
relapse before this time. Denied numbness, tingling, weakness
___ the left leg. Reported 10 out of 10 pain ongoing secondary
to the hip. Patient was transferred on a ___ because he
stated that if he had to live with that pain ___ his hip he would
"kill himself ".
Patient initially presented to ___ where labs are notable for
ESR 110. Left hip x-ray was normal at ___. Due to concern
for possible septic hip given significant pain with range of
motion, patient was transferred for further evaluation.
___ the ED, initial VS were: 99.1, 73, 154/79, 17, 97% RA. Exam
notable for L hip ttp without overlying erythema; any ranging of
the L hip causes severe pain.
Basic labs fairly unremarkable but CRP>300. US Left Hip showed a
4.7 x 0.9 x 3.3 cm fluid collection within the left hip.
Blood cultures were collected, he was given vanc/CTX, then
subsequently underwent both ___ hip aspiration as well as
wash out via ortho ___ the OR.
Then admitted to medicine.
Past Medical History:
IVDU
Depression
Anxiety
Social History:
___
Family History:
No significant family history of cardiac disease or cancer.
Physical Exam:
ADMISSION EXAM
==============
VS: 99.6, 132/72, 60, 18, 95% RA
GENERAL: NAD, unkept
HEENT: AT/NC, anicteric sclera, MMM, poor dentition
NECK: supple, no LAD
CV: RRR, S1/S2, no obvious murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender ___ all quadrants, no
rebound/guarding
EXTREMITIES: left hip with dressing anteriorly, tender to
palpation, extremely limited ROM due to pain, otherwise no
cyanosis or edema
PULSES: 2+ radial/DP pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, numerous excoriations on upper
extremities with occasional pacthes
DISCHARGE EXAM
==============
VITALS: ___ 1147 Temp: 98.2 PO BP: 107/51 HR: 81 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: WDWN male ___ NAD, Lying back ___ bed, sleepy
CARDIAC: RRR, no murmurs, rubs or gallops
Lungs: CTAB
Abdomen: nontender to palpation ___ all four quadrants
Extremities: no lower leg edema
NEURO: Sleepy, pupils round and reactive, not dilated or
constricted. CN II-XII grossly intact, moving
all four extremities with purpose.
Pertinent Results:
ADMISSION LABS
==============
___ 11:50PM BLOOD WBC-10.1* RBC-4.10* Hgb-12.0* Hct-34.9*
MCV-85 MCH-29.3 MCHC-34.4 RDW-14.3 RDWSD-43.9 Plt ___
___ 11:50PM BLOOD Neuts-75* Bands-3 Lymphs-12* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-7.88* AbsLymp-1.21
AbsMono-1.01* AbsEos-0.00* AbsBaso-0.00*
___ 11:50PM BLOOD Plt Smr-NORMAL Plt ___
___ 07:40AM BLOOD ___ PTT-25.6 ___
___ 11:50PM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-139
K-3.5 Cl-100 HCO3-27 AnGap-12
___ 07:24AM BLOOD ALT-11 AST-19 AlkPhos-136* TotBili-1.0
___ 07:24AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.0 Iron-27*
NOTABLE LABS
============
___ 07:24AM BLOOD calTIBC-150* Ferritn-588* TRF-115*
___ 05:33AM BLOOD 25VitD-24*
___ 06:32AM BLOOD CRP-276.3*
___ 04:26AM BLOOD CRP-114.6*
___ 09:05AM BLOOD CRP-118.4*
___ 11:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:32AM BLOOD HCV Ab-POS*
___ 06:32AM BLOOD HCV VL-5.7*
NOTABLE MICRO
=============
___ 11:50 pm BLOOD CULTURE Site: ARM
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
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.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 0.5 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___ (___),
___ @ 17:56.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 12:42 pm SWAB
WORKUP REQUESTED BY ___. ___ (___) ___.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
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.
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.
PSEUDOMONAS AERUGINOSA. RARE 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
___ this
culture.
___ ALBICANS. RARE GROWTH.
Yeast Susceptibility:.
Fluconazole MIC = 0.25 MCG/ML = SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 16 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
NOTABLE IMAGING
==============
___ US LEFT HIP
Approximately 4.7 x 0.9 x 3.3 cm fluid collection within the
left hip.
___ TTE
Mild global left ventricualr hypokinesis with regional variation
as above. Possible tricuspid valve vegetation (versus redundant
leaflet - see above). TEE could better distinguish ___
transgastric views.
___ CT CHEST
1. Geographic areas of ground-glass opacity ___ the right upper
and right
middle lobes may represent developing hematogenously spread
infectious
process.
2. Pulmonary nodules measure up to 11 mm for which follow-up
chest CT is
recommended as below.
3. Please see separately submitted Abdomen and Pelvis CT report
for
subdiaphragmatic findings.
___ CT ABD PELVIS
1. Multiple fluid collections ___ the muscles surrounding the
left hip,
including the iliacus, gluteus, and quadriceps muscles. These
are consistent
with extensive, mostly intramuscular, abscesses. No defnite
fluid ___ the hip
joint itself. The presence of air within these collections may
be due to
infection or recent intervention, noting anterior staple line.
2. Nonocclusive small focal left internal iliac vein thrombus.
3. Mild splenomegaly.
4. Please see the separately submitted report of the same day CT
Chest for
findings above the diaphragm.
___ TEE
Moderate sized vegetation on the anterior leaflet of the
tricupid valve with probable perforation. Moderate tricuspid
regurgitation. Mild pulmonary artery systolic hypertension.
___ CT PELVIS
1. Interval decrease ___ sizes of multiple abscesses ___ muscles
surrounding the left hip after pigtail catheter insertion.
2. Interval resolution of the nonocclusive small focal left
internal iliac
vein thrombus.
3. Mild increase of a fluid collection containing gas subjacent
to the skin staples ___ the left proximal thigh.
___ CT ABD PELVIS
1. Interval decrease ___ size of multiple abscesses ___ the
muscles surrounding the left hip ___ which 3 pigtail catheters
are seen.
2. 8 mm lingula nodule to be followed ___ 3 months.
___ US LLE
Complex fluid collection ___ the region of previously drained
abscess, deep to the incision site, which measures 6.4 x 1.5 x
2.2 cm, previously 6.3 x 1.2 x 2.8 cm on the CT of ___.
___ CT Pelvis w/ Contrast
1. Reaccumulation of abscess left anterior thigh at site of
prior surgical
drain as detailed above which may be accounting for patient's
recurrence of
fevers.
2. Continued decrease ___ size of multiple abscesses surrounding
the pigtail
drainage catheter within the left gluteal musculature.
3. No significant residual abscess noted surrounding the pigtail
drainage
catheter located within the region of the left iliac muscle.
DISCHARGE LABS
=============
Brief Hospital Course:
BRIEF SUMMARY
___ w/ IVDU, opiate dependence, anxiety, admitted with septic
arthritis of L hip (s/p multiple washouts on this admission -
growing ___, MRSA endocarditis of
tricuspid valve, and MRSA abscess of L iliacus and gluteus
maximus (s/p ___ drains ___. He completed micafungin,
ciprofloxacin, and six weeks of MRSA coverage ___ house
(initially vanco, then ceftaroline, then daptomycin).
ACTIVE ISSUES
=============
# Left Hip Septic Arthritis
# Left Hip Muscle Abscesses
Presented with five days for worsening left hip pain and
inability to bear weight. Initial work up revealed a WBC 10, ESR
89, CRP > 300, with left hip ultrasound showing a 4.7 x 0.9 x
3.3 cm fluid collection within the left hip. He initially
underwent an ___ guided hip aspiration and then OR washout by
orthopedic surgery on ___. Initial studies showed bacterial
joint infection with cultures growing MRSA. He then underwent
another washout and had two drains placed by ___ ___ the left
thigh muscles on ___. Due to worsening hip pain and incision
site purulence, he underwent another washout on ___. Cultures
grew MRSA as well as GNRs and ___. His antibiotics were
broadened from vancomycin to
vancomycin/ceftazidime/fluconazole. GNRs later speciated to
ceftaz-resistant pseudomonas so he was switched to cefepime and
then later ciprofloxacin on ___ due to concern for
cefepime-induced drug fever. Given persistent fevers, he
underwent further washouts on ___ and then again on ___ after
imaging showed fluid reaccumulation within the surgical bed. The
final washout revealed hematoma without signs of infection.
Later, fluconazole was switched to micafungin given concern for
drug fevers/rash and vancomycin was switched to daptomycin due
to eosinophilia. He completed a two week course of antifungal
coverage and pseudomonas coverage (___), and continued
daptomycin to complete a 6 week course for MRSA (___).
# Triscupid endocarditis
# High Grade MRSA Bacteremia
Patient presented with hip pain, found to have high grade
bacteremia with seeding of his joints and muscles. TEE on ___
demonstrated a tricuspid vegetation, no abscess, and possible
perforation with eccentric jet. He was evaluated by cardiac
surgery, who recommended non-operative management. He was
treated with vancomycin, briefly switched to ceftaroline
(___) given difficult to quench bacteremia before
transitioning back. He then was switched to daptomycin on ___
after worsening mild eosinophilia. He completed a 6 week course
(end date ___.
# Morbiliform rash
Developed a mildly pruritic rash over his trunk on ___,
which was felt to be due to a drug reaction from ceftazidime. He
was switched to cefepime and then later ciprofloxacin. Later ___
the hospital course, he had recurrent, though more severe, rash
over his trunk with progression into all four extremities. No
oral or palmar involvement. He had a mild eosinophilia without
LFT abnormalities. Ultimately fluconazole was switched to
micafungin and vancomycin was switched to daptomycin with
resolution of his rash. Fluconazole was added to his allergy
list per ID recommendations.
#Drug Fevers
Hospital course complicated by nightly fevers following
source control of his infection. Overall presentation consistent
with drug fevers, likely due to fluconazole. He was switched to
micafungin with resolution of his fevers ___ 2 days. Fluconazole
was added to his allergy list per ID recommendations.
# Suicidal Ideation
The patient underwent ___ prior to ___ transfer
given suicidal statements ___ the setting of the infection. He
reported having one prior suicide attempt ___ years ago from
hanging. He was seen by psychiatry who felt there were no acute
safety concerns. Following improvement ___ the infection, his
mood stabilized.
# IVDU (Heroin)
Long history of IV heroin use and had most recently been
sober for approximately one year. He was treated symptomatically
with clonidine TID for anxiety. Clonidine was tapered off and he
was monitored for rebound hypertension. SW discussed with
patient about starting methadone or suboxone to help him
maintain sobriety, but since he had entirely detoxed while being
___ the hospital for six weeks, he quite logically felt that this
would just re-introduce a physical dependence. To help him stay
clean without opiate replacement, he was offered the option of
Vivitrol, but he declined that also. Despite being told that he
is statistically unlikely to succeed, he wants to stay clean the
"old fashioned way." He will need outpatient follow up for
ongoing support and management.
# Left-sided sciatica
The patient complained of left sided sciatica ___ the setting
of his infection. He was resumed on gabapentin with good effect.
This medication has street value among opiate users and would
consider tapering him off it as he continues to recover.
# Anxiety and insomnia
The patient reports a longstanding history of anxiety and
insomnia and has been on Klonopin ___ the past. Inpatient
providers found it necessary to resume this medication ___ house,
especially since late symptoms of opiate withdrawal include
exacerbation of anxiety and insomnia. This medication has street
value and abuse potential and would consider tapering him off it
as he continues to recover. He was given a ten day supply at
discharge.
CHRONIC/STABLE ISSUES
=====================
# Normocytic Anemia
Admission labs notable for anemia, unclear baseline. Normal RBC
morphology. Iron saturation 18%, ferritin elevated ___ setting of
infection. Etiology felt to be a combination of iron deficiency
and anemia of inflammation. He will need outpatient follow up
for colonoscopy screening (49 and anemia).
# Bilateral shoulder pain
On ___, the patient reported bilateral shoulder pain. Given
high grade bacteremia, he underwent aspiration with ___ on ___,
which showed no signs of septic joint. His pain improved with
time and symptomatic treatment.
# Hepatitis C
Noted to have positive HCV antibody with viral load 5.7. LFTs
weren't normal. He will need outpatient hepatology follow up for
genotyping and treatment.
# Vitamin D deficiency
Gave weekly high-dose repletion ___ house.
TRANSITIONAL ISSUES
==================
[] Continue to strongly encourage Suboxone or Vivitrol given
high rate of IVDU relapse.
[] ___ have iron deficiency, and thus needs outpatient
colonoscopy
[] Refer for treatment of HCV, provided social situation remains
stable enough to ensure adherence with treatment.
[] Lung nodule: 8 mm lingula nodule should be followed on repeat
CT ___ ___ ___ this high-risk patient.
[] Would repeat TTE (or a careful physical exam of the heart) at
some point ___ the future to make sure his TR hasn't progressed
to a degree that could cause complications and potentially
require further specialist referral.
[] As he went through opiate withdrawal ___ house, his providers
have found it necessary to restart him on Klonopin and
gabapentin. Because he is doing well on these, they were also
continued at discharge for a ten-day supply. He was advised that
these medications have abuse potential/street value and that his
PCP may or may not think it is ___ his best interest to continue
them. He was also advised that if there is any evidence he is
diverting them or misusing then they certainly will not be
renewed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
OVER THE COUNTER
2. ClonazePAM 1 mg PO QHS:PRN insomnia
RX *clonazepam 0.5 mg 1 tablet(s) by mouth daily and 2 tablets
at night Disp #*30 Tablet Refills:*0
3. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth TID PRN Disp #*90
Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine [Lidocaine Pain Relief] 4 % 1 patch to painful
area on hip daily Disp #*30 Patch Refills:*0
7. melatonin 5 mg oral QHS
OVER THE COUNTER
8.Crutches
Dx: Septic Hip joint
ICD10 M00.052
PX: Good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- MRSA bacteremia
Secondary diagnoses
- MRSA tricuspid endocarditis
- Septic left hip
- Left hip muscle abscess
- Opioid use disorder
- Drug rash
- Drug fevers
- IV drug use
- Normocytic anemia
- Chronic hepatitis C infection
- Insomnia and anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a bacterial infection
(MRSA) ___ your blood. This infection was introduced by IV drug
use.
The infection spread to your heart (endocarditis) and to the
joints and muscles of your left leg. You required multiple
surgeries from the orthopedic team to wash out the infection
from your hip joint, and had drains placed to remove pockets of
pus from the muscles of your buttocks.
You required 6 weeks of antibiotics (vancomycin) to treat the
MRSA infection ___ your blood. You also grew some other bacteria
and yeast ___ your hip which required additional antibiotics.
At the time of your discharge you are totally off ALL opiate
pain medications. Because you are already fully detoxed from
your opiate addiction, you did not want to start Suboxone or
methadone. Even without the physical addiction you will still be
at high risk to relapse. If you get any cravings SEEK HELP. We
do not want you to have another life-threatening infection.
For your anxiety, your nerve pain, and to help you through the
tail end of the withdrawal process (which can take up to a month
or so to resolve fully) we have continued your scripts for
KLONOPIN and GABAPENTIN. These medications have some potential
for abuse and your new primary care doctor may or may not think
it is ___ your best interst to continue them. If your urine tests
positive for opiates or negative for Klonopin, they certainly
will not be continued.
It was a privilege to care for you ___ the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19618753-DS-6
| 19,618,753 | 21,298,114 |
DS
| 6 |
2156-12-23 00:00:00
|
2156-12-23 12:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fluconazole
Attending: ___.
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
___ left hip aspiration ___
left hip incision and drainage
Placement of antibiotic spacer
girdlestone procedure
History of Present Illness:
Mr. ___ is a ___ male with history of IVDU
and recent complicated admission for septic arthritis of the
left
hip, Infective Endocarditis and gluteal abscess who presents now
with with 2 days of worsening left hip pain.
Patient had a long admission in ___ of this year
for
septic arthritis of L hip (s/p multiple washouts - growing
___, MRSA endocarditis of tricuspid valve,
and MRSA abscess of L iliacus and gluteus maximus (s/p ___ drains
___. He completed micafungin, ciprofloxacin, and six weeks of
MRSA coverage in house (initially vanco, then ceftaroline, then
daptomycin). He was discharged on ___ and states has been doing
well up until ___ days ago when he developed recurrent pain in
the left thigh and left hip similar to prior presentation. He
denies relapse in IVDU since discharge but states he did take a
couple of percocets off the street 2 days ago for uncontrolled
pain. He denies fevers, CP, SOB, abdominal pain, nausea,
vomiting, diarrhea.
In the ED:
VS: Tmax 99.8, P 72-78, BP 130-154/68-81, RR ___, 98-100% on
RA
PE: Good pulses. Severe pain with movement.
Labs: CRP 218, WBC 10.9, Hgb 9.4
Imaging: Abscess with intra-articular extension shown on CT
Impression: Will admit the patient. According to orthopedics,
will hold antibiotics at this time pending ___ guided aspiration
and admit to medicine.
Interventions: gabapentin 600mg, IV morphine 4mg x2
Consults:
___ - Body (CT/US): Requested 07:54
>Orthopedics: Completed 07:39 - would recommend ___ guided
aspiration of hip to determine if infected and admission to
medicine for management of presumed left septic hip. P ___
Went to ___ from ED for hip aspiration. Spoke with ID who agreed
with starting antibiotics based on prior culture data, holding
off on antifungal therapy for now and consulting ID officially
on
___ when culture data from the hip aspiration ois back.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Opiate use disorder with heroin
Depression
Anxiety
Incision & drainage left hip ___ ___
Repeat left hip washout (___)
Repeat left hip washout (___)
Repeat left hip washout (___)
Repeat left hip washout (___)
Left Hip wound closure (___)
Social History:
___
Family History:
No significant family history of cardiac disease or cancer.
Physical Exam:
VITALS: Temp: 99.7, BP: 161/83, HR: 68, RR: 16, O2 sat: 99%, O2
delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
Vitals: Temp 98.6; BP 135/78; HR 86; RR 18; O2 97%
GENERAL: Middle aged man laying in bed, NAD
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, normal perfusion, no JVD appreciated, soft
___ SEM over LUSB
RESP: Normal respiratory effort with no stridor or labored
breathing.
GI: Abdomen soft, non-distended, non-tender
Skin: warm and dry without rashes
MSK/NEURO: AOx3. Pain in the left hip limits motion (improving),
TTP; neurovascularly intact, Alert, oriented
PSYCH: normal mood and affect,
Pertinent Results:
ADMISSION LABS:
___ 03:35AM BLOOD WBC-10.9* RBC-3.53* Hgb-9.4* Hct-30.0*
MCV-85 MCH-26.6 MCHC-31.3* RDW-16.5* RDWSD-50.4* Plt ___
___ 03:35AM BLOOD Neuts-74.9* Lymphs-13.2* Monos-9.5
Eos-1.7 Baso-0.3 Im ___ AbsNeut-8.19* AbsLymp-1.44
AbsMono-1.04* AbsEos-0.19 AbsBaso-0.03
___ 03:35AM BLOOD ___ PTT-25.0 ___
___ 03:35AM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-145
K-3.9 Cl-109* HCO3-23 AnGap-13
___ 07:05AM BLOOD ALT-7 AST-8 LD(LDH)-129 AlkPhos-83
TotBili-0.5
___ 03:35AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
___ 03:35AM BLOOD CRP-218.0*
___ 03:48AM BLOOD Lactate-1.1
SED RATE BY MODIFIED 46 H
Hip X-ray left ___
FINDINGS:
There is no fracture or dislocation. There is superior joint
space narrowing in the left hip with underlying acetabular
erosions and prominent subchondral sclerosis in the femoral
head. There is no suspicious lytic or sclerotic lesion. There
is no soft tissue calcification or radio-opaque foreign body.
IMPRESSION:
No evidence of acute fracture. Left acetabular erosions and
subchondral
sclerosis in the left femoral head are concerning for septic
arthritis and
associated osteomyelitis, given progression from CT from ___.
CT Left hip ___
FINDINGS:
2 tubular mildly hypodense, likely communicating collections are
seen along
the left ilium extending inferiorly towards the site of a prior
anterior thigh
drain. More superior focus measures 1.2 x 6.5 cm, similar to
prior. The more
inferior collection measures 4 x 1.5 x 2 cm.
A hypodense collection seen along the left femoral neck measures
1.3 x 2 cm,
decreased in size compared to prior previously 2.7 x 1.3 cm, (2;
29) however
with intra-articular extension ___ 23). There is extensive
soft tissue
density surrounding the left hip joint which is increased
compared to prior,
which likely represents some combination of edema, hemorrhage,
and phlegmonous
changes.
Compared to prior there is new erosion of the left acetabulum
and left femoral
head with femoral head subchondral sclerosis.
The small large bowel loops are within normal limits. The
appendix is normal.
The urinary bladder and distal ureters are unremarkable. There
is no free
fluid in the pelvis. There is no pelvic or inguinal
lymphadenopathy. The
prostate and seminal vesicles are within normal limits. There
is mild
atherosclerotic disease. A fat containing left inguinal hernia
is noted.
IMPRESSION:
1. Interval increase in soft tissue density surrounding the left
hip joint
with several areas of hypodensity along the left ilium, left
femur and
tracking into the left hip joint are concerning for phlegmon,
including
involvement of the hip joint, and possible abscess formation,
however fluid component of abscess cannot be reliably
distinguished given extensive surrounding inflammatory tissue.
2. Bony destruction of the left hip joint, new compared to
prior.
CXR ___ FINDINGS:
Study is slightly limited by patient positioning. There has
been interval
placement of a left upper extremity PICC which terminates in the
superior vena cava. There is no focal consolidation, pleural
effusion or pneumothorax. The cardiomediastinal silhouette is
within normal limits. No acute osseous abnormalities are
identified.
TTE ___- No evidence of endocarditis. LVEF 50%, mild TR, mod
pulm HTN
Discharge labs:
___ 05:23AM BLOOD WBC-8.9 RBC-2.80* Hgb-7.4* Hct-24.1*
MCV-86 MCH-26.4 MCHC-30.7* RDW-17.2* RDWSD-53.6* Plt ___
___ 05:23AM BLOOD Glucose-85 UreaN-22* Creat-1.0 Na-142
K-5.3 Cl-104 HCO3-28 AnGap-10
___ 05:08AM BLOOD CK(CPK)-41*
___ 05:08AM BLOOD CRP-35.4*
Brief Hospital Course:
Mr. ___ is a ___ male with history of opiate use
disorder with heroin and recent complicated admission for septic
arthritis of the left hip, Infective
Endocarditis and gluteal abscess who presents now with 2 days of
worsening left hip pain.
ACUTE/ACTIVE PROBLEMS:
#Left Hip Abscess / Septic joint - Recent admission with
endocarditis, septic hip and gluteal abscess status post
multiple drainages and washouts. Now returning with left hip
pain found to have elevated CRP with imaging consistent with
abscess and septic joint. He underwent ___ drainage on arrival,
___ with culture growing out MRSA. He was initially started on
Vancomycin and Cipro, but reported that he thinks his "skin fell
off" with Vancomycin in the past, though he did receive a dose
on admission without any immediate complications. He was changed
from Vancomycin to Daptomycin ___. He had PICC line placed on
___. ID consulted and recommended a ___nding
___. He will need CBC, CK, Cr, CRP, and ESR on ___.
He is s/p resection arthroplasty, Placement of Articulating
Antibiotic Spacer, Left Hip on ___ with orthopedic surgery.
He had a TTE on ___ which did not show endocarditis. He has
remained stable on the above regimen. He was seen by ___ who
recommended rehab which he was discharged to. He was discharged
on aspirin for 4 weeks per orthopedics recommendations to
prevent DVT. He is WBAT to ___. He has follow up with orthopedics
scheduled.
#History of Opiate Use Disorder - Long history of IV heroin use,
and he reports using up to 5g/day previously. He was admitted a
month prior to admission after relapsing and required methadone
taper for acute opiate withdrawal. All opiates weaned off prior
to discharge and patient opted against maintenance therapy at
time
of discharge. Currently denies relapse since last discharge
except for taking percocets off the street 2 days prior to
admission. He continued to decline maintenance methadone or
suboxone therapy on admisison. There was concern for substance
injection on the evening of ___ after a visit from his wife.
Addiction psychiatry consulted on ___ who agreed with use of
oxycodone to help managed acute pain meds as patient declining
alternatives with methadone and suboxone as noted above.
#Fever ___ - Post-op he developed fever. Blood cultures and
urine culture were negative. CRP has been downtrending with no
further signs of infection or fever.
#Hip pain- Despite increasing his oral Dilaudid pain was
uncontrolled. Chronic pain service consulted who recommended
stopping oral Dilaudid and changing to Dilaudid PCA to see his
needs ___. His gabapentin was titrated up to current dose of
1200mg TID which he was discharged on. He was weaned off the
dilaudid PCA and per chronic pain services recommendations he
was discharged on oxycodone 20mg PO Q4h PRN with an additional
dose of oxycodone 5mg PO prior to working with ___. He was also
discharged on naproxen 500mg BID standing and tylenol ___ TID
standing. He reported ongoing pain but gradual improvement on
discharge. He was continued on lidoderm patch and his home
klonopin. He was prescribed protonix to prevent developed of
ulcer disease given dual use of naproxen and aspirin.
#Insmonia - He reported ongoing insomina this admission and was
prescribed Ramelteon which he will be discharged o.n
#Normocytic Anemia - first noted last hospital admission, CBC
stable compared to recent baseline. Iron saturation 18%,
ferritin elevated in setting of infection. Likely combination of
iron deficiency and AOCD, with possible contribution from acute
illness. He should have colonoscopy as outpatient (age ___,
anemia). He completed 4 days of IV iron repletion and was
discharge on ferrous sulfate for ongoing repletion.
#Hepatitis C - Antibody positive, viral load 5.7 in ___.
He should follow up with hepatolog as an outpatient.
#Hyperkalemia- Found to have elevated potassium level to 5.5,
that has been uptrending for the past week. Unclear etiology.
Not on any obvious causative medications. Recvieved a dose of
kayexelate 15mg PO x1 with improvement in potassium levels.
Continue to monitor as an outpatient
Transitional Issues:
[] follow up with orthopedics as scheduled
[] continue to wean off oxycodone
[] consider weaning of klonopin
[] obtain weekly labs as noted above (CBC, CK, Cr, CRP, and ESR
on ___
[] monitor potassium levels over the next few days
Greater than 30 min spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
3. ClonazePAM 1 mg PO QHS:PRN insomnia
4. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
5. Lidocaine 5% Patch 1 PTCH TD DAILY
6. Gabapentin 600 mg PO TID
7. melatonin 5 mg oral QHS
Discharge Medications:
1. Aspirin 81 mg PO BID
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Daptomycin 400 mg IV Q24H septic hip
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Naproxen 500 mg PO Q12H
7. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
8. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
please use daily as needed prior to working with physical
therapy
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Ramelteon 8 mg PO QHS:PRN insmonia
Should be given 30 minutes before bedtime
12. Senna 8.6 mg PO BID
13. Acetaminophen 1000 mg PO Q8H
14. Gabapentin 1200 mg PO TID
15. ClonazePAM 1 mg PO QHS:PRN insomnia
16. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
17. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
septic joint
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Orthopedic 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.
8. ANTICOAGULATION: Anticoagulation is needed for four (4) weeks
after surgery to help prevent deep vein thrombosis (blood
clots). If you were given aspirin, continue the 81mg twice daily
x 4 wks.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after surgery while wearing your aquacel
dressing, but no tub baths, swimming, or submerging your
incision until after your first checkup and cleared by your
surgeon. After the aquacel dressing is removed 7 days after your
surgery, you may leave the wound open to air. Check the wound
regularly for signs of infection such as redness or thick yellow
drainage and promptly notify your surgeon of any such findings
immediately.
10. ___ (once at home): Home ___, Aquacel removal POD#7, and
wound checks.
11. ACTIVITY: Weight bearing as tolerated with two crutches or
walker for as long as you need. The physical therapist will help
guide you until you are safe to wean from assistive devices.
Posterior hip precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
You were admitted for worsening hip pain and found to have
likely infection of your hip. You were seen by orthopedics and
underwent repeat surgery to clear out the infection. You were
resumed on antibiotics with improvement of symptoms. Given your
pain you were started back on opiates that were weaned down
prior to discharge. These should be continued to be down
titrated as your pain improves.
New medications:
1) Aspirin is a medication as noted above to prevent blood clots
2) Oxycodone is a narcotic medication to help control your pain.
PLease take as prescribed and wean off as your pain improves by
decreasing frequency and amount.
3) Naproxen is a medication to help control your pain. Please
take as prescribed.
4) Protonix is a medication to help prevent stomach damage while
you are on aspirin and naproxen.
5) Ferrous sulfate is a medication to help replete your low iron
stores.
6)Daptomycin is an antibiotic to treat your infection. Please
take as prescribed through ___.
7) Your home medication of gabapentin was increased. Please take
at increased dose as prescribed.
8) senna, colace, miralax are medications to help prevent
constipation. Please take as prescribed as needed.
Best of luck in your recovery,
Your ___ care team
Followup Instructions:
___
|
19618919-DS-20
| 19,618,919 | 27,175,339 |
DS
| 20 |
2152-01-27 00:00:00
|
2152-01-29 20:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrochlorothiazide / heparin / triamterene / Sulfa (Sulfonamide
Antibiotics) / vancomycin
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
TLSO brace fitted
Foley exchanged
History of Present Illness:
___ with CHF with preserved EF (65% in ___, CAD s/p CABG,
bilateral hydronephrosis with bilateral stents and chronic
indwelling c/b ESRD on HD four months ago TuThSa (last session
___, presents with one week of dyspnea with cough productive of
clearish sputum. In additon pt notes ___ weeks of worsening back
pain.
Regarding dyspnea, pt states that she became short of breath the
night prior to presentation to ___ with left sided chest
pain and productive cough. She denies fever, chills, abdominal
pain, nausea, vomiting. There CXR with mild vascular engorgement
(per radiology read), RML opacity and chronic right pleural
effusion. BP was 90/60 with BNP 1200. Pt was transferred to ___
___ due to lack of ICU beds. She recieved meropenem prior to
transfer and pain control for her back.
Regarding back pain, the patient has known T12 and L3 fractures
being managed conservatively and reports continued low back
pain. Denies weakness, numbness or tingling.
___ Labs: notable for WBC 8.6>11.2/35.2<203, trop 0.04, BNP
1264, vitals: T 99.2 60 93/52 20 100% 4L Nasal Cannula
In the ED, pt was hypotensive to 70/33 in ED. ED talked to ID
given allergies, ok to do azithromycin/meropenem. Cannot do vanc
given allergy or linezolid given Zoloft. PIV x2. UA with
possible UTI.
MICU course: On arrival to ___, vitals were: 98.4 67 84/38 13
96% NC. SBPs have been in the ___ (sometimes ___ while
sleeping), with complete intact mentation. HR in the 50-60s.
Remained afebrile.
Lactate on admission was 0.7. Pain treated with oxycodone.
Neurosurgery consulted and TLSO brace for 3 months was
recommended. Chronic pain service consulted with no targetted
intervention recommended.
On transfer to floor, VS were 97.6 59 102/39 15 99% on 2L
NC. On arrival, patient reports her back was a "bother" and is
very concerned about blowing sound in her right ear. Denies
pain, SOB, CP, dizziness, nausea, vomiting, diarrhea. Reports
last BM 3 days ago. PCP reports baseline BPs in clinic in ___ were 92/50-110/58, HR ___.
Past Medical History:
Paroxysmal a fib not on anticoagulation
Rheumatic fever
ESRD on HD
Bilateral hydronephrosis with stents and chronic indwelling
Foley
catheter with unknown start date
Critical AS - last TTE ___ at ___, peak gradient
90 mmHg, mean gradient 48, velocity 4.6 m/s, ___ 0.5 cm2
Hx of c diff
Compression fractures - T12, L3, L5 from MRI ___. From
Meditech report of MRI ___, chronic T12 and acute L3
fractures, no L5 fracture.
Duodenal AVM - per PCP, avoid anticoagulation
___ UTIs- with enterobacter, group B strep, enterococcus,
klebsiella, stenotrophomonas, psuedomonas, citrobacter, and
proteus.
Social History:
___
Family History:
non contributory to compression fractures, hypotension, hypoxia
Physical Exam:
ON ADMISSION
Vitals: vitals T 98, 63, 92/41, 94%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: decreased breath sounds bilaterally R>L. +faint rales, no
rhonchi
CV: Regular rate and rhythm, loud holosystolic murur radiating
to the carotids, moderate diastolic murmur best heard 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
MSK: point tenderness over T4-5, no clear stepoff.
SKIN: intact, HD line in place
NEURO: A/O x 3, no focal neurologic deficits.
ON DISCHARGE
Vitals: 98.7 59 92/37 (90-115/38-41) 16 100% on 1 L NC
General: AAOx3, in NAD
HEENT: MMM. OP clear, no LAD, JVP 6
Lungs: sparse bilateral crackles, no w/r/r
CV: RRR, ___ crescendo late decrescendo not obliterating S2
radiating to carotids, no diastolic murmur appreciated
Abdomen: NABS, soft, nondistended, nontender. Large ventral
hernia obscuring liver border
GU: foley in place
Skin: tunneled catheter on right non-erythematous
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. Grossly normal strength and sensation.
Pertinent Results:
LABS ON ADMISSION
___ 03:10PM BLOOD WBC-6.9 RBC-2.93* Hgb-9.8* Hct-29.5*
MCV-101* MCH-33.5* MCHC-33.3 RDW-15.8* Plt ___
___ 03:10PM BLOOD Neuts-75.8* Lymphs-14.3* Monos-6.9
Eos-2.4 Baso-0.5
___ 05:35PM BLOOD ___ PTT-28.3 ___
___ 03:10PM BLOOD Glucose-86 UreaN-23* Creat-3.2* Na-138
K-4.4 Cl-99 HCO3-31 AnGap-12
___ 04:49AM BLOOD ALT-17 AST-31 AlkPhos-66 TotBili-0.3
___ 03:10PM BLOOD cTropnT-0.02*
___ 05:15PM BLOOD cTropnT-0.02*
___ 07:58PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1
___ 03:15PM BLOOD Lactate-0.7
___ 04:30PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 04:30PM URINE Color-Red Appear-Cloudy Sp ___
___ 04:30PM URINE RBC-30* WBC-152* Bacteri-FEW Yeast-NONE
Epi-1
LABS ON DISCHARGE
___ 06:56AM BLOOD WBC-8.8 RBC-3.16* Hgb-10.5* Hct-32.0*
MCV-102* MCH-33.1* MCHC-32.6 RDW-15.5 Plt ___
___ 06:56AM BLOOD Plt ___
___ 06:56AM BLOOD
___ 06:56AM BLOOD Glucose-84 UreaN-24* Creat-3.7*# Na-136
K-3.9 Cl-98 HCO3-27 AnGap-15
___ 06:56AM BLOOD ALT-51* AST-106* LD(LDH)-186 AlkPhos-78
TotBili-0.4
___ 06:56AM BLOOD Albumin-3.0* Calcium-8.8 Phos-2.4*#
Mg-1.9
FURTHER STUDIES
CXR ___: Large right pleural effusion has increased since
earlier in the day accompanied by sufficient worsening
atelectasis to prevent mediastinal shift. Vascular congestion
and mild edema in the left lung are unchanged. Cardiomediastinal
silhouette is enlarged but hard to assess because the right
heart border is obscured.
CT C-Spine ___: No acute fracture or prevertebral soft tissue
abnormality.Bilateral pleural effusions, moderate on the right
and small on the left, with right sided atelectasis. Compression
deformities of the T12 and L3 and superior endplate of the L5
vertebral bodies, with no significant bony spinal canal
stenosis. Chronic right L1 transverse process fracture. 5 x 7 x
5 mm lytic nonspecific right sacral lesion. Paranasal sinus
disease of right sphenoid sinus, concerning for chronic
sinusitis with potential fungal component.
MRI ___: T3 late subacute compression fracture. Complete
compression of T12, similar to ___ CT, indicating
subacute timing. Acute to subacute compression fractures of T10,
L3, L5. Mild spinal canal narrowing at T10, T12, L3, but no
evidence for neural impingement. Incompletely evaluated
extra-spinal findings include right greater than left loculated
pleural effusions, scattered bilateral pulmonary opacities,
atrophic kidneys with multiple cystic lesions and presumed
collecting system air secondary to the nephroureteral stents (as
seen on the prior abdominal CT), and nonspecific presacral
edema.
CT chest ___: Moderate to large loculated right pleural
effusion is minimally larger since ___. Adjacent
consolidation is more likely atelectasis than bronchopneumonia.
TTE ___: Moderate increase of left ventricular cavity size with
mild symmetric hypertrophy and preserved regional/global
biventricular systolic function. Severe calcific aortic stenosis
with moderate aortic regurgitation. Moderate-severe functional
mitral regurgitation. Moderate-severe tricuspid regurgitation
with severe pulmonary artery systolic hypertension.
Brief Hospital Course:
___ with hx of afib (not anticoagulated), dCHF, critical AS,
ESRD
on HD, indwelling ureteral stents and chronic catheter,
compression fractures p/w dyspnea and hypotension and found to
have UTI, new compression fractures of T3, T10, L5 since ___
and moderate loculated right pleural effusion and atelectasis.
Hypotension and dyspnea likely secondary CHF and critical AS,
possibly with some component of bacteremia from UTI.
# Hypoxia: AS, MR and fluid overload likely cause given hypoxia
has markedly improved with HD and fluid removal. Moderate
loculated chronic R pleural effusion and atelectasis (likely
chronic) also compromise respiratory capacity. Initially
required 2L O2, now off O2. Initially treated with doxycycline
___ concern for PNA based on CXR, which was
discontinued after CT was more consistent with chronic effusion
# Nausea: Likely due to antibiotic and constipation (no BM for 5
days.) Improved after doxycycline d/c'd on ___ and 3 BM after
aggressive bowel regimen with senna/colace/bisacodyl BID.
Treated with odansetron 4 mg PO PRN.
# Compression fractures: Appears to have both chronic T12 and L3
fx and subacute fractures at T3, T10, L5 that occured likely 2+
months ago per level of edema. Pain treated with Tylenol ___ mg
q8h, with vicodin for breakthrough pain, which patient
requested once in evening every day during her stay. A TLSO
brace was fit per neurosurgery recommendations and should be
worn whenever she is sitting up or head is elevated > 30degrees.
___ is okay with brace. BRACE MUST BE WORN FOR SUPPORT unless
patient refuses.
# UTI: Klebsiella predominant bacteria, though non-speciated
gram negative and yeast also growing in lesser quantity per
___ urine culture. Patient was treated for klebsiella.
Foley was exchanged on HOD1 at ___, which likely treated yeast
component. Patient was started on ceftazidime (day 1: ___,
discontinued ___ on cipro 500 mg PO Q24H on ___ for
total 7 day course with last day of treatment ___.
# Hypotension: Improved after 4 L of fluid removed via HD over
HOD1 and 2. Patient's baseline BPs in ___. Continue HD
regimen.
# Aortic stenosis: Critical per repeat TTE on ___. Has explored
options for valve replacement at ___, deemed not possible
given concommitant TR and MR. ___ to be volume sensitive.
Treat volume status via HD.
# Atrial fibrillation: Not on anticoagulation, per PCP due to
history of duodenal AVM. Currently in sinus rhythm. Was
continued on amiodarone.
# DVT PPX: Heparin allergy per ___ with borderline heparin
antibodies. Was not treated with heparin, and fondaparinaux not
possible in ESRD. DVT prophylaxis was given with pneumoboots.
# ESRD on HD: HD ___ with 100-200 cc UOP daily, bilateral
hydronephrosis s/p stents changed every 2 months and chronic
indwelling catheter. Phos has been intermittenly elevated. Per
renal, does not need phos binder unless Phos >10 and phos binder
not shown to change clinical outcomes. Home dialysis schedule
was continued with additional session on ___.
# Goals of care: DNR/DNI, confirmed with patient ___.
# Anemia: Presumably secondary to ESRD.
# Coagulopathy: INR 1.4, likely nutrition-related.
=====================================================
TRANSITIONAL ISSUES
=====================================================
- f/u in 4 wks with Dr. ___.
- had mild transaminitis with ALT to 106 and AST to 51 on ___,
thought to be related to her ABx regimen. Repeat LFTs in ___
days after discharge and abdominal ultrasound if RUQ pain
- Complicated UTI: needs to finish 7 day course of antibiotics
with Cipro 500 mg Q24H, last day of treatment ___.
- Needs to wear TLSO brace at all times unless lying in bed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Liquacel (amino ac-protein hydr-whey pro) ___ gram-kcal/30
mL oral daily
4. Sertraline 50 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Mesalamine ___ 800 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H UTI Duration: 7 Days
Last day of therapy is ___
2. Amiodarone 200 mg PO DAILY
3. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
q4hrs Disp #*15 Tablet Refills:*0
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Acetaminophen 650 mg PO Q6H
9. Bisacodyl ___AILY
10. Calcium Acetate 1334 mg PO TID W/MEALS
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Miconazole 2% Cream 1 Appl TP BID
14. Senna 8.6 mg PO BID:PRN constipation
15. Liquacel (amino ac-protein hydr-whey pro) ___ gram-kcal/30
mL oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subacute compression fractures T3, T10, L5
Chronic compression fractures at T12, L3
Severe aortic stenosis with concommitant TR and MR
___ UTI
___
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed WITH BRACE with assistance to chair
or wheelchair.
Discharge Instructions:
Dear ___ was a pleasure to take care of you at ___.
You were admitted for low oxygen levels and low blood pressure,
which improved after hemodialysis and removal of extra fluid
from your blood.
During your admission, you were found to have several new
compression fractures of your back. Our colleagues in
neurosurgery fit you for a brace that goes around your chest and
belly. IT IS IMPORTANT TO WEAR YOUR BRACE WHENEVER YOU ARE OUT
OF BED AND WITH ANY ACTIVITY TO PREVENT FURTHER INJURY TO YOUR
BACK. It is also important to follow up in one month with Dr.
___ surgeon.
During your admission, you were also found to have a urinary
tract infection. It is important to continue to take antibiotics
(ciprofloxacin) to get rid of the infection.
Again, it was a pleasure to care for you. We wish you all the
best.
-Your ___ team
Followup Instructions:
___
|
19619069-DS-16
| 19,619,069 | 21,529,340 |
DS
| 16 |
2140-01-28 00:00:00
|
2140-01-28 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
trazodone
Attending: ___.
Major Surgical or Invasive Procedure:
LP ___
attach
Pertinent Results:
ADMISSION LABS
================
___ 04:45PM BLOOD WBC-9.0 RBC-4.17 Hgb-13.4 Hct-43.3
MCV-104* MCH-32.1* MCHC-30.9* RDW-12.3 RDWSD-47.8* Plt ___
___ 04:45PM BLOOD Neuts-72.8* ___ Monos-5.9
Eos-0.0* Baso-0.6 Im ___ AbsNeut-6.56* AbsLymp-1.84
AbsMono-0.53 AbsEos-0.00* AbsBaso-0.05
___ 04:45PM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-128*
K-4.2 Cl-93* HCO3-21* AnGap-14
___ 08:29AM BLOOD Na-123*
DISCHARGE LABS
=================
___ 11:43PM NA+-128*
___ 04:49PM NA+-124*
___ 12:07PM NA+-122*
___ 08:29AM ___ COMMENTS-GREEN TOP
___ 08:29AM NA+-123*
___ 08:20AM GLUCOSE-99 UREA N-13 CREAT-0.7 SODIUM-125*
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-21* ANION GAP-11
___ 03:30AM URINE HOURS-RANDOM SODIUM-57
___ 03:30AM URINE OSMOLAL-530
___ 03:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:30AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:30AM URINE RBC-1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 03:30AM URINE MUCOUS-RARE*
___ 01:32AM GLUCOSE-113* UREA N-14 CREAT-0.6 SODIUM-126*
POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-21* ANION GAP-12
___ 01:32AM OSMOLAL-260*
___ 04:45PM GLUCOSE-108* UREA N-16 CREAT-0.7 SODIUM-128*
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-21* ANION GAP-14
___ 04:45PM NEUTS-72.8* ___ MONOS-5.9 EOS-0.0*
BASOS-0.6 IM ___ AbsNeut-6.56* AbsLymp-1.84 AbsMono-0.53
AbsEos-0.00* AbsBaso-0.05
___ 04:45PM PLT COUNT-218
___ 11:43PM NA+-128*
IMAGING
=================
___ EEG
IMPRESSION: This is an abnormal routine EEG in the awake and
drowsy states due
to:
1) 2 focal electrographic seizures (~75 seconds each) from the
right temporal
region. Clinically, they were "focal-onset seizures with
preserved awareness,"
and showed a clinical correlate of anxiety, left shoulder
paresthesia,
abnormal sensation in the stomach moving to the head and chest,
and burning in
the throat.
2) Occasional brief bursts of focal slowing seen independently
and
synchronously in the temporal regions bilaterally. This finding
indicates
bilateral independent foci of subcortical dysfunction, but the
etiology cannot
be specified by the recording. Vascular disease is a common
cause.
No interictal epileptiform discharges were evident.
MICROBIOLOGY
=================
___ 3:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ is a ___ year old healthy woman who presented with focal
seizures and hyponatremia, transferred to general neurology for
further workup of seizure given EEG findings. She was monitored
on EEG showing R temporal discharges and many electrographic
seizures that correlated with an abnormal sensation in her
stomach and the feeling of someone lurking behind her. Workup of
her seizures showed a positive anti-TPO antibody 176 which is
non-specific, elevated ___ 1:40, and a mildly elevated CEA at
5.8. CSF with 0 WBC and 42 protein. Her serum and CSF
paraneoplastic panels are pending. Her hyponatremia
self-resolved with mild fluid restriction.
She was started on Keppra 1g BID, and this was titrated up to
1500mg BID (she was temporarily on 2g BID but had nausea; in
retrospect this was likely seizure and not med side effect),
subsequently loaded on lacosamide and then uptitrated to 200mg
BID. Her EEG worsened regarding frequency and duration of
discharges, with more electrographic seizures on ___.
She has never had motor involvement or loss of awareness or
consciousness with seizures. We started Onfi 5mg BID on ___.
There was some improvement in discharge frequency, but given the
overall worsening of her clinical condition, we started
methylpred 1g daily for a ___. 24 hours
after her first dose of steroids, there have been no more
electrographic seizures and her symptoms have not recurred.
Regarding her malignancy workup, she had a normal mammogram 1
month prior to admission, a negative colonoscopy within ___ year,
a negative CT torso w/wo contrast, and had a PET scan ___ which
was negative. We would recommend repeat malignancy screen with
CT torso or PET in 6 months.
Our working diagnosis is autoimmune vs paraneoplastic epilepsy,
though reassuring that she has had a negative malignancy workup.
She has responded well to steroids, suggesting an inflammatory
epilepsy, also evidenced by the positive anti-TPO titer. The
paraneoplastic panel is currently pending in the CSF and serum.
She was ready for discharge on ___ with a plan to remain on
prednisone 60mg daily for the next few months until follow up in
neurology clinic. She will been seen in general neurology clinic
with Dr. ___. She was discharged on GI protective meds,
calcium, and vitamin D to protect her from the side effects of
medications. She should discuss with her PCP consideration of
bisphosphonates as she may be on steroids for a prolonged period
of time. We discussed at length the possible side effects of
long term steroids including mood instability, ulcers, weakening
of the bones, and adrenal insufficiency if steroids are acutely
discontinued.
#Seizures
-Continue Keppra, Onfi, Lacosamide
-Prednisone 60mg daily until neurology clinic follow up
-Follow up in neurology clinic with Dr. ___ driving for 6 months of seizure freedom
#Hyponatremia
-Self resolved
-Continue to monitor with PCP
___ protectants
-___, vitamin D, PPI
-F/U with PCP for monitoring bone health
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO QAM
RX *calcium carbonate [Calci-Chew] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth qam Disp #*30 Tablet Refills:*6
2. Clobazam 5 mg PO BID
RX *clobazam 10 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*5
3. LACOSamide 200 mg PO BID
RX *lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*6
4. LevETIRAcetam 1500 mg PO BID
RX *levetiracetam [Keppra] 750 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*6
5. Pantoprazole 40 mg PO Q24H Steroid protection
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
6. Ramelteon 8 mg PO QPM:PRN insomnia
RX *ramelteon 8 mg 1 tablet(s) by mouth qhs prn Disp #*30 Tablet
Refills:*3
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
===========
Seizures
Secondary
===========
Hyponatremia
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 here because you were having seizures and your sodium
was low. We lowered the amount of water you drink everyday which
made your sodium better. For your seizures, we started you on
two medications, Keppra and Vimpat. We performed a number of
imaging and lab tests to try and determine what might be causing
your seizures. We found that you had abnormal antibodies in your
system which are associated with epilepsy, but we still don't
know what is causing the antibodies.You had a PET scan on
___, which revealed no evidence of malignancy, and we have
made a clinic appointment for you in the next few weeks, the
time and date still need to be confirmed, and the clinic will
reach out to you with confirmation.
When you leave, it is important to take your medications as
prescribed. It is also important you attend your follow-up
appointments as listed below.
We wish you the best of luck!
Your ___ Care Team
Followup Instructions:
___
|
19619252-DS-20
| 19,619,252 | 26,004,597 |
DS
| 20 |
2183-01-07 00:00:00
|
2183-01-07 11:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Hydrochlorothiazide / azithromycin / chlorthalidone
/ amlodipine
Attending: ___.
Chief Complaint:
abdominal pain, syncope, constipation
Major Surgical or Invasive Procedure:
Paracentesis ___ and ___
___ Procedures:
___: US guided paracentesis yielding 1450mL blood-tinged
purulent ascites. ___ exodus placed to suction RLQ. Cultures
grew
mixed E.coli and pseudomonas.
___: CT guided placement of 2 ___ pigtail catheter placements to
left mid abdomen & anterior pelvis both to JP (one sample grew
Pseudomonas)
Drains removed on ___
History of Present Illness:
___ male with the past medical
history of CKD due to FSGS on high-dose steroids, hypertension,
gout, recent prolonged hospitalization from ___ to the
start
of ___ for provoked lower extremity DVT, atrial
fibrillation, acute blood loss anemia, ___ on CKD, and NSTEMI,
esophageal candidiasis, and left lower extremity cellulitis. He
was discharged on ___ to a ___ facility and there has been
improving. He was referred to the emergency department after he
reported dizziness and had a possible syncopal episode. He was
sent ___ for head CT. There is a rehab also noted that he was
having difficulty with voiding. He reports that he was voiding
100 cc at a time. Patient reports that over the course of the
last several weeks he has had increased difficulty with burning
and burning on urination.
___ the emergency department this patient was seen and evaluated.
His initial vital signs were stable. His white blood cell count
was 9.3 down from a persistent leukocytosis that he had during
his prior hospitalization of ___ range. His H&H was stable
with a hemoglobin of 11.4 up from a discharge hemoglobin of
10.1.
His INR was 3.4. His creatinine was 2.3 down from a discharge
creatinine of 3.1 and a peak creatinine during prior
hospitalization of 4.2. The patient's head CT was unremarkable
for any intracranial process. The ED reports that the talk to
the
patient's primary care provider who requested admission to the
medical service for further evaluation.
On arrival to the floor the patient reports that he is feeling
slightly better. He reports that on presentation to the rehab
facility on his for several physical therapy episodes he had
dizziness and lightheadedness and had to be set back down. He
describes the sensation as almost blacking out. He reports that
since then they have been taking it easy with him with physical
therapy he has had no further episodes. He reports the last
episode was approximately 1 week ago. He otherwise reports that
he has had decreased bowel movements over the course of his time
at the rehab facility. He reports that he feels like his
abdomen
is slightly more distended than it had been ___ the past. He
reports that he continues to pass gas but that he has not had a
bowel movement ___ ___ days. He reports that this is very
unusual
for him. He reports that he did not have difficulty with
urinating until after he started to feel constipated. He denies
any new numbness or weakness.
ROS: Pertinent positives and negatives as noted ___ the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HYPERTENSION
FSGS
ERECTILE DYSFUNCTION
GYNECOMASTIA
LOW TESTOSTERONE
GOUT
HYPERTENSIVE NEPHROPATHY
AFIB
PROVOKED ___ DVT
IVC CLOT
NSTEMI
Social History:
___
Family History:
- Mother- breast cancer, deceased
- Father- deceased
- ___ family history of kidney disease
Physical Exam:
ADMISSION EXAM:
===============
T 97.6 PO BP: 142/95 R Lying HR: 102 RR: 18 O2 sat: 100%
GEN: AAM ___ NAD.
HEENT: Dry MM.
CV: RRR w/o m/r/g.
RESP: CTAB no w/c.
ABD: Soft, obese, minimal TTP over suprapubic region, no rebound
or guarding.
GU: Foley ___ place.
EXTR: 2+ edema ___ RLE and 1+ edema ___ LLE.
NEURO: Alert, appropriate, generalized weakness.
DISCHARGE EXAM:
===============
VS: 24 HR Data last updated ___
Temp: 98.2 (Tm 98.7), BP: 135/85 (106-127/67-81), HR: 105
(75-133), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: Ra
General: Sitting comfortably ___ bed, NAD
LUNGS: Aeration heard throughout with minimally decreased lung
sounds left>right to auscultation bilaterally ___ peripheral lung
fields, no wheezes, rales, rhonchi
CV: RRR no murmurs, rubs, gallops
ABD: Soft, nontender, without rebound or guarding. S/P 3 JP
drains with serosanguinous fluid. Sites c/d/I. Now with two new
JP drains. Draining serosanguinous fluid
EXT: Warm, well perfused, 1+ pitting edema ___ feet
SKIN: No rashes, striae and scattered and diffuse speckled
pattern of hypopigmentation noted on bilateral upper and lower
extremities and also head. The hypopigmentation is especially
apparent on bilateral arm flexures. Diffuse xerosis.
NEURO: CNII-XII grossly intact, AOX3, moves all extremities
withpurpose
Pertinent Results:
ADMISSION LABS:
================
___ 09:22AM BLOOD WBC-6.6 RBC-2.96* Hgb-9.0* Hct-27.7*
MCV-94 MCH-30.4 MCHC-32.5 RDW-15.9* RDWSD-54.2* Plt ___
___ 09:22AM BLOOD ___
___ 09:22AM BLOOD Glucose-94 UreaN-35* Creat-2.0* Na-137
K-3.6 Cl-97 HCO3-31 AnGap-9*
___ 07:08AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.4
HOSPITAL COURSE LABS:
====================
TSH 8.3/Free T4 1.0
CRP 268.7
TGs 209--> ___
Ferritin 2811
TRF 52
Hapto 249
TIBC 68
DISCHARGE LABS:
================
___ 05:37AM BLOOD WBC-7.7 RBC-2.96* Hgb-8.8* Hct-26.9*
MCV-91 MCH-29.7 MCHC-32.7 RDW-17.0* RDWSD-56.7* Plt ___
___ 05:37AM BLOOD ___
___ 05:37AM BLOOD Glucose-84 UreaN-31* Creat-1.8* Na-141
K-3.3 Cl-111* HCO3-18* AnGap-12
PERTINENT IMAGING:
===================
PERC IMAGE GUID FLUID COLLECT DRAIN W
CATH(ABSC,HEMA/SEROMA;LYMPHOCELE,CYST);PERIT/RETROPERITONEAL
___
Successful US-guided paracentesis and placement of an ___
pigtail
catheter into the right lower quadrant. Samples were sent for
chemistry,
hematology, cytology, and microbiology.
CT A/P ___. Interval development of free air within the abdomen and
pelvis without
definite etiology. There is no extraluminal oral contrast to
suggest bowel perforation.
2. There is slight increase ___ volume of the hemorrhagic
ascites.
3. There is interval decrease ___ size of the hematomas anterior
to the IVC as well as adjacent to the duodenum.
4. There is a large stool ball measuring up to 7.9 cm ___
greatest diameter.
No evidence of colitis or proctitis.
5. Atelectasis of the left lower lobe with foci of increased
density within the parenchyma suggestive of possible mild
aspiration of the oral contrast. Small left pleural effusions
similar to prior. Interval improvement ___ right pleural
effusion.
CT A/P ___. Moderate volume ascites, slightly increased compared to the
prior study
from ___. Air-fluid level ___ the left lower
quadrant along the
anti mesenteric border of a few jejunal loops, favored to
represent
extraluminal gas trapped between jejunal loops and ascites.
Additional
locules of trapped extraluminal gas seen within pelvic ascites.
Pneumoperitoneum also appears overall increased from prior.
2. No extraluminal oral contrast indicate site of bowel
perforation.
3. Interval decrease ___ size of the hematoma adjacent to the
duodenum and
anterior to the IVC.
4. Diffuse body wall edema. Increased fluid within the left
lateral chest
wall musculature.
CT ABD & PELVIS W/O CONTRAST ___:
1. No evidence of retroperitoneal or intraperitoneal hemorrhage.
2. Re--demonstrated minimally improved moderate amount of
intraperitoneal
fluid with peritoneal thickening and foci of air consistent with
peritonitis.
3. Multiple fluid collections around the pancreas with
pancreatic enlargement and edema concerning for pancreatitis.
Correlation with laboratory should be considered.
4. Loculated collection with air-fluid levels ___ the left lower
abdomen has
slightly increased ___ size measuring 7.6 cm compared to 6.3 cm
previously.
5. Worsening pleural effusions. High-density material within
the collapsed
lungs concerning for aspiration of contrast previously.
CT ABD & PELVIS W/O CONTRAST ___. Re-demonstration of a moderate amount of loculated
intraperitoneal fluid
with peritoneal thickening consistent with peritonitis. The
largest
collection ___ the pelvis is not significantly changed ___ size,
however has
increased air within it, concerning for a large peritoneal
abscess. An
additional abscess ___ the left upper quadrant is slightly
decreased ___ size.
No new fluid collections.
2. No significant change ___ pancreatic enlargement and edema
with multiple
surrounding peripancreatic fluid collections.
3. No significant change ___ moderate bilateral pleural effusions
and adjacent
consolidations at the lung bases.
CT ABD & PELVIS W/O CONTRAST ___. Overall decrease ___ size of intra-abdominal fluid and air
collections
within the anterior pelvis, left and right pericolic gutters and
within the
loops of small and large bowel. The anterior pelvic fluid
collection now
measures 9.6 x 3.2 cm ___ the interloop collection measures 3.0 x
2.4 cm.
Given the decrease ___ size of all the previously seen
collections to the
placement of the pigtail drain, as well as resolution of air,
the collections
may be interconnected.
2. No evidence for bowel perforation.
3. Small right and incompletely assessed likely moderate left
pleural effusion
with overlying atelectasis.
4. Interval increase ___ size of a small pericardial effusion.
ECHO ___
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a trivial/physiologic pericardial effusion. There is
significant, accentuated respiratory variation ___
mitral/tricuspid valve inflows, consistent with
effusive-constrictive physiology.
IMPRESSION: No clinically-significant pericardial effusion.
Effusive-constrictive physiology, likely transient.
ECHO ___
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
IMPRESSION:
1) Small serous largely inferolaterally located pericardial
effusion without tamponade signs. The tricuspid inflow pattern
shows respiratory variation however no significant pericardial
effusion visualized ___ vicinity to invoke localized tamponade
and likely due to cardiac cause.
2) Moderate aortic sinus venosus dilation.
Compared with the prior study (images reviewed) of ___,
pericardial effusion smaller and respirophasic variation ___
mitral inflow no longer seen. The proximal aorta was visualized
better.
ECHO ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). The right ventricular free
wall is hypertrophied. Right ventricular chamber size is normal
with depressed free wall contractility. There is abnormal
systolic septal motion/position consistent with right
ventricular pressure overload. The aortic root is mildly dilated
at the sinus level. The number of aortic valve leaflets cannot
be determined. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent ___ the
presence of elevated right sided pressures. A left pleural
effusion is present.
Compared with the prior study (images reviewed) of ___,
heart rate is increased; left ventricular ejection fraction is
decreased. A moderate sized pericardial effusion is now
present.
KUB ___:
Redemonstration of small amount of pneumoperitoneum. Mild
gaseous distention of the colon compatible with ileus. No
findings to suggest obstruction as the oral contrast from prior
CT is now ___ the colon.
CT HEAD ___:
There is no evidence of acute territorial
infarction,hemorrhage,edema, or
mass. The ventricles and sulci are normal ___ size and
configuration for
patient age. There is no evidence of fracture. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits
are unremarkable.
MICROBIOLOGY:
=============
___ 10:53 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay.
___ 1:19 pm URINE
URINE CULTURE (Final ___:
ESCHERICHIA COLI >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed ___ MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 8:31 am PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) AT 1403
___.
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. HEAVY GROWTH.
Cefazolin interpretative criteria are based on a dosage regimen
of
2g every 8h.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___ MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 4:54 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set ___ the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0200 ON ___ -
___.
GRAM POSITIVE COCCI ___ CLUSTERS.
(Reference Range-Negative).
___ 4:00 pm PERITONEAL FLUID
ACID FAST CULTURE AND STAIN ADDED ON PER ___ AT
2039 ON
___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
Reported to and read back by ___ ___ (___) @ 2046
___.
FLUID 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
___ this
culture.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
ESCHERICHIA COLI. SPARSE GROWTH.
IDENTIFICATION AND Susceptibility testing requested by
___
___.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ___ COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 16 I <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S =>4 R
GENTAMICIN------------ <=1 S 4 S
MEROPENEM------------- 4 I <=0.25 S
PIPERACILLIN/TAZO----- R <=4 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
PERITONEAL CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
Fibrinopurulent exudate consistent with the patient's clinical
diagnosis of abscess collection
Foreign body material, some of which appears to be plant
material and other suggestive of the drug such as Sevelamer.
Clinical correlation to exclude intestinal perforation is
recommended.
___ 4:19 pm PERITONEAL FLUID LEFT MID ABDOMEN.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ (___) @
___ ON
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringens, and C.septicum.
None of
these species was found.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of chronic
kidney disease, secondary to collapsing FSGS, hypertension,
atrial fibrillation (on Coumadin), BPH, and a recent
hospitalization for hemorrhagic shock secondary to
retroperitoneal bleed/peripancreatic hemorrhage ___ the setting
of anticoagulation, who presented on ___ with dizziness. He
was found to have hemorrhagic ascites with secondary E. Coli
peritonitis, E. coli UTI, pneumoperitoneum, coag negative and
staph bacteremia. His hospital course was complicated by
afib/flutter with rapid ventricular response and hypotension
requiring care ___ the MICU, Clostridium difficile infection,
severe lower extremity edema, secondary to his underlying
nephrotic syndrome necessitating aggressive diuresis, and
peritoneal abscess now s/p drainage by ___.
# Hemorrhagic Ascites
# Bowel microperforation
# E.Coli, Pseudomonal bacterial peritonitis
# Intra-abdominal abscesses
# Large peritoneal abscess now s/p ___ drainage on ___ and ___
CT A/P ___ was obtained given abdominal pain/constipation
which showed development of hemorrhagic ascites and free air
within the abdomen and pelvis without definite etiology. He
subsequently underwent paracentesis w/ >187K RBCs, >27K TNC, &
heavy growth of GNRs. No extraluminal oral contrast to suggest
bowel perforation. ACS was consulted given concerns for free air
but felt there was no need for acute surgical intervention given
non-peritoneal exam. Peritoneal fluid culture ___ showed E.
coli. Peritonitis thought most likely secondary to gut
translocation from microperforation and/or C.Diff colitis. The
patient completed two weeks IV ceftriaxone and Flagyl ___,
ended ___. Unfortunately, abdominal pain continued during
hospitalization and repeat CT abd/pelvis ___ and ___ showed
recurrent intraperitoneal abscesses. ___ drained these abscess on
___ and ___, with 3 drains placed. The ascites fluid has grown
E.Coli as well as Pseudomonas. Cytology showed "medication
particles" concerning for microperforation. ACS consulted,
albeit no surgical indication at this time. Per ID, patient was
restarted on broad spectrum antibiotics (D1: ___ with PO
Flagyl, IV Vanc, and IV cefepime. Antibiotics narrowed to
Cefepime and Flagyl. Drains were successfully removed by ___
prior to discharge with resolution of abdominal pain. He will
need close follow up with Infectious disease.
# C. diff:
The patient reported loose stools and stool studies showed a
positive C.diff on ___. ID was consulted, and felt that this
was not likely an acute infection, however ___ the setting of
prolonged antibiotics for infections (above) he was treated with
Flagyl for a 10-day course (last day ___. He had continued
diarrhea so he was restarted on treatment. He will need to be
treated for 14 day course past end of IV antibiotics.
# CKD stage III-IV ___ FSGS:
# Nephrotic syndrome
# Lower extremity edema
The patient's baseline creatinine was unclear but ~1.3 ___
___, and peaked at 4.6. He presented while on a
prednisone taper for FSGS. Given FSGS and anasarca, renal was
consulted on ___ for recommendations regarding
immunosuppression and diuresis. He was diuresed approximately
-22L on this admission. Diuresis was limited by soft blood
pressures, and held at discharge. Losartan was trialed for
proteinuria, but held ___ setting ___ at discharge. Consider
restarting losartan and/or diuresis as an outpatient. Per renal,
outpatient follow-up with Dr. ___ consideration of
immunosuppressive medications. He was continued on gastric ulcer
prophylaxis with PPI due to prolonged steroids. He was
discharged on 5 mg daily for now. He was continued on home
vitamin D, sevelamer, calcium, and Nephrocaps. Cr at discharge
1.9. Given 1L IVF prior to discharge for possible mild
hypovolemia.
# Atrial fibrillation: CHADSVASC ___.
Course complicated by atrial fibrillation with rapid ventricular
response, likely precipitated by severe inflammatory state, and
possibly exacerbated by intravascular depletion from aggressive
diuresis. Rates sustaining >130bpm. He underwent attempted DCCV
with Cardiology on AM of ___ but ___ was unsuccessful ___ the
setting of ongoing infection. He received several amiodarone
loads with intermittent success at restoring sinus rhythm. PO
amiodarone was continued, and he was started on diltiazem and
metoprolol for rate control. He was stable on metoprolol
tartrate during admission and will be discharged on metoprolol
succinate with first dose evening of ___. The patient was
initially on IV heparin gtt anticoagulation, then bridged to
warfarin.
# Provoked non-occlusive LLE DVT/IVC Filter Thrombus:
The patient was diagnosed with a left lower extremity deep vein
thrombosis during his previous admission on ___. This was
felt to be provoked given context of FSGS and anti-thrombin III
loss with nephrotic syndrome, and lower left leg cellulitis
(treated last admission). The patient had an IVC filter during
his previous admission. Attempted IVC filter removal on ___,
but an active thrombus was seen within the filter, and therefore
removal was aborted. He was continued on heparin drip and
bridged to warfarin once INR was therapeutic above 2. The
patient should have a repeat venogram with possible filter
retrieval ___ 3 months unless it is medically necessary for the
filter to remain ___ place.
# Severe Protein Calorie Malnutrition:
Given the patient's hypoalbuminemia from FSGS, nutrition was
consulted for recommendations regarding high protein, low salt
diet. His reported dry weight is 111.4kg from his most recent
discharge prior to this admission. His discharge weight was 93.9
kg on ___ (bed weight). Nutrition recommended Nepro Frappe TID
and multivitamin w/ minerals.
# Anemia:
Admission Hb 11, and stabilized around 8 while admitted. He
required 2 units of pRBCs during this admission. This was likely
secondary to phlebotomy, renal failure, chronic
illness/inflammation, and likely stress ulcer from critical
illness. He was continued on prophylaxis with PPI as above.
#Mild thrombocytopenia: Patient with drop ___ platelets during
hospital stay. Felt to most likely be due to cefepime. Plts on
discharge 140. Was not on heparin when platelets were dropping,
thus no concern for HIT.
#Hyperkeratosis
Hypopigmented scattered plaques with speckled appearance on
bilateral arms, legs, and head. Dermatology was consulted and
suggested most likely ___ the setting of illness, severe
malnutrition, and significant anasarca. Improvement seen with
liberal application of aquaphor.
# Hyperlipidemia:
Continued atorvastatin 20 mg PO QHS.
# BPH:
Continued tamsulosin 0.4 mg PO QHS, which was increased to 0.8mg
PO qhs ___ setting of urinary retention. Foley was removed with
successful void trial.
#HTN
Continued long-acting diltiazem and metoprolol per above.
# Diabetes Mellitus:
The patient was managed on an insulin slididng scale, which was
discontinued given adequate sugar control.
# Oral candidiasis: This was secondary to prolonged steroid use.
He was continued on nystatin until oropharynx was clear.
TRANSITIONAL ISSUES:
=====================
[] Monitor for any signs of worsening abdominal pain,
fevers/chills, and consider repeat CT abdomen/pelvis to evaluate
for unresolved bacterial abscesses/peritonitis
[] Continue antibiotics for bacterial peritonitis, was on IV
Cefepime and PO Flagyl (D1: ___, switching to ertapenem 1 g
IV daily on discharge. Last day ___ pending repeat imaging
with infectious disease specialists to show resolution of
infection.
[ ] Please send weekly CBC w/ differential, BUN, Cr, AST, ALT,
TBili, Alk Phos
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
[] Continue PO vancomycin for C. Diff colitis for 2 weeks after
broad spectrum antibiotics are discontinued. Last day will be
determined based on ID OPAT decision when to discontinue
antibiotics for peritonitis.
[] Continue warfarin daily for atrial fibrillation as well as
known IVC filter clot with INR monitoring, goal INR ___
[] Continue diltiazem and metoprolol for rate control of atrial
fibrillation, with titration to rate <110bpm
[] Follow up with cardiology, would consider discontinuation of
amiodarone once recovered from acute illness at outpatient
cardiology follow-up
[] Follow up with nephrology, patient to possibly be started on
cyclosporine as outpatient given clinical failure of prolonged
prednisone taper
[] Consider restarting PO torsemide and losartan per nephrology
for FSGS and nephrotic syndrome. Losartan was held ___ setting of
___. Cr at discharge 1.9.
[] Follow up with ___ as an outpatient, with plan for repeat
venogram ___ 3 months. Consider removal of IVC filter unless
medically necessary to keep ___.
# Code Status: Full Code
> 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Vitamin D ___ UNIT PO 1X/WEEK (WE)
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Amiodarone 200 mg PO DAILY
6. Atovaquone Suspension 1500 mg PO DAILY
7. PredniSONE 30 mg PO DAILY
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 4 tapered doses
8. PredniSONE 20 mg PO DAILY
Start: After 30 mg DAILY tapered dose
This is dose # 4 of 4 tapered doses
9. PredniSONE 10 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
10. Nystatin Oral Suspension 5 mL PO TID
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Omeprazole 20 mg PO DAILY
13. Warfarin 7 mg PO DAILY16
14. Torsemide 50 mg PO DAILY:PRN weight gain
15. Metoprolol Tartrate 25 mg PO Q8H
16. Glargine 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
17. Senna 8.6 mg PO BID:PRN constipation
18. Docusate Sodium 100 mg PO BID
19. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
2. Aquaphor Ointment 1 Appl TP BID dry skin
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID:PRN
Mouth Rinse
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Ertapenem Sodium 1 g IV DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP<90, HR <60
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nystatin Oral Suspension 10 mL PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Vancomycin Oral Liquid ___ mg PO QID
11. PredniSONE 5 mg PO DAILY
12. Simethicone 80 mg PO QID:PRN Gas Pain
13. Tamsulosin 0.8 mg PO QHS
14. Warfarin 1 mg PO DAILY16 Duration: 1 Dose
15. Amiodarone 200 mg PO DAILY
16. Atorvastatin 20 mg PO QPM
17. Calcium Carbonate 500 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Pantoprazole 40 mg PO Q24H
20. Vitamin D ___ UNIT PO 1X/WEEK (WE)
21. HELD- Glargine 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin This medication was
held. Do not restart Insulin until speaking with your doctor
22. HELD- Torsemide 50 mg PO DAILY:PRN weight >3 pounds increase
This medication was held. Do not restart Torsemide until
speaking with your kidney doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
=======
#Collapsing FSGS / Nephrotic syndrome
#Peritoneal Abscess
#Multiple abdominal fluid collections
#Free Intraperitoneal air
#Hypervolemia
#Acute urinary retention
#CDiff
#Severe protein calorie malnutrition
#Provoked non-occlusive LLE DVT s/p IVC filter with
non-occlusive thrombus
#Afib / Aflutter
#Oral thrush / esophageal candidiasis
#Vasovagal syncope
#Constipation
#Hypopigmented lesions
#Question of pancreatitis / diarrhea
#Secondary E. coli peritonitis / pneumoperitoneum / hemorrhagic
ascites
#Ecoli UTI
#Coag negative staph bacteremia
#RP hematoma
#Trivial pericardial effusion
Secondary
==========
#HTN
#HLD
#BPH
#DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you were dizzy.
WHAT WAS DONE WHILE YOU WERE ___ THE HOSPITAL
- While you were ___ the hospital we found
1) Blood and air ___ your belly
2) Infection ___ your belly
3) Infection ___ your urine
4) Infection ___ your blood
5) Infection ___ your intestines called C. diff
- You got antibiotics for your infections
- You had fluid collections ___ your abdomen drained
- Your heart rate was fast, so you got medications to slow the
rate
- You got steroids and medications for your kidney disease
- You got diuretics for the fluid ___ your legs
- We restarted your warfarin to prevent clotting and stroke
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up at your outpatient appointments.
2) Please take your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19619647-DS-19
| 19,619,647 | 29,408,693 |
DS
| 19 |
2165-03-13 00:00:00
|
2165-03-13 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
food impaction
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with no prior PMH who presents with globus sensation found
to have food bolus on EGD. Patient was at a funeral reception
when acutely felt like food was stuck in his throat after eating
a piece of chicken. He continued to have difficulty handling
secretions and given this, he went to the ED for further
evaluation. Patient was evaluated by GI who recommended urgent
EGD. On EGD, he was found to have food impaction that was
cleared. As it was being cleared, a small tear was noted in the
distal esophagus with brief bleeding, but no active bleeding at
the end of procedure. Physical examination post-procedure
revealed no crepitus. Otherwise normal EGD to third part of the
duodenum. He was then sent to the PACU for post-op monitoring
and given downtrending H/H (12.4 from 13.9) and tachycardia with
spikes to 140/150, admitted to medicine for overnight
monitoring.
On interview, endorses mild chest pain since procedure ___. No
SOB, difficulty breathing. No fever, chills, nausea, abdominal
pain, dizziness.
Past Medical History:
Opiate abuse
Social History:
___
Family History:
na
Physical Exam:
Vitals: 98.0
PO 124 / 75
R Sitting 81 22 99 RA
General: WDWN Caucasian male. A&O x 3 in NAD.
HEENT: EOMs in tact. dry MM. no pharyngeal erythema
Neck: supple, no crepitus
CV: RRR. S1/S2. no m/g/r
Lungs: CTAB
Abdomen: soft, NTND. +BS. no guarding/rebound
GU: no foley
Ext: wwp, 2+ pulses, no edema
Neuro: no gross focal deficits
Skin: no crepitus, no rash
LABS: reviewed in OMR
Pertinent Results:
___ 12:45AM BLOOD WBC-8.9 RBC-4.53* Hgb-13.9 Hct-40.7
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.4 RDWSD-40.3 Plt ___
___ 12:45AM BLOOD Neuts-77.4* Lymphs-13.6* Monos-5.5
Eos-3.0 Baso-0.2 Im ___ AbsNeut-6.89* AbsLymp-1.21
AbsMono-0.49 AbsEos-0.27 AbsBaso-0.02
___ 12:45AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-143
K-3.9 Cl-104 HCO3-26 AnGap-17
___ 05:12AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.9
___ 06:53AM BLOOD WBC-7.1 RBC-4.14* Hgb-12.7* Hct-37.4*
MCV-90 MCH-30.7 MCHC-34.0 RDW-12.5 RDWSD-41.1 Plt ___
___ 04:00PM BLOOD Hgb-12.4* Hct-36.2*
___ 05:12AM BLOOD WBC-6.7 RBC-4.40* Hgb-13.6* Hct-39.4*
MCV-90 MCH-30.9 MCHC-34.5 RDW-12.5 RDWSD-41.1 Plt ___
___ 05:12AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-142
K-4.0 Cl-105 HCO3-25 AnGap-16
IMAGING:
CXR (___): per my read, no acute cardiopulmonary process,
no obvious subcutaneous air
EGD report:
___
A column of liquid was encountered in the esophagus and was
cleared with suctioning. An obstructing bolus of food was noted
at 38cm. The gastroscope was unable to pass around it. The food
bolus was cleared piecemeal with large cap forceps and
eventually passed into the stomach. As the food was being
cleared, a small tear was noted in the distal esophagus with
brief bleeding. This was carefully examined after the food bolus
was cleared and there was no active bleeding at the end of the
procedure. Abnormal mucosa in the esophagus. The patient
remained hemodynamically stable throughout the procedure and
awoke with no pain. Physical examination post-procedure revealed
no crepitus. Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with no prior PMH who presents with globus sensation found
to have food bolus on EGD and distal esophageal tear, with H/H
drop from 13.9 to 12.4, now admitted for post-op monitoring.
# Food impaction: Patient was at a funeral reception when
acutely felt like food was stuck in his throat after eating a
piece of chicken. He continued to have difficulty handling
secretions and given this, he went to the ED for further
evaluation. On EGD, he was found to have food impaction that was
cleared.
# Esophageal tear/bleeding: seen on EGD while food impaction
being cleared with no evidence of bleeding at end of procedure.
H/H initially dropped from 13.9 to 12.4, but remained stable
after. Monitored overnight with no issues. Discharged on
omeprazole to facilitate healing.
# opiate abuse: pt reported hx of opiate abuse which he is self
treating with mother's ___ 2mg BID. Only mother knows about
it. Seen by social worker. Patient was agreeable and will follow
up with PCP ___: further care for opiate abuse.
Medications on Admission:
None
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Food Impaction
Esophageal tear and bleeding
Opiate abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen in the hospital with concern for your recent
trouble swallowing and were found to have a impaction of food
which was removed by our GI team. You had small tear and brief
bleeding. You were monitored overnight in the hospital with no
other abnormalities. Your blood work in the morning remained
stable. You will be contacted by our GI team to have endoscopy
in ___ weeks. You told us that you have had concerns over opiate
abuse and have been self treating. You were seen by our social
worker. You should continue to discuss with your PCP to get
further care.
Sincerely,
___ team
Followup Instructions:
___
|
19620042-DS-19
| 19,620,042 | 26,177,090 |
DS
| 19 |
2188-04-24 00:00:00
|
2188-04-30 21:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Ace Inhibitors
Attending: ___
Chief Complaint:
Respiratory failure, seizure
Major Surgical or Invasive Procedure:
Intubation, central venous access, arterial line placement,
surgical tracheostomy, down-sizing of tracheostomy collar,
placement of NG feeding tube
History of Present Illness:
___ y/o man with HTN, HLD, CKD,DM, critical carotid disease b/l
s/p L CEA on ___ who is transferred from OSH for status
___. To summarize all
transfer documents, his wife reported that she had been out
hanging laundry (for ___ minutes) and came in to find her
husband at 10:39 AM experiencing seizure-like activity with
snoring respirations. EMS was called at 10:41 AM. During
transport from scene to ___, he was reported to
be
having non-stop seizure activity. There was some bleeding from
his mouth noted during the seizure activity and suction was
unable to be performed due to locking of jaw. He arrived at
___ at 10:51 AM with continued seizure activity.
He was given Ativan 4 mg IV, which by report stabilized him; he
was then intubated for airway protection and was subsequently
loaded with Dilantin. Seizure was reported as lasting between
___ minutes. Per ___ notes, the seizure
activity
was "predominantly RUE with flaccid LUE." At OSH, he was sent
for
___ and CTA head and neck, which showed no hemorrhage, old
left
occipital infarct and patent left carotid artery but extremely
stenotic right carotid. He we sent to ___ for
further evaluation and was subsequently transferred to ___ for
further evaluation and treatment.
He is not known to have a history of seizures. According to
notes sent with his transfer paperwork, he had an episode of
confusion at the end of ___ and ___ at that time was
suggestive of left sided infarct. Carotid dopplers showed
critical right ICA stenosis and a subcritical left ICA stenosis.
He underwent left CEA on ___, with plan to perform right CEA
in 8 weeks from that time.
Past Medical History:
-bilateral carotid artery stenosis (right noted as being >90%
stenotic)
-s/p L CEA ___
-CAD
-DM ___ years, with retinopathy, nephropathy and neuropathy)
-HTN
-HLD
-CKD
-BPH
-PVD s/p LLE stent
-s/p hip replacemebt b/l
Social History:
___
Family History:
Positive for diabetes
Physical Exam:
On admission:
Vitals: T: 97.8 (@ OSH) P: 80 R: 20 BP: 172/53
vent CPAP
Examined immediately upon arrival, with Propofol having been
running during transport
General: intubated, sedated
HEENT: ET tube in place
Neck: Supple
Pulmonary: lcta b/l anteriorly
Cardiac: RRR, S1S2
Abdomen: soft, nondistended. hypoactive BS
Extremities: warm, well perfused
Neurologic: No eye opening. Does not follow any commands. Pupils
in midline; they are 1 mm and minimally reactive to light. No
Doll's eyes appreciated. Brisk corneals b/l. Intact cough and
gag. He is moving his LUE spontaneously. No other spontaneous
movements noted. He withdraws left lower extremitiy antigravity
to noxious stimuli but did not do so right lower extremity.
Grimmaces to noxious stimulus throughout. Reflexes 1+ and
symmetric at biceps, brachioradialis and patlla. Unable to
elicit
ankle jerks. Toes are tonically in extensor position.
On day of discharge:
Tmax: 36.6 °C (97.9 °F)
Tcurrent: 36.6 °C (97.9 °F)
HR: 54 (43 - 55) bpm
BP: 94/53(62) {83/43(52) - 159/99(115)} mmHg
RR: 11 (11 - 16) insp/min
SpO2: 100%
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale
Head, Ears, Nose, Throat: NCAT
Cardiovascular: Bradycardic, no m/r/g
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender, non distended, no r/r/g
Extremities: No edema
Neurologic: A/Ox3, non focal
Pertinent Results:
Admission Labs:
___ 07:14PM BLOOD WBC-10.7 RBC-3.47* Hgb-11.2* Hct-34.1*
MCV-98 MCH-32.3* MCHC-32.9 RDW-13.3 Plt ___
___ 07:14PM BLOOD Neuts-89.9* Lymphs-6.4* Monos-3.6 Eos-0.1
Baso-0.1
___ 07:14PM BLOOD ___ PTT-26.9 ___
___ 07:14PM BLOOD Glucose-420* UreaN-32* Creat-1.8* Na-141
K-5.2* Cl-106 HCO3-25 AnGap-15
___ 02:16AM BLOOD ALT-16 AST-21 CK(CPK)-280 AlkPhos-55
TotBili-0.3
___ 07:14PM BLOOD cTropnT-0.09*
___ 02:16AM BLOOD CK-MB-6 cTropnT-0.09*
___ 09:45AM BLOOD CK-MB-9 cTropnT-0.09*
___ 02:16AM BLOOD Albumin-2.5* Calcium-7.3* Phos-3.8 Mg-1.6
Cholest-107
___ 02:16AM BLOOD %HbA1c-6.7* eAG-146*
___ 02:16AM BLOOD Triglyc-79 HDL-47 CHOL/HD-2.3 LDLcalc-44
___ 09:06AM BLOOD Phenyto-11.7 Phenyfr-2.1* %Phenyf-18*
___ 07:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:17PM BLOOD Type-ART PEEP-5 pO2-233* pCO2-49* pH-7.35
calTCO2-28 Base XS-0 Intubat-INTUBATED
___ 10:27PM BLOOD freeCa-1.02*
___ 07:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:00PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 08:48PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 08:52PM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-194
___ 08:52PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-8
___ Monos-28
MICROBIOLOGY:
___ CSF;SPINAL FLUID GRAM STAIN-negative; CULTURE
negative
___ BLOOD CULTURE negative
___ BLOOD CULTURE negative
___ URINE CULTURE negative
SPUTUM CX ___ NEGATIVE
SPUTUM ___ NEGATIVE
BCX ___
BCX ___
BCX ___
UCX ___
.
Reports:
EEG ___: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of ___ Hz throughout
the
recording indicative of a severe encephalopathy. There are no
epileptiform discharges or electrographic seizures.
EEG ___: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of ___ Hz briefly
reaching up
to ___ Hz during periods of stimulation, for example during
physical
examination. These findings are indicative of a moderate
encephalopathy. There is a single pushbutton activation for left
hand
tremor which does not have electrographic evidence of seizure
activity.
Compared to the previous day's recording, there is minimal
improvement
in background frequency.
EEG ___: This is an abnormal ICU continuous video EEG due
to the
presence of severely attenuated low voltage background of ___ Hz
during
the initial phase of the recording. After a period of
disconnection,
the background appears higher voltage at 4 Hz but still
consistent with
a moderate to severe encephalopathy. There are intermittent
bilateral
frontal broad- based sharp wave discharges with a right frontal
emphasis
which occurred, at times, in a periodic fashion at 1 Hz lasting
___
seconds without evolution to suggest ongoing seizure activity.
There is
no clinical change during this. These findings are indicative of
bifrontal cortical irritability, particularly in the right
frontal
region with an increased propensity to seizures. There are no
clear
electrographic seizures.
EEG ___: This is an abnormal ICU continuous video EEG due
to the
severely attenuated low voltage background of 4 Hz with
reactivity
consistent with a moderate to severe encephalopathy. There are
infrequent periodic broad-based sharp waves in the bilateral
frontal
region lasting ___ seconds at a time without evolution to
suggest
ongoing seizure activity. There is no clinical change during
this.
These findings are indicative of bifrontal cortical irritability
particularly in the right frontal region with an increased
propensity
to seizures. Additionally, new 2 Hz delta frequency slowing is
seen in
the left frontal central region starting around 4:30 a.m., but
it does
not have a good field, and likely represents artifact. There are
no
clear electrographic seizures.
EEG ___, EEG ___: This is an abnormal continuous ICU
monitoring study because of diffuse attenuation and mild slowing
of background consistent with a mild to moderate diffuse
encephalopathy of non-specific etiology. No epileptiform
discharges or electrographic seizures are present in the
recording.
NCHCT ___: 1. No acute intracranial process. Focal
hypodensity within the right frontal lobe may reflect a prior
ischemic stroke. If clinically indicated, could consider further
evaluation with an MRI.
MRI Head: An area of T2/FLAIR hyperintensity in the left
occipital lobe. It shows hyperintense signal on DWI images,
however there is no corresponding low signal on ADC images. This
likely represents sequela of old infarct. Areas of
encephalomalacia in bilateral frontal lobes and right parietal
lobes which are likely sequelae of old infarcts. Mild
generalized cerebral volume loss with moderate atrophy of
bilateral
medial temporal lobes. Moderate changes of chronic small vessel
ichemic disease.
Carotid U/S: There is 70 to 79% stenosis in the right internal
carotid artery. There is no significant stenosis in the left
internal carotid artery.
CXR ___: ET and NG tubes appear to be positioned
appropriately though the tip of the NG tube is not included in
the field of view. No gross
consolidation, effusion, pneumothorax.
CXR ___: Lung volumes are lower, reflected in increasing
moderate-to-severe bibasilar atelectasis, and there has also
been an increase in moderate bilateral pleural effusion,
moderate cardiomegaly and vascular engorgement of the lungs and
mediastinum, not yet presenting as pulmonary edema. Right
internal jugular line ends at the thoracic inlet. No
pneumothorax.
.
TTE ___ The left atrium is elongated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. The aortic valve is not well seen. There
is mild aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined. The
pulmonary artery is not well visualized. There is no pericardial
effusion.
.
CT Neck ___. Limited examination demonstrating retained
secretions and probable narrowing of the hypopharynx and
extrathoracic trachea, likely due to retropharyngeal edema. No
focal masses or circumferential strictures
identified.
2. Near-complete opacification of the mastoid air cells and
middle ear
cavities. Please evaluate for otitis media and mastoiditis.
CT Neck ___: 1. No evidence of retropharyngeal mass or abscess.
2. Tracheostomy tube is in place.
3. A 1.7 cm nodule in the left parotid gland, is not completely
characterized
in this study.
4. Mild subglottic narrowing, without evidence of focal mass in
this limited
non-contrast CT
.
CT head ___: No acute intracranial pathology. Left occipital
lobe
hypodensity, likely corresponds to the old infarct seen in the
prior study. If there is concern for an acute infarct, an MRI
with DWI can be obtained
.
___ DVT U/S Upper ext: No right upper extremity deep vein
thrombosis
.
Post Pyloric Tube Placement (___): At the time of discharge,
final read of imaging conforming post-plyoric tube placement was
pending. However, the tube was advanced under fluoroscopy with
Interventional Radiology and palcement was confirmed by the
Interventional Radiology team.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with PMH significant for HTN, HLD, CKD,
DM, critical carotid disease b/l s/p L CEA on ___ who was
transferred from OSH for status ___ on ___.
.
#Seizures: Patient was found by his wife in status ___
and underwent traumatic intubation in the field for airway
protection. Seizure was reported as lasting between ___
minutes and appeared predominantly in the RUE with flaccid LUE.
At OSH, he was sent for ___ and CTA head and neck, which
showed no hemorrhage, old left occipital infarct and patent left
carotid artery without indwelling thrombus but extremely
stenotic right carotid. He was transferred to ___ for further
evaluation and treatment. He is not known to have a history of
seizures. According to notes sent with his transfer paperwork,
he had an episode of confusion at the end of ___ and NCHCT at
that time was suggestive of left sided infarct. Carotid dopplers
at our institution showed critical right ICA stenosis and a
subcritical left ICA stenosis. He underwent left CEA on ___,
with plan to perform right CEA in 8 weeks from that time. He was
intially admitted to the NEURO ICU and had an EEG which showed
diffuse encephalopathy but no seizure activity. Overnight on the
day of admission he had episodes of bradycardia and hypotension
which were unexplained. EP consult felt this could have been
seizure related. His encephalopathy was thought to possibly be
dilantin related as he was noted to have poor creatinine
clearance, and may have been becoming toxic on his dosing. He
was switched to keppra, but remained encephalopathic. He was
able to have an MRI once it was confirmed his leg stents were
MRI compatible, and that showed no acute strokes or lesions.
After taken off the vent, the patient became increasingly
confused, was restarted on the vent, and a head CT was obtained
which showed no evidence of new acute process. Pt's mental
status improved on Keppra, and he is maintained on Keppra 500mg
BID, with no acute change in mental status prior to D/C.
#Upper Airway Obstruction, edema: As he had no seizure activity
documented on his EEG, he was initially extubated on ___.
However, he was found to have large blood clots in his throat,
and ENT felt pt had a paralyzed L vocal cord likely from
traumatic intubation. He was reintubated for airway protection
and started on a course of IV dexamethasone to help improve the
edema. After three days of having a cuff leak, patient's
swelling was felt to have improved to the point where he could
be extubated on ___. Within hours of extubation, despite
adequate saturations and good ABGs, he became notably
stridorous. ENT was called to examine the patient again and felt
he continued to have persistent airway edema that severely
compromised his airway and necessitated re-intubation. Reason
for persistent airway edema was unclear. CT Neck showed
retropharyngeal edema but no focal signs of infection. MRI could
not be obtained due to patient's kidney function. Due to
repeated failures with extubation, patient underwent
tracheostomy on ___. Patient was weaned off the mechanical
ventilator on the same day and the trach cuff was changed on POD
#5. He experienced an episode of respiratory distress and
hypoxemia, attributed to mucus plugging, resolved with
bronchoscopy, and resuming mechanical ventilation. Successfully
liberated from mechanical ventilation within 24 hrs and remained
off mechanical ventilation, breathing comfortably on trach
collar. ENT downsized the tracheotomy tube on the day of
discharge.
.
# Acute Kidney Injury: Patient has chronic renal insufficiency
with baseline creatinine of 1.8. During his hospitalization, his
creatinine peaked at 3.3 though was otherwise stably elevated in
the ___ range likely due to ATN from hypotension given the
granular casts seen on sediment. A subsequent rise in creatinine
occurred in the setting of overdiuresis while trying to optimize
patient for extubation. Throughout, patient's electrolytes and
urine output remained robust, and he is currently in the 2.0-2.4
range at time of discharge.
.
# Labile HTN: Initially required a nicardipine gtt but was
eventually transitioned to oral labetalol, in addition to
amlodipine.
.
# Hyperglycemia: While on the dexamethasone burst, patient
initially required an insulin drip to cover his elevated blood
sugars. He was transitioned to a SC insulin regimen once off
steroids.
.
# Fevers and leukocytosis: Felt to be related to VAP or
non-occlusive upper extremity DVT. Retropharyngeal process
considered but not supported by imaging. Patient completed eight
day course of vanc and zosyn on ___, and has since been
afebrile, off of antibiotics.
.
Transitional care:
# CODE: FULL
# Contacts: daughter ___
# Medical management:
- f/u with ENT
Medications on Admission:
-Plavix 75 mg daily
-ASA 81 mg daily
-Hytrin 4 mg qhs
-Simvastatin 40 mg daily
-Amlodipine 10 mg daily
-NPH Insulin 50 units qAM and 30 units qPM
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. docusate sodium 50 mg/5 mL Liquid Sig: ___ tsp PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever/pain.
13. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
14. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. levetiracetam 500 mg/5 mL Solution Sig: Five (5) ml
Intravenous BID (2 times a day).
17. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
18. lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for agitation.
19. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg
Injection Q2H (every 2 hours) as needed for pain.
20. NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Five (45) units Subcutaneous twice a day: Please take in morning
and ___. .
21. insulin regular hum U-500 conc 500 unit/mL Solution Sig:
___ units Injection qachs as needed for sliding scale: Please
give 2 units of regular humalog for blood sugars above 100, and
an additional 2 units for every additional 50mg/dl of blood
sugar.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status, status epillepticus, airway swelling,
subglottal stenosis, pneumonia,
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you in the intensive care unit
at ___ were admitted to
while having a very bad seizure. You had been intubated prior to
coming to us, meaning that a tube was needed to breath for you.
You developed a severe troat problem that required mechanical
ventilation in the Intensive Care Unit. Our surgeons needed to
place a tube into your trachea to help you breath. You developed
pneumonia, which required antibiotics to treat. We gave you
anti-seizure medications, which you will continue to take. These
medications have prevented further seizures. We also needed to
control your blood pressure with new medications. It is
important that you continue to take these medications at your
facility, and monitor your blood pressure carefully.
The following is your new medication regimen:
heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
docusate sodium 50 mg/5 mL Liquid Sig: ___ tsp PO BID (2
times a day).
senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours)
as needed for wheezing.
acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every
6 hours) as needed for fever/pain.
fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
levetiracetam 500 mg/5 mL Solution Sig: Five (5) ml
Intravenous BID (2 times a day).
pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for agitation.
hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg
Injection Q2H (every 2 hours) as needed for pain.
NPH insulin human recomb 100 unit/mL Suspension Sig: Forty
Five (45) units Subcutaneous twice a day: Please take in morning
and ___. .
insulin regular hum U-500 conc 500 unit/mL Solution Sig:
___ units Injection qachs as needed for sliding scale: Please
give 2 units of regular humalog for blood sugars above 100, and
an additional 2 units for every additional 50mg/dl of blood
sugar.
Followup Instructions:
___
|
19620109-DS-16
| 19,620,109 | 27,886,137 |
DS
| 16 |
2132-10-22 00:00:00
|
2132-10-22 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lipitor /
Verapamil / Lescol / Etodolac / Rofecoxib / Valdecoxib
Attending: ___.
Chief Complaint:
"occipital intraparenchymal hemorrhage and
right visual field cut"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage (___) from amyloid angiopathy who
now
presents with headache and vision loss. Yesterday (___)
afternoon while doing some strenuous yardwork (cutting/hauling
branches) she developed a bilateral dull headache with the left
side being more intense sharp pain than the right side. She
then
noticed that her left eye seemed to be "frozen." Thereafter,
she
says that she lost vision in her left eye and began bumping into
furniture. She did not want to go to the hospital yesterday.
Headache persisted this morning and she took aspirin 81mg
without
relief. She also developed some nausea but no weakness, no
sensory changes or confusion.
She eventually agreed to be taken to ___
today where head CT showed a left occipital intraparenchymal
hemorrhage without any midline shift or herniation. She was
given IV dilaudid and reglan and transferred to ___ ED for
further care. In the ED, initial blood pressure was 121/72 and
she was given IV zofran, morphine and tylenol. Neurology was
consulted for further management.
On neuro ROS, the pt endorses dull bilateral headache, loss of
vision in her left eye, no blurred vision, no diplopia, no
dysarthria, no dysphagia. No vertigo, no tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness or parasthesiae. No
bowel or bladder incontinence or retention. No unsteadiness
with
ambulation but is bumping into walls/furniture.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. No cough
or shortness of breath. Denies chest pain or tightness,
palpitations. No nausea or vomiting. No diarrhea,
constipation.
No abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-right occipital intraparenchymal hemorrhage (biopsy confirmed
amyloid angiopathy)-brought on by vigorous snow shoveling.
-osteoporosis
-asthma
-coronary artery disease
-hypertension and hyperlipidemia (mentioned in cardiology
records)
Social History:
___
Family History:
Mother died of stroke in her ___. Father had asthma
and emphysema. Brother died of heart attack in his ___.
Physical Exam:
At admission:
Vitals: T: 98.5 P: 74 R: 20 BP: 121/72 SaO2: 94% on 2L.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rash or lesions.
Neurologic:
-Mental Status: Alert, oriented x 2. Tells me her name, ___
and ___ but cannot remember month or day. Able to relate
history without difficulty but at time confuses order of events
from yesterday. Able to name ___ forwards but not backwards. .
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. Not able to test
reading secondary to visual field deficits. Could identify
single letters of words without difficulty. Speech was not
dysathric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. Dense right homonymous hemianopia
and spotty left peripheral field deficit. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was downgoing bilaterally.
-Coordination: No tremors. No dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally but does pass point slightly
secondary to her vision loss.
-Gait: Deferred gait and Romberg for bedrest. Was walking
normally earlier in the day per family.
At discharge:
Neuro: Dense right homonymous hemianopia and left peripheral
visual field deficit, no motor deficits. Mood is anxious and
frequently tearful
Pertinent Results:
___ 07:38PM WBC-10.6 RBC-4.53 HGB-14.2 HCT-42.2 MCV-93
MCH-31.4 MCHC-33.7 RDW-12.9
___ 07:38PM NEUTS-75.1* ___ MONOS-4.3 EOS-1.4
BASOS-0.7
___ 07:38PM PLT COUNT-186
___ 07:38PM ___ PTT-31.5 ___
___ 07:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:38PM GLUCOSE-106* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
___ 05:30AM BLOOD WBC-7.6 RBC-3.84* Hgb-12.2 Hct-35.7*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.7 Plt ___
___ 05:30AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-139
K-3.2* Cl-103 HCO3-32 AnGap-7*
___ 05:30AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___ 07:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ECG:
Sinus rhythm. Diffuse ST-T wave abnormalities most noticably in
the
anterolateral leads. Cannot rule out underlying myocardial
ischemia. Compared to the previous tracing of ___ wave changes persist. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 ___ 29 2 40
___ NCHCT:
IMPRESSION:
1. Left occipital intraparenchymal hemorrhage with extension
into the
extra-axial space. Mild-to-moderate surrounding vasogenic edema
and sulcal and left lateral ventricle effacement. Slight
effacement of the left ambient cistern is noted but with overall
relatively little mass effect.
2. New but chronic-appeearing focus of encephalomalacia in the
left anterior frontal lobe.
EEG:
FINDINGS:
ABNORMALITY #1: Occasional bursts of right posterior quadrant
___ Hz
delta frequency activity were seen.
ABNORMALITY #2: In the most electrographically awake-appearing
portions
of this tracing, a symmetric ___ Hz theta frequency background
was
seen.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: The technologist inadvertently
did not
perform this activation procedure; if clinically warranted, a
repeat
tracing to obtain photic stimulation will be provided.
SLEEP: Periods of a more symmetric ___ Hz theta frequency
background
were seen along with periods of a slower (but still symmetric) 6
Hz
theta frequency background were seen. This variability may be
due to
periods of relative drowsiness and wakefulness, though clinical
correlate through video review did not appreciably demonstrate a
change
in clinical state.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This is an abnormal EEG due to the presence of
occasional
bursts of slowing seen involving the right posterior quadrant
superimposed upon a slow background. The former abnormality may
represent a focal area of subcortical disturbance, while the
slow
background is more consistent with a larger, subcortical, deep
midline
abnormality. No frank epileptiform activity was seen during this
recording, but if the patient has frequent symptoms, continuous
EEG
recording with event monitoring and spike and seizure detection
algorithms may provide additional diagnostic information
Portable NCHCT:
IMPRESSION: Intraparenchymal hemorrhage with small extraaxial
component in
the left occipital lobe is unchanged compared with prior exam,
without
significant mass effect.
___ NCHCT:
IMPRESSION:
Essentially unchanged left occipital lobe hemorrhage and small
left subdural hemorrhage given differences in scan technique.
___ NCHCT:
IMPRESSION:
1. No significant interval change in size of the left occipital
lobe
intraparenchymal hemorrhage with continued mass effect on the
occipital horn of the left lateral ventricle, unchanged.
2. Small subdural hematoma overlying the left parietal lobe is
less
conspicuous on the present study.
3. No new intracranial hemorrhage or infarction.
___ ___:
IMPRESSION:
1. Little change in comparison to prior study from yesterday
with no
significant change in the interval size of the left occipital
intraparenchymal
hemorrhage with continued mass effect on the occipital horn of
the left
lateral ventricle.
2. Stable appearance of small subdural hematoma overlying the
left parietal lobe.
Brief Hospital Course:
___ is a ___ year old right-handed female with a
history of coronary artery disease, osteoporosis, asthma and
right occipital hemorrhage (___) from amyloid angiopathy who
now presents with headache and vision loss. Her neurological
exam is significant for right homonymous hemianopia and spotty
left peripheral field deficit. She is also having some mild
memory deficits and inability to perform ___ backwards both of
which are reportedly new according to her family. These are most
likely due to her anxiousness and has improved prior to
discharge. Head CT shows a left occipital intraparenchymal
hemorrhage. Her right visual field deficits are consistent with
the hemorrhage in the left occipital cortex. The left peripheral
field deficits are chronic deficits due to the prior right
occipital hemorrhage in ___. The most likely etiology of her
hemorrhage is from cerebral amyloid angiopathy.
.
NEURO: Amyloid angiopathy with new occipital hemorrhage
- mannitol used initially for symptomatic improvement. Weaned
off.
- HA pain control with acetaminophen and oxycodone prn.
Anxiousness is a large contributing factor
- cont celexa 20mg po daily to help with mood and rehabilitation
- completed 1 week of anti-sezire prophylaxis with Keppra. No
need to continue at this time
- goal SBP 140-160, hydralazine 10mg prn SBP>170
.
GI: Patient is on regular diet but has been intermittently
nauseated. Concern about how many calories she is taking in.
- I and O's and calorie count. Starting Enlive and magic cup
supplements
- nutrition consult following
- started remeron 15mg po qhs for appetite stimulus and further
mood improvement
.
HOSPITAL ISSUES:
-activity as tol
-regular diet
-SQH tid
-senna/colace, ranitidine and pneumoboots for prophylaxis
-full code
-Dispo: floor
-contact: ___ ___
Medications on Admission:
albuterol prn wheezing
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6
hours) as needed for cough.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puff Inhalation q4hrs as needed for shortness of breath or
wheezing.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain: for headache. Limit to < 4 grams per
day.
9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every ___ hours as
needed for Pain: Please use as breakthrough if acetaminophen is
not effective.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left occipital lobe hemorrhage
amyloid angiopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: Dense right homonymous hemianopia and left peripheral
visual field deficit, no motor deficits. Mood is anxious and
frequently tearful
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of vision changes and
confusion. It was found that you had a bleed on the left side of
your brain, in the area known as the occipital lobe, which
process visual information. Unfortunately, since a few years ago
you had a bleed in the same area on the right side of your
brain, your vision is now very limited. Understandably this is
certainly causing a degree of anxiousness that would be
expected. To help you with this anxiousness and with your
recovery we have started you on a medication, celexa 20mg by
mouth daily.
The cause of the current bleed is the same as your previous, a
disorder called amyloid angiopathy, which makes your brain
arteries more likely to have these bleeds.
You have not felt like eating much due to things not tasting
well. A formal swallow evaluation showed that when you eat you
have no trouble from their perspective. We have started you on a
appetite stimuling medicine, remeron 15mg by mouth nightly,
which will also likely help with your mood. Please continue to
eat/drink nutrition supplements as well to ensure you are
getting all your nutrients.
We would like you to follow up with an outpatient neurologist.
We have made an appointment for you with Dr. ___ as listed
below. We would like you to have a repeat MRI of your brain
vessels given that on your imaging there was an incidental
finding of a small 3.5mm aneurysm. An aneurysm of this size
typically do not bleed, but this should be followed over time
with repeat imaging to ensure it does not enlarge over time.
Additionally, we have asked our Neuro-ophthalomolgist, Dr.
___, to see you in her clinic to evaluate your vision. We have
made you an appointment on ___ at 9:30am with visual field
testing at 10:30am.
Followup Instructions:
___
|
19620258-DS-13
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DS
| 13 |
2168-08-15 00:00:00
|
2168-08-17 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Left axillary lymph node biopsy
History of Present Illness:
This patient is a ___ yo male from ___ with no significant
past medical history who presents with 3 days of fevers. He was
in his usual state of health until 3 weeks ago, when he had a
fever that defervesced without intervention. He was then well
until 3 days ago, when he experienced chills and fevers again to
___. This was associated with a bilateral headache lasting
several hours. Of note, Mr. ___ normally has headaches
approximately every week, and has presented to the ED in ___
in the past for treatment of his headaches (occurs approximately
once every ___ years). He has also presented to the ___ ED in
___ for treatment of fever. He cannot recall the
determined etiology and treatment, except that he purchased OTC
medications.
Mr. ___ last returned from ___ 6 weeks ago. He was there for
35 days. He emigrated from ___ to ___ ___ years
ago to attend ___. He denies any sick
contacts, tick exposure or mosquito bites.
In the ED, he recalls having some palpitations and temporary
SOB, with HRs in the 110s, that subsequently resolved. In the ED
initial vitals were:
Time Pain T HR BP RR Pox
Triage19:53 3 101.4 141 127/85 16 99%
Today 20:32 3 114 104/56 29 98% RA
Today 21:16 0 102.8 119 105/45 34 95% RA
Today 22:48 0 98.6 ___ 30 97% RA
Labs were significant for lactate 1.2, normal LFTs, normal
chem7, and mild anemia (Hgb 12.8), and positive urine
amphetamines. CT head and CXR were unremarkable. Lumbar puncture
was attempted, but was unsuccessful due to large body habitus.
He was treated empirically for meninigitis, and given
ceftriaxone 2g, acetaminophen, ketorolac, vancomycin and 3 L
IVF.
On the Medicine floor, he endorses fever, chills, fatigue,
malaise, poor appetite and occasional cough, but no current
rash, headaches, vision changes, rhinorrhea, sinus congestion,
throat pain, swollen glands, chest pain, palpitations, SOB,
abdominal pain, N/V, constipation/diarrhea, jaundice, BRBPR,
melena, hematuria, dysuria, arthralgias, myalgias or back pain,
aside from the attempted LP. He denies ever being sexually
active. He denies the use of any medications, including OTCs and
illicits. He smokes hookah and smoked cigarettes for ___ years,
but has quit.
Past Medical History:
- Laser removal of nasal polyp as child
- ___ ED visit ___ for LRTI
Social History:
___
Family History:
Denies history of diabetes or recurrent infections. Reports
history of MI in father, uterine cancer in 1 aunt, lung cancer
in another aunt, and an unknown cancer in his grandmother.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Vitals: T98.0-99.3F. BP 114/44. HR 97. RR 22. O2 sat 98% RA. Wt
155.2 kg.
General: alert, oriented, no acute distress, under several
blankets
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no
hepatosplenomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No joint erythema or edema.
Back: Ecchymosis on sacrum in area of attempted LP.
Neuro: CNs2-12 intact, ___ strength in upper and lower
extremities. Sensation intact in upper and lower extremities.
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: T98.3-99.7 (98.9). BP 103-124/45-70 (110/62). HR 83-115
(83). RR ___. O2 94-100% RA.
General: alert, oriented, no acute distress.
Skin: Skin warm and moist. No rashes, petechiae or nail bed
abnormalities. Ecchymosis present on sacrum at the site of
attempted LP.
HEENT: sclera anicteric, no conjunctival pallor, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
Chest: Heart regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops. Blood-tinged dressing over wound (taped
with Tegederm) under L axilla. Skin intact.
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no
hepatosplenomegaly
GU: no foley. No LAD.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No joint erythema or edema.
Neuro: CNs2-12 intact, motor function grossly normal.
Pertinent Results:
==============
ADMISSION LABS
==============
COMPLETE BLOOD COUNT
___ 08:25PM WBC-6.9 RBC-4.77 HGB-12.8* HCT-39.0* MCV-82
MCH-26.9* MCHC-32.9 RDW-15.5
___:25PM NEUTS-65.3 ___ MONOS-12.4* EOS-1.6
BASOS-0.4
___ 08:25PM PLT COUNT-232
CHEMISTRIES
___ 08:25PM GLUCOSE-93 UREA N-10 CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
LIVER ENZYMES/LIVER FUNCTION TESTS
___ 08:25PM ALT(SGPT)-23 AST(SGOT)-35 ALK PHOS-100 TOT
BILI-0.9
___ 08:25PM ALBUMIN-4.0
TOX SCREEN
___ 08:25PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 10:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
URINE
___ 10:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.5
LEUK-NEG
___ 10:50PM URINE RBC-7* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-3
___ 10:50PM URINE AMORPH-RARE
___ 10:50PM URINE MUCOUS-MANY
OTHER CHEMISTRIES
___ 08:25PM cTropnT-<0.01
___ 08:25PM LIPASE-16
___ 08:31PM LACTATE-1.2
BLOOD GASES
___ 10:59PM O2 SAT-86
___ 10:59PM ___ TEMP-37.0 PO2-51* PCO2-35 PH-7.42
TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA
=============
HOSPITAL LABS
=============
COMPLETE BLOOD COUNT
___ 07:56AM BLOOD WBC-5.2 RBC-4.28* Hgb-11.5* Hct-34.7*
MCV-81* MCH-26.8* MCHC-33.0 RDW-15.7* Plt ___
___ 08:11AM BLOOD WBC-6.5 RBC-4.51* Hgb-12.1* Hct-36.1*
MCV-80* MCH-26.8* MCHC-33.5 RDW-15.4 Plt ___
___ 08:10AM BLOOD WBC-6.4 RBC-4.43* Hgb-11.9* Hct-35.8*
MCV-81* MCH-26.9* MCHC-33.4 RDW-15.7* Plt ___
___ 08:30AM BLOOD WBC-5.1 RBC-4.24* Hgb-11.3* Hct-35.1*
MCV-83 MCH-26.6* MCHC-32.1 RDW-15.7* Plt ___
CHEMISTRIES
___ 07:56AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-137 K-4.1
Cl-101 HCO3-24 AnGap-16
___ 08:11AM BLOOD Glucose-85 UreaN-7 Creat-0.8 Na-135 K-4.1
Cl-98 HCO3-24 AnGap-17
___ 08:10AM BLOOD Glucose-91 UreaN-7 Creat-0.7 Na-137 K-4.2
Cl-100 HCO3-26 AnGap-15
___ 08:30AM BLOOD Glucose-94 UreaN-6 Creat-0.8 Na-139 K-4.7
Cl-98 HCO3-28 AnGap-18
COAGS
___ 08:10AM BLOOD ___ PTT-29.5 ___
URINE
___ 03:13AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:13AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
HEMATOLOGY
___ 05:20PM BLOOD ESR-98* Parst S-NEGATIVE
___ 01:03PM BLOOD Ferritn-538*
___ 07:56AM BLOOD Parst S-NEGATIVE
___ 05:30PM BLOOD Parst S-NEGATIVE
___ 08:11AM BLOOD Ret Aut-1.4
___ 08:11AM BLOOD calTIBC-237* TRF-182*
IMMUNOLOGY
___ 01:03PM BLOOD CRP-140.7*
___ 01:17PM BLOOD ___
___ 07:56AM BLOOD IgG-1673* IgA-164 IgM-71
INFECTIOUS DISEASE WORKUP
___ 01:03PM BLOOD HIV Ab-NEGATIVE
___ 01:03PM BLOOD HCV Ab-NEGATIVE
___ 01:03PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:11AM BLOOD QUANTIFERON-TB GOLD - Negative
___ 05:20PM BLOOD DENGUE FEVER ANTIBODIES (IGG, IGM)-
Negative
___ 01:03PM BLOOD ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) - Negative
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
OTHER LABS
___ 01:03PM BLOOD LD(LDH)-196 CK(CPK)-48
============
MICROBIOLOGY
============
Blood Culture, Routine (Final ___: NO GROWTH
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:30 pm BLOOD CULTURE x 2 - pending
___ 5:30 pm BLOOD CULTURE - pending
___ 7:45 pm BLOOD CULTURE - pending
___ 2:00 pm TISSUE LEFT AXILLARY LYMPHNODE.
VCMV ADDED PER ADD ON REQUEST ON ___.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
Reported to and read back by ___ ___
10:55AM.
GRAM POSITIVE BACTERIA. 1 COLONY ON 1 PLATE.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
=======
IMAGING
=======
EKG (___): Sinus tachycardia. Within normal limits apart
from rate. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
136 132 98 272/405 37 57 11
CT Head W/O Contrast (___):
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction or
midline shift. There is no hydrocephalus. There is no edema.
There is no fracture. Visualized paranasal sinuses and mastoid
air cells are clear.
IMPRESSION:
Unremarkable unenhanced head CT.
Chest X-Ray (___):
FINDINGS:
The lungs are clear. There is no evidence of pneumonia,
pneumothorax, or
pleural effusion. Cardiac silhouette is normal in size.
IMPRESSION:
Normal chest x-ray.
CT Abd & Pelvis W Contrast (___):
IMPRESSION:
1. No radiological explanation for patient's fever identified.
2. Partially visualized soft tissue lesion in the left inguinal
canal may represent an undescended testis - for physical exam
correlation/ palpation.
CT Chest W Contrast (___):
IMPRESSION:
Significant unilateral left axillary lymphadenopathy.
Differential
considerations include systemic lymphoproliferative disease,
however given its unilaterally other etiologies include local
(upper extremity or
thoracoabdominal wall) malignancy and infection, although there
is no evidence for necrosis or suppurative lymph nodes. Further
evaluation with tissue biopsy should be strongly considered.
=========
PATHOLOGY
=========
Lymph Node Biopsy (___): report not finalized
IMMUNOPHENOTYPING-FNA-AXILLARY (___): report not finalized
Brief Hospital Course:
Mr. ___ is a ___ year old previously healthy man from ___
presenting with acute onset fever and malaise in the setting of
resolved headache 2 days prior to admission.
# FEVER: Patient presented with 3 days of cyclical fevers to
___ and general malaise with recent travel to the ___.
His headaches were not necessarily related to his fevers, since
he has a history of recurrent headaches, and his headache has
since resolved. He had no signs or symptoms that pointed to an
infectious etiology. However his elevated ESR and CRP prompted
an infectious workup. Blood parasite smear was negative for
malaria or babesiosis. Tests for viral hepatitis, ehrlichiosis,
Dengue, Lyme and EBV/CMV infection were negative. Blood cultures
were sent given concern for possible sepsis (tachy to 110s),
although all blood cultures to date have been negative. The
negative infectious workup prompted CT scan of the chest and
abdomen, which showed innumerous enlarged lymph nodes in the
left supraclavicular and left axillary regions that was
concerning for infection vs. malignancy. He went for left
axillary lymph node biopsy on ___, which expressed a fleshy 7 x
5 x 5 cm lymph node with no evidence of pus. The surgery was
uncomplicated with negligible blood loss. Patient's pain was
well-controlled with oxycodone, and he felt comfortable to
return home on ___. The tissue grew 1 colony of gram positive
bacteria on anaerobic culture, but gram stain, acid fast smear
and fungus culture was negative. The final pathology report has
not yet been finalized. An appointment for PCP ___ was
scheduled for review of the pathology report and monitoring of
his fevers. Patient may require referral to heme/onc based on
path findings.
# ANEMIA: Patient presented with mild normocytic anemia - Hgb
12.8/Hct 39.0 - that was persistent and stable during his
hospital stay. Normal reticulocyte count, in addition to normal
LDH and Tbili, was consistent with an underproduction anemia.
Elevated ferritin, low iron and low TIBC is consistent with
anemia of chronic inflammation, presumably related to the
underlying cause of Mr. ___ fevers and elevation in
inflammatory markers. Iron deficiency anemia often times
accompanies anemia of chronic inflammation; patient was
discharged with supplemental iron.
# URINE AMPHETAMINES: Unclear cause, as patient denies illicit
drug use, or the use of any prescription medication, including
Adderall or Ritalin. He took ___ medication from ___ when
mother was in town 2 days prior to admission, which may have
contained a stimulant.
# MICROSCOPIC HEMATURIA: Initial UA upon hospital admission
showed 7 RBCs with Cr 1.1. Remainder of U/A unimpressive. Repeat
urine dip on ___ showed no RBCs, so likely an incidental
finding that is unrelated to the patient's presentation.
Transitional Issues:
=====================
[ ] f/u lymph node biopsy path results
[ ] f/u final culture results
[ ] Recommend heme/onc consultation pending lymph node biopsy
results
[ ] Check CBC at discharge f/u appointment to f/u on anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
Please do not take this with alcohol or while driving
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*6 Tablet Refills:*0
4. 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
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for further
evaluation of ongoing fevers. During your admission a number of
tests were run to rule out an infectious cause of your fevers.
Many of those tests are negative and some are still pending. In
addition, imaging was done of your chest and abdomen which
showed enlarged lymph nodes which was concerning for a possible
malignancy. You underwent surgery to remove one of these lymph
nodes. Additional testing will be done on the lymph node to
help determine a diagnosis. These tests may not be complete for
another ___ weeks. We have set you up with a primary care
physician at ___ with whom you
will follow up and who can help with setting up further care
that you may need and who can follow up on the results of you
lymph node biopsy. Your iron levels and blood counts were also
noted to be low, which may be related to your fevers or to not
enough nutritional intake of iron. You should take an iron
supplement daily and follow up with your primary care physician
regarding this.
Regarding your surgical wound - you may remove the clear plastic
bandage tomorrow, however please leave the steri-strips
underneath in place, these will come off on their own. Your
stitches are absorbable and do not need to be removed. You may
place dry guaze held in place with tape for the next week to
help keep the wound dry and protected. Please try and avoid
getting your wound/bandaging wet. If you notice any increased
redness, pain, or drainage from the wound, please seek medical
care as this may indicate an infection.
With regards to your fevers, please take tylenol as needed. You
may take up to 1 gram of tylenol every 8 hours. Please do not
take more than 3 grams in one day as this may cause damage to
your liver. Please abstain from alcohol while taking tylenol.
In addition, please drink plenty of fluids to avoid dehydration.
We hope you continue to feel better. Please take your
medications as prescribed and keep your follow up appointments
as scheduled.
- Your ___ Team
Followup Instructions:
___
|
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2168-09-14 10:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bleomycin
Attending: ___
___ Complaint:
Cellulitis around port site.
Major Surgical or Invasive Procedure:
___: Underwent day 15 chemotherapy (AVD) during
hospitalization.
History of Present Illness:
Mr. ___ is a ___ year old male with PMH of Hodgkin lymphoma s/p
___ cycle of chemotherapy with ABVD regimen day 15 (bleomycin
was discontinued due to reaction) who presents with erythema and
pain at the port site. He received the port on ___. This
all started the night prior to admission when he noticed this
pain. The pain is described as a burning sensation that lasts
about 10 seconds and resolves without any intervention. These
pains occur approximately once an hour. This was also associated
with erythema surrounding the port site as well as tenderness to
palpation and warmth. There has been no discharge from the site.
There are no particular positions that increase or decrease the
pain. He has not taken any medications to resolve the pain.
Additionally, he notes some discomfort with the port in the
upper right chest under the skin that is tender to palpation.
Of note he denies any fevers, chills, night sweats, nausea,
vomiting, diarrhea, chest pain, chest pressure, shortness of
breath, swelling in any of his extremities, or rash.
In the Emergency Department he received vancomycin 1000 mg IV x1
and cefepime 2 gram IV x 1. An ultrasound of the upper extremity
was negative.
Vitals in the ED were temperature 98.5, HR 84, BP 120/69, Pulse
Ox 98% on RA.
Prior to transfer vitals were temperature 98, HR 74, BP 106/47,
20, 99% on RA.
Past Medical History:
ONCOLOGIC HISTORY: Per OMR- per ___.
-___: Develops fevers to 103 and is admitted to ___.
Infectious workup was unrevealing. CT chest shows enlarged left
axillary nodes. Fevers resolve without intervention.
-___: Excisional biopsy of left axillary lymph node
demonstrates Classical Hodgkin lymphoma, Nodular sclerosis
subtype.
- ___: Discharged to home.
- ___: PET/CT shows multiple enlarged left axillary FDG-avid
lymph nodes. There was also FDG avid soft tissue in the left
inguinal canal possibly representing an undescended testicle.
Bilateral FDG-avid inguinal lymph nodes may be reactive in
nature. Focus of FDG-avidity anterior to the spleen near the
splenic vein that does not have a clear anatomical correlate on
imaging. Mildly increased FDG-avidity is noted in the T11
vertebral body, though no lesion is noted on imaging. ESR
elevated at 71, albumin 4.1. Final Staging: Stage I, early stage
with unfavorable risk factors (elevated ESR, B symptoms).
- ___: C1D1 AVD (bleomycin omitted because of allergic
reaction to test dose).
PAST MEDICAL/SURGICAL HISTORY:
- Hodgkin Lymphoma
- Undescended left testicle
- Possible Klinefelter syndrome
- Nasal polyp as a child
Social History:
___
Family History:
Father died of coronary artery disease in ___.
Aunt-uterine cancer.
Aunt-lung cancer
Question of lymphoma within family.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 97.4, 110/70, 66, 20, 98% on RA.
Gen: Pleasant laying in bed comfortably, does not appear in any
acute distress.
HEENT: MMM, no oropharyngeal lesions.
CV: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNGS: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
ABD: obese abdomen, soft, non-tender, non-distended, no rebound
or guarding.
EXT: No lower extremity swelling. 2+ Pulses.
SKIN: No rashes, lesions, ecchymoses.
NEURO: A&Ox3.
LINES: Tunneled catheter in place on right. Right upper chest
site is slightly erythematous and slightly tender to palpation.
Warm to touch. There is no evidence of pus or discharge and no
fluctuance in the area. No arms swelling or ertyhema, and no
facial fullness.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.4-98.1, 100-114/62-68, 70-83, ___, 96-98%.
Gen: Laying in bed, does not appear in any distress, resting
comfortably.
HEENT: MMM, no oropharyngeal lesions.
CV: RRR, No murmurs, rubs or gallops.
LUNGS: Clear to auscultation, no wheezes, rales, or rhonchi.
ABD: soft, non-tender, no rebound or guarding.
EXT: No lower extremity swelling. No right arm swelling. No
facial plethora. 2+ Pulses.
SKIN: No rashes, lesions, ecchymoses.
NEURO: A&Ox3.
LINES: Tunneled catheter in place on right. Erythema surroudn
gthe right chest site is improved from yesterday. Non-tender to
palpation, warmth has decreased from yesterday. No
pus/discharge/or fluctuance.
Pertinent Results:
ADMISSION LABS
==============
___ 12:40AM BLOOD WBC-2.4* RBC-4.71 Hgb-12.5* Hct-39.2*
MCV-83 MCH-26.5* MCHC-31.8 RDW-17.3* Plt ___
___ 12:40AM BLOOD Neuts-25* Bands-0 Lymphs-48* Monos-10
Eos-12* Baso-0 Atyps-5* ___ Myelos-0
___ 12:40AM BLOOD Glucose-94 UreaN-10 Creat-0.9 Na-144
K-3.9 Cl-109* HCO3-25 AnGap-14
___ 12:40AM BLOOD ALT-36 AST-26 LD(LDH)-173 AlkPhos-92
TotBili-0.1
___ 12:56AM BLOOD Lactate-1.6
DISCHARGE LABS
==============
___ 12:00AM BLOOD WBC-1.1*# RBC-4.57* Hgb-12.4* Hct-38.3*
MCV-84 MCH-27.2 MCHC-32.5 RDW-17.6* Plt ___
___ 12:00AM BLOOD Neuts-31* Bands-0 Lymphs-57* Monos-8
Eos-3 Baso-0 Atyps-1* ___ Myelos-0
___ 12:00AM BLOOD ___ PTT-29.8 ___
___ 12:00AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-138 K-4.5
Cl-107 HCO3-23 AnGap-13
___ 12:00AM BLOOD Calcium-9.0 Phos-2.0* Mg-1.9
MICROBIOLOGY
============
___: BLOOD CULTURES: PENDING
IMAGING
=======
___: UNILATERAL UPPER EXTREMITY VEINS ULTRASOUND
IMPRESSION: No evidence of deep vein thrombosis in the right
upper extremity. No evidence of fluid collection concerning for
abscess at the right chest port or right internal jugular
venotomy site.
___: CHEST PA AND LATERAL
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ year old male with PMH of Hodgkin lymphoma s/p ___ cycle of
chemotherapy with AVD (bleomycin was discontinued due to
reaction to medication) who presents with erythema and pain at
his tunneled subclavian port site.
# CELLULITIS: Mr. ___ presented with erythema, tenderness and
warmth surrounding the port site. Due to concern of cellulitis
he was started on intravenous vancomycin. The IV team saw Mr.
___ and did not believe there was any significant cellulitis and
thought this was all a normal reaction to the tunneled catheter
being placed. An ultrasound of the right upper extremity was
obtained which did not reveal any abscess or deep venous
thrombosis. He received two days worth of vancomycin. At the
time of discharge the pain and tenderness decreased and was not
present. He was discharged on an additional three days of
cephalexin (500 milligrams PO Q6H) with end date on ___.
# HODGKIN'S LYMPHOMA: Hodgkin's lymphoma was diagnosed in
___. Stage I, early stage with unfavorable risk factors
(elevated ESR, B symptoms). He is cycle 1 of AVD. As he was
hospitalized on day 16 of the cycle, he did receive his
regularly scheduled chemotherapy (AVD) on ___. He
tolerated this treatment with only minimal nausea. At the time
of discharge his ANC was 341.
TRANSITIONAL ISSUES
===================
# ANTIBIOTIC REGIMEN: Cephalexin 500 mg Q6H for three days with
end date on ___.
# CODE STATUS: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO TID
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Cellulitis
Hodgkin's Lymphoma
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 ___
after experiencing redness and tenderness at the site of your
port. During your hospitalization you underwent an ultrasound of
the right upper extremity which did not reveal any abscess or
clot. You received antibiotics to help clear the infection of
the skin. The redness and tenderness decreased with the
antibiotics. At the time of discharge your redness and
tenderness was improved.
We recommend you take a medication called cephalexin for 500
milligrams every 6 hours with end date on ___.
It was pleasure taking care of you during your hospitalization!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19620291-DS-15
| 19,620,291 | 24,004,808 |
DS
| 15 |
2171-02-18 00:00:00
|
2171-02-18 19:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin / Vicodin
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
ICD Device Placement ___
IP lung biopsy ___
History of Present Illness:
___ year old male with unremarkable past medical history who
presents with subacute worsening dyspnea on exertion, chest
tightness since ___. His chest tightness is accompanied
by
weakness and pain in bilateral leg muscles, symptoms only
present
with exercise. Previously running ___ miles ___ times/week, he
had sudden worsening of symptoms 10 days prior to presentation
and was unable to run beyond a quarter mile recently. First
assessed by ___ office NP ___ with ectopic atrial rhythm noted
on EKG. CBC, BMP, TSH, Lyme antibody unremarkable. CXR showed
"Increased markings in the superior perihilar region suggesting
atypical pneumonia". He was referred for stress test with plan
to
treat for CAP if negative.
ETT on ___ showed NSR at rest with development of 2:1 AV block
4
minutes into the test. There were no ST changes concerning for
ischemia. TTE showed mild concentric LVH with septum and inf
wall
echogenicity, without significant valvular disease. EF 55-60%,
trace to mild MR. ___ overall consistent with infiltrative
cardiomyopathy. Lyme western blot (neg), SPEP/UPEP (nl), ACE
level 43 (nl) were sent.
Cardiac MR ___ was notable for regional T2 signal increase in
the
LV suggesting inflammation/edema and late gadolinium enhancement
consistent with non-ischemic cardiomyopathy in more than 20% of
the LV. It also showed bronchial wall thickening and enlarged
bilateral hilar lymph nodes measuring up to 2.0 cm in the right
hila. CT chest was recommended for assessment of possible
sarcoidosis.
Given MRI findings, he was referred to ___ for expedited EP
and
pulmonary workup. In the ED, vital signs were notable for blood
pressure of 124/83, subsequently 98/56. Saturating 98% on room
air. EKG shows an ectopic atrial rhythm at 55 bpm. CBC and BMP
are unremarkable. CT chest was ordered but not yet performed.
He did not receive any medications. He was evaluated by EP and
taken for dual chamber ICD prior to arrival to the cardiac
floor.
Past Medical History:
1. CARDIAC RISK FACTORS
None
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
None
Social History:
___
Family History:
Father - PVD, ?CAD
Mother - DM
___ Grandmother - CVA
No family history of sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
___ 1128 Temp: 98.0 PO BP: 105/66 R Lying HR: 51 RR: 18 O2
sat: 97% O2 delivery: Ra The ICD site is bandaged, some mild
serous exudate, bleeding, but no erythema warmth. Mildly tender
to palpation. Anicteric sclerae, moist because membranes. JVP
normal, normal carotids, no lymphadenopathy, normal thyroid.
Clear to auscultation bilaterally without any rales or wheezes.
Normal respiratory expiratory effort. Regular rate and rhythm,
normal S1-S2 without any murmurs rubs or gallops. No RV heave,
PMI normal. Abdomen normal, soft nontender nondistended with
positive bowel sounds. No gross masses or bruits. No cyanosis
clubbing or edema. No evidence of any rashes or ecchymosis.
Normal pulses throughout.
DISCHARGE PHYSICAL EXAM
======================
___ ___ Temp: 99.0 PO BP: 97/68 R Sitting HR: 61 RR: 18 O2
sat: 100% O2 delivery: Ra
General: Lying in bed, alert and awake, in no apparent distress
HEENT: Anicteric sclerae, no cervical lymphadenopathy.
EOMI. No conjunctival pallor, erythema or injection.
Cardiac: S1 and S2 heard, no M/R/G
Lungs: No rales, crackles, wheezes. Breathing without accessory
muscles of inspiration
Abdominal: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, no peripheral edema
SKIN: No rashes, decreased redness around site of ICD
PULSES: Radial pulses 2+ bilaterally, DP pulses 1+ bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 05:55AM BLOOD WBC-9.6 RBC-4.34* Hgb-13.5* Hct-38.6*
MCV-89 MCH-31.1 MCHC-35.0 RDW-12.5 RDWSD-40.8 Plt ___
___ 11:35AM BLOOD Neuts-74.2* Lymphs-15.6* Monos-7.5
Eos-1.7 Baso-0.7 Im ___ AbsNeut-4.48 AbsLymp-0.94*
AbsMono-0.45 AbsEos-0.10 AbsBaso-0.04
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD ___ PTT-30.9 ___
___ 05:55AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-142
K-4.4 Cl-104 HCO3-24 AnGap-14
___ 03:27AM BLOOD Glucose-107* UreaN-14 Creat-1.1 Na-144
K-4.5 Cl-105 HCO3-28 AnGap-11
___ 05:55AM BLOOD ALT-23 AST-20 LD(LDH)-249 AlkPhos-74
TotBili-1.3
___ 05:55AM BLOOD Albumin-4.2 Calcium-9.0 Phos-3.8 Mg-2.1
___ 05:55AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 05:55AM BLOOD HCV Ab-NEG
___ 03:46AM BLOOD ___ pO2-27* pCO2-59* pH-7.30*
calTCO2-30 Base XS-0
___ 03:46AM BLOOD Lactate-1.5
DISCHARGE LABS
==============
___ 12:30AM BLOOD WBC-8.4 RBC-4.20* Hgb-13.1* Hct-36.8*
MCV-88 MCH-31.2 MCHC-35.6 RDW-12.4 RDWSD-39.7 Plt ___
___ 12:30AM BLOOD Neuts-86.1* Lymphs-5.7* Monos-6.8
Eos-0.8* Baso-0.1 Im ___ AbsNeut-7.21* AbsLymp-0.48*
AbsMono-0.57 AbsEos-0.07 AbsBaso-0.01
___ 05:55AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-142
K-4.4 Cl-104 HCO3-24 AnGap-14
___ 05:55AM BLOOD ALT-23 AST-20 LD(LDH)-249 AlkPhos-74
TotBili-1.3
___ 05:55AM BLOOD Albumin-4.2 Calcium-9.0 Phos-3.8 Mg-2.1
___ 05:55AM BLOOD HCV Ab-NEG
Brief Hospital Course:
SUMMARY STATEMENT:
====================
___ male with no significant past medical history
admitted for management of 2:1 block on exertion, subacute DOE,
and cardiac sarcoidosis. His cardiac MRI prior to admission
showed late gadolinium enhancement in a pattern consistent with
cardiac sarcoidosis. He received an ICD on ___. On ___
he had a biopsy of hilar lymph nodes to attempt to diagnose
sarcoidosis, pathology pending at discharge. He was discharged
home on ___ with a plan to initiate prednisone along with PCP
and GI prophylaxis once diagnosis was confirmed, as well as a
3-day course of cephalexin to prevent ICD pocket infection.
TRANSITIONAL ISSUES:
====================
[] ___ is discharged with a supply of prednisone, which she
should start taking when his biopsy results return and confirm
sarcoidosis. Several of the studies sent on the biopsy and BAL
studies will take weeks to return, he should not await these
results to start the prednisone.
[] He will likely require long course of prednisone, thus he is
initiated on Bactrim single strength and omeprazole for PCP and
GI prophylaxis.
[] He will require outpatient ophthalmology follow-up due to new
diagnosis of likely sarcoidosis.
[] Scheduled for outpatient PFTs.
[] He was discharged on a 3-day course of Keflex to prevent
device infection. Day 1 of antibiotics ___, last dose will be
taken ___.
[] 1 cm hyperenhancing lesion in the right lobe of liver. If the
patient has no hepatic risk factors, is likely benign and no
further follow-up is needed. Otherwise, consider nonemergent
MRI.
ACTIVE ISSUES:
=================
# Cardiac Sarcoidosis
# 2:1 AV block on ETT s/p dual chamber ICD ___
# Nonischemic Cardiomyopathy
Followed by Atrius cardiology, ETT on ___ showed NSR at rest
with development of 2:1 AV block 4 minutes into the test. There
were no ST changes concerning for ischemia. S/p ICd ___.
Outpatient TTE showed mild concentric LVH with septum and
inferior wall echogenicity, without significant valvular
disease. EF 55-60%, trace to mild MR. ___ overall
consistent with infiltrative cardiomyopathy. Cardiac MR with
large amount of patchy late gadolinium enhancement consistent
with scar in a non-coronary pattern and increased T2 signal
intensity in the inferior septum and patchy left ventricular
early gadolinium enhancement consistent with inflammation. L___
___ blot (neg), SPEP/UPEP (nl), ACE level 43 (nl), A1c 4.8%.
Overall findings concerning for cardiac sarcoidosis. He was
evaluated by the pulmonary and rheumatology teams, who jointly
recommended initiating prednisone 40 mg following confirmation
of sarcoidosis diagnosis on biopsy. Along with this, he will
initiate Bactrim single strength and omeprazole 20 daily for PCP
and GI prophylaxis. He was also discharged on a 3-day course of
cephalexin to prevent device/pocket infection. See transitional
issues for follow up plan.
# Liver Nodule
Identified incidentally on chest CT. See transitional issues.
Likely benign given no hepatic risk factors.
Code status: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cephalexin 500 mg PO QID Duration: 3 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*12 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY PCP ___
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Pulmonary Sarcoidosis
SECONDARY DIAGNOSES:
Extrapulmonary Sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of your progressive
shortness of breath and the findings of your cardiac MRI and
stress test.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, a pacemaker was placed due to the cardiac
rhythm abnormalities that were seen on your stress test. You
received a biopsy by the interventional pulmonology team to
confirm the diagnosis of sarcoidosis which was suspected based
on your cardiac MRI. The results of this biopsy are pending.
You were evaluated by the pulmonology and rheumatology teams,
who are helping to manage your sarcoidosis.
- You are given prednisone, which you should not take until you
hear the results of your biopsy. You are also being given a
medication to prevent infections in patients on steroids and
medication to prevent gastric ulcers in patients taking
steroids. You are also given a 3-day course of antibiotics to
prevent ICD pocket infection.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- If you do not receive a telephone call with the results of
your biopsy by ___, please reach out to Dr. ___
office at ___ to discuss the plan regarding your
steroids.
- If you are still taking cephalexin when you are due to start
Bactrim, you may delay the start of Bactrim until your course of
cephalexin is finished.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19620469-DS-6
| 19,620,469 | 27,429,558 |
DS
| 6 |
2181-12-30 00:00:00
|
2181-12-31 21:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Topamax / Vicodin / Lidoderm / Cymbalta / ___ nuts / Haldol /
Ritalin / topiramate / tree nuts / adhesive
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
Medically complex pt with h/o CAD s/p LAD DES ___, recurrent
PE ___ on Xarelto, severe vaginal bleeding on anticoagulation
requiring hysterectomy at ___ ___, cx'd by vaginal cuff
infection, with abx d/c'd ___, AODM, chronic pain, panic
disorder, intellectual disability, and HTN who arrived at office
visit today c/o feeling "out of it" and recent low BP of 90/60,
and high BS last night in 300's. she was lethargic and nodded
off
during her appt. Her BP was 90/60 and her BS was 405. She's
being
referred for hydration and w/u of change in mental status. We
will stop the lisinopril that was just added 2 days ago for an
elevated BP.
patient with recently very labile blood pressures. Prior
baseline
of high blood pressures but more recently has been hypotensive.
This is in the context of recently starting Lisinopril as well
as
restarting her propranolol which had been off but was resumed 2
weeks ago after her surgery. She also self increased her
torsemide dose from 20 to 40mg daily because she wasn't peeing
enough on the 20. patient recently diagnosed with vaginal cuff
infection when seen at urgent care and was started on
clindamycin
later transitioned to augmentin when she developed GI side
effects. When seen in ___ clinic by her surgeon she was told
there was no evidence of infection and told to stop her
antibiotics. Despite this she continues with malodor, pelvic
pain
and some vaginal discharge
In the ED:
VS: Initial VS: 97.6 64 86/39 22 96% RA
--> 90 122/79 16 99% RA
PE: pelvic exam: thin prurulent discharge, exquisite tenderness
to vagina and cuff
Labs: WBC 8.5, Hgb 10.1, lactate 2.3 -> 1.5
Imaging: CT A/P with possible mesenteric panniculitis and
surgical changes from recent hysterectomy with trace pelvic
fluid.
Impression: hypotension, suspected sepsis from vaginal cuff
infection
Interventions: IVF LR 1000 mL x2, IV Morphine Sulfate 4 mg x3,
IV Clindamycin 600 mg, IV Hydrocortisone Na Succ. 100 mg, IV
Gentamicin 490 mg
Consults: OB/Gyn: Completed 20:10
___ 2 weeks s/p TVH, LS here with hypotension and abdominal
pain. BPs resolved with IVF. Abdominal exam benign. Per ED
resident, pelvic exam notable for foul vaginal discharge and
tenderness. Swabs collected and pending. CT abd/pelvis normal.
Given patient has been afebrile, has normal white count and no
imaging concerns, low suspicion for acute GYN etiology of blood
pressures. Would defer further doses of IV antibiotics unless
clear infectious source is noted. If admitted, GYN will continue
to follow peripherally.
D/w Dr. ___ attending
___, PGY-3
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Bursitis, trochanteric
Obesity
Pain syndrome, chronic
GERD (gastroesophageal reflux disease)
Hypertension, essential
IBS (irritable bowel syndrome)
HSV-2 infection
Shoulder impingement
Hypothyroidism
Hypercholesterolemia
Obstructive sleep apnea
Somatization disorder
Borderline intellectual functioning
OPIOID AGREEMENT violated ___ with neg urine tox screen,
Chondromalacia patellae of left knee
Nonalcoholic steatohepatitis (NASH)
Panic disorder with agoraphobia, mild agoraphobic avoidance and
moderate panic attacks
Superficial thrombophlebitis of leg
Pulmonary emboli ___
Depression with anxiety
Tobacco use disorder, moderate, dependence
Generalized anxiety disorder
Major depressive disorder, recurrent, mild
Alcohol abuse
Type 2 diabetes mellitus with diabetic nephropathy, with
long-term current use of insulin
DVT femoral (deep venous thrombosis) with thrombophlebitis,
right s/p insertion of IVC (inferior vena caval) filter
Other hemorrhoids
Gastroesophageal reflux disease without esophagitis
Nonintractable migraine
Primary insomnia
Atelectasis
Bradycardic cardiac arrest
Mild persistent asthma without complication
Coronary artery disease involving native coronary artery of
native heart without angina pectoris
Costochondritis
Labile hypertension
Chronic diastolic congestive heart failure
Social History:
___
Family History:
Reviewed and found to be noncontributory to current
hospitalization
Physical Exam:
ADMISSION:
==========
VS: ___ 2258 Temp: 98.4 PO BP: 122/62 R Lying HR: 74 RR: 16
O2 sat: 97% O2 delivery: RA FSBG: 357
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE:
===========
Temp: 98.5 PO BP: 111/71 HR: 79 RR: 20 O2 sat: 100% O2 delivery:
Ra
GENERAL: obese, lying comfortably in bed in NAD
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: irreg, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
CHEST WALL: reproducible TTP of sternum
GI: obese, + BS, soft, RUQ mildly TTP, mild RLQ/suprapubic TTP,
unable to appreciate HSM given habitus, no R/G
GU: exam deferred given Gyn exam on ___
SKIN: 5mmx5mm ulcerated lesion on medial L thigh with mild
surrounding erythema, non-tender without purulence, at site of
resected skin tag
MSK: Lower ext warm without edema
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
=========
___ 12:16PM BLOOD WBC-8.5 RBC-4.24 Hgb-10.1* Hct-34.0
MCV-80* MCH-23.8* MCHC-29.7* RDW-17.5* RDWSD-51.3* Plt ___
___ 12:16PM BLOOD Neuts-71.4* ___ Monos-5.4 Eos-1.3
Baso-0.6 Im ___ AbsNeut-6.09 AbsLymp-1.78 AbsMono-0.46
AbsEos-0.11 AbsBaso-0.05
___ 12:16PM BLOOD ___ PTT-29.6 ___
___ 12:16PM BLOOD Glucose-362* UreaN-26* Creat-1.2* Na-135
K-3.9 Cl-96 HCO3-24 AnGap-15
___ 12:16PM BLOOD ALT-15 AST-13 AlkPhos-134* TotBili-0.3
___ 12:16PM BLOOD cTropnT-<0.01
___ 12:09PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:16PM BLOOD Albumin-3.9 Calcium-9.5 Phos-4.9* Mg-1.7
___ 06:20AM BLOOD TSH-2.4
___ 05:25AM BLOOD Cortsol-3.1
___ 12:26PM BLOOD Lactate-2.3* K-3.5
Other notable:
Ferritin 14, TIBC 368, Iron 21
B12 286, Folate 7
Hapto 214
TSH 2.4
Cortisol 3.1
Trop <0.01
D-dimer 304
Lact 2.3 -> 1.5
DISCHARGE:
==========
___ 06:45AM BLOOD WBC-7.9 RBC-4.01 Hgb-9.5* Hct-32.1*
MCV-80* MCH-23.7* MCHC-29.6* RDW-17.3* RDWSD-51.0* Plt ___
___ 06:45AM BLOOD Glucose-213* UreaN-19 Creat-0.8 Na-140
K-4.1 Cl-102 HCO3-28 AnGap-10
UA (___): tr bld, neg nit, mod ___, 30 prot, 2 RBCs, 19 WBCs, few
bact
UCG: neg
Flu A/B: neg
UCx (___): negative
Vaginal swab (___): Indeterminate. Altered vaginal flora that
does not meet criteria for diagnosis of bacterial vaginosis. Neg
for yeast
BCx (___): pending x 2
Tele: frequent PVCs/bigeminy
IMAGING:
========
EKG (___):
NSR at 87 bpm with PVCs, PR 156, QRS 84, QTC 447, no ischemic
changes (PVCs new compared to ___
R ___ (___):
No evidence of deep venous thrombosis in the right lower
extremity veins.
TTE (___):
Suboptimal image quality. Normal study. Mild pulmonary artery
systolic hypertension. Frequent ventricular ectopic activity. EF
65%.
EKG (___):
NSR at 63 bpm, nl axis, PR 168, QRS 113, QTC 439, no clear
ischemic changes
CT A/P w/cont (___):
1. Status post total hysterectomy and left salpingectomy. Trace
pelvic free fluid and stranding about the surgical bed is likely
postsurgical. No organized fluid collection or abscess.
2. Infrarenal IVC filter in situ.
3. Mild splenomegaly.
CXR (___):
No acute intrathoracic process
Brief Hospital Course:
___ F with history of developmental delay, T2DM, obesity, RLE
DVT and recurrent PE s/p IVC filter, chronic HFpEF, OSA, chronic
pain, abnormal uterine bleeding s/p TVH, LS on ___ (___) c/b
vaginal cuff infection s/p outpatient antibx (d/c'd ___
presenting from PCP office with hypotension and R-sided
abdominal pain, with course c/b orthostasis, chest pain, and
rectal bleeding.
# Lightheadedness/dizziness:
# Hypotension / orthostasis:
Patient presented with symptomatic hypotension, with initial
SBPs in the ___ in the ED. Suspect secondary to medication
effect, primarily from recent resumption of lisinopril (___) and
propranolol (resumed post-operatively) and increase in her home
torsemide from 20mg to 40mg daily in ___. Hypotension
improved with 2L IVFs in the ED, and orthostatics were
subsequently negative. Given weight gain and hx of chronic
HFpEF, torsemide was resumed at half her home dose on ___, with
recurrence of orthostatic hypotension. Her torsemide dose was
adjusted, and she will be discharged on 10mg 3x per week. Home
lisinopril and propranolol were held, discontinued on discharge.
She was cleared by ___ for home with home ___. Follow up
arranged with cardiology and PCP. She will need close
monitoring as an outpatient for titration of her diuretics and
antihypertensives.
# Atypical chest pain:
# CAD s/p stent placement:
# Chronic HFpEF:
Does have a hx of CAD for which a stent was placed previously.
Had chest pain on admission c/w costochondritis given
reproducibility on exam, non-ischemic EKG, and negative
troponin. TTE ___ with EF 65%, no significant valvular disease,
and mild pulmonary artery systolic hypertension. Recurrent
reproducible chest pain on ___ again most c/w MSK etiology given
non-ischemic EKG and nl troponin. Volume assessment remains
challenging in the setting of her habitus, apparent weight gain
while hospitalized, and orthostatic hypotension. As above her
diuretics were adjusted, and she will be discharged on 10mg
torsemide 3x week. Plavix and statin were continued.
# Frequent PVCs:
Occasionally symptomatic but unlikely contributing to
hypotension. Home propranolol was discontinued on admission as
above. She was trialed on fractionated metoprolol, and
discharged on metop succinate 12.5 mg. F/u with outpatient
cardiologist Dr. ___ at ___ ___
scheduled for ___.
# Hematochezia:
Developed BRBPR ___ AM. Exam reveals slow, active bleeding and
rectal polyp with no external hemorrhoids. Sigmoidoscopy ___
showed internal hemorrhoids and 9mm anal polyp prolapsing from
rectum. Nl colonoscopy in ___ reportedly (per note in ___
records). Hgb is stable, and low suspicion for GI hemorrhage
contributing to presenting hypotension/orthostasis. Resolved
despite continuation of Xarelto and Plavix. Would recommend
outpatient follow-up with GI or colorectal surgery.
# Chronic pain:
Complained of R-sided abdominal/pelvic pain. RLQ pain may be
secondary to expected post-TVH pain, which is now improving.
Review of chart suggests that RUQ pain is chronic s/p CCY and
has been previously evaluated by GI (Dr. ___ in ___,
attributed to obesity and MSK etiologies. Further work-up of her
chronic abdominal pain was deferred to her outpatient providers.
She was continued on her home oxycodone, tramadol, and Tylenol
as needed, which should be weaned as tolerated as an outpatient
given risks of polypharmacy. In addition, she would likely
benefit from weight loss, possibly facilitated by referral to a
bariatric specialist.
# S/p TVH, LS c/b vaginal cuff infection:
Seen by Gyn in ED and pelvic exam performed ___, without
evidence of vaginal cuff cellulitis or other vaginal infection.
Mild RLQ pain expected post-hysterectomy per Gyn. She was not
treated with antibiotics this admission. She should follow-up
with her outpatient gynecologist at ___.
# DM:
Mildly hyperglycemic. Home Lantus was increased to 50 units in
the morning from her home dose of 45 units. Home metformin was
held while hospitalized, resumed on discharge.
# RLE DVT:
# Recurrent PE s/p IVC filter:
Low suspicion for PE as above given nl D-dimer. Patient
complained of subjective RLE swelling, with trace R>L ___, but R
___ this admission negative for DVT. Home Xarelto continued.
# Chronic pain:
- continued home oxycodone and tramadol
- continued home tizanidine
- continued home gabapentin
- would consider weaning above as outpatient
# Anxiety:
- continued home buspirone, Lorazepam (would consider weaning as
outpatient)
# Insomnia:
- continued home trazodone and zolpidem
- consider weaning both as outpatient
# COPD:
- continued home spiriva and prn albuterol
# OSA:
Reports that she is currently being evaluated for an
appropriately fitting CPAP. As above she would also benefit
from weight loss, possibly facilitated by bariatric surgery
referral.
# Hypothyroidism:
TSH WNL. Continued home levothyroxine.
# GERD:
Continued home PPI.
# Developmental delay:
AOx3, but per brother has cognitive capacity of ___.
Currently at baseline. Lives home alone with assistance from
aunt ___, mother ___, friend ___, and brother ___.
** TRANSITIONAL **
[ ] Close monitoring of weights and blood pressures, with
titration of antihypertensives and diuretics as needed
[ ] Follow-up with outpatient cardiologist for CAD, heart
failure, and frequent PVCs
[ ] Follow-up rectal bleeding and microcytic anemia: Consider
referral to GI or colorectal surgery
[ ] Wean opiates and benzodiazepines as tolerated
[ ] Ensure pulmonary follow-up for likely OSA
[ ] Ensure follow-up with outpatient gynecologist for recent
hysterectomy
[ ] Further work-up for chronic abdominal pain deferred to
outpatient providers
# ___ and Communication:
Name of health care proxy: ___
Relationship: brother
Phone number: ___
Cell phone: ___
Proxy form in chart: No
Verified on date: ___
Friend/caretaker ___ is also very involved and can receive
information: ___
# Code Status/ACP: FULL (presumed)
> 30 mins spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Lisinopril 10 mg PO DAILY
3. Ondansetron ODT 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
4. MetroNIDAZOLE Gel 0.75%-Vaginal 1 Appl VG QHS
5. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
6. Clopidogrel 75 mg PO DAILY
7. Tizanidine 4 mg PO TAKE 1 TAB IN AM AND 1 TAB MIDDAY AND 3
TABLETS AT BEDTIME AS NEEDED FOR MUSCLE SPASM
8. OxyCODONE (Immediate Release) 5 mg PO ___ TABLETS EVERY 6
HOURS AS NEEDED UP TO 6 TABS DAILY
9. Rivaroxaban 20 mg PO DINNER
10. TraZODone 200 mg PO QHS
11. MetFORMIN (Glucophage) 500 mg PO BID
12. LORazepam 1 mg PO DAILY
13. LORazepam 1 mg PO DAILY:PRN anxiety
14. Torsemide 40 mg PO DAILY
15. Pantoprazole 40 mg PO Q12H
16. Atorvastatin 40 mg PO QPM
17. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
18. Levothyroxine Sodium 100 mcg PO DAILY
19. BusPIRone 15 mg PO TID
20. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous 45U qam
21. Propranolol LA 60 mg PO QPM
22. Tiotropium Bromide 1 CAP IH DAILY
23. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Torsemide 10 mg PO 3X/WEEK (___)
RX *torsemide 10 mg 1 tablet(s) by mouth 3x/week (tues, thurs,
sat) Disp #*30 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Atorvastatin 40 mg PO QPM
5. BusPIRone 15 mg PO TID
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous 45U qam
9. Levothyroxine Sodium 100 mcg PO DAILY
10. LORazepam 1 mg PO DAILY
11. LORazepam 1 mg PO DAILY:PRN anxiety
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Ondansetron ODT 4 mg PO Q6H:PRN Nausea/Vomiting - First
Line
14. OxyCODONE (Immediate Release) 5 mg PO ___ TABLETS EVERY 6
HOURS AS NEEDED UP TO 6 TABS DAILY
15. Pantoprazole 40 mg PO Q12H
16. Rivaroxaban 20 mg PO DINNER
17. Tiotropium Bromide 1 CAP IH DAILY
18. Tizanidine 4 mg PO TAKE 1 TAB IN AM AND 1 TAB MIDDAY AND 3
TABLETS AT BEDTIME AS NEEDED FOR MUSCLE SPASM
19. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
20. TraZODone 200 mg PO QHS
21. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypotension, likely medication effect
Coronary artery disease
Diabetes mellitus
Hematochezia, likely hemorrhoidal
Microcytic anemia
COPD
Morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with low blood pressure,
likely due to the combination of your outpatient medications.
There was no evidence of infection, and your heart appears to be
working well. Your medications were adjusted, and your low
blood pressure is improved. While in the hospital, you had some
chest pain, which does not appear to represent a heart attack.
In addition you had abdominal pain, which is likely due to your
recent hysterectomy as well as some mild liver inflammation that
had largely resolved at the time of discharge.
Please note the following changes in your medications at
discharge:
1. STOP taking lisinopril.
2. STOP taking propranolol, and START metoprolol.
3. REDUCE torsemide to 3x a week (___)
- Weigh yourself once you get home and notify your PCP ___
cardiologist if your weight changes (up or down) 2 lbs in one
day or 5 lbs in one week.
4. Increase your lantus to 50u.
Please follow-up with your outpatient doctors as below, and take
your medications as prescribed.
With best wishes,
___ medicine
Followup Instructions:
___
|
19620469-DS-7
| 19,620,469 | 29,604,279 |
DS
| 7 |
2182-02-07 00:00:00
|
2182-02-08 06:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Topamax / Vicodin / Lidoderm / Cymbalta / ___ nuts / Haldol /
Ritalin / topiramate / tree nuts / adhesive
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___: cardiac catheterization
History of Present Illness:
___ female medically complex pt with h/o CAD s/p LAD DES
___, recurrent PE ___ on Xarelto and IVC filter ___
in ___, severe vaginal bleeding on anticoagulation
requiring hysterectomy at ___ ___, cx'd by vaginal cuff
infection, with abx d/c'd ___, insulin dependent diabetes,
chronic pain, panic disorder, intellectual disability, and HTN
who presents today with chest pain.
Of note, patient was recently admitted from ___ to ___ for
hypotension. Hypotension thought to be from lisinopril,
propranolol, and increase in torsemide dosing and it improved
after fluids. She was discharged on torsemide 10mg 3 times
weekly
due to orthostatic hypotension and lisinopril and propranolol
were held. She also had chest pain during that admission thought
to be due to chostochondritis. TTE ___ with EF 65%, no
significant valvular disease, and mild pulmonary artery systolic
hypertension. She had frequent PVCs and was discharged on
metoprolol succinate 12.5mg PO daily. Course was also
complicated
by hematochezia that resolved without discontinuing
xareleto/Plavix.
Since discharge, she has been seen multiple times by her
providers. She saw her PCP ___ ___, and was complaining of
elevated blood pressures and weight gain. At that visit, her
torsemide was increased from 10mg 3 times per week to 20mg three
times per week and her lantus was increased to 55qam. On ___,
she was seen by cardiology and given 80 mg of IV Lasix. She
continued to have weight gain and was placed on alternating
doses
on 20mg and 10mg torsemide. On ___, her torsemide was changed
to 20mg daily. However, due to hypotension, her dose changed day
to day. Her pre-hospital dose was 20mg twice weekly and 10mg
5x/week. She skipped her metoprolol if her SBP is 120/130 or
lower. She had intermittent BP to 190s/110s and was taking
intermittent amlodipine 2.5mg but also called her PCP due to
episodes of hypotension. She is scheduled to see neurology in
___ for RLE weakness. Her oxycodone was tapered down and she
was
started on iron supplementation as well. She was seen in clinic
on ___ for vaginitis and treated with PO metronidazole.
In terms of her present complaints, she was seen on ___ for
shortness of breath and was scheduled to have a lower extremity
ultrasound on ___ due to her recurrent DVTs. However, around
noon on ___, she developed crushing substernal chest pain and
was transferred instead to ___ urgent care. At urgent care,
she complained of substernal chest pain which radiated to the
back and to the shoulders. It was waxing and waning, sharp,
pleuritic chest pain and associated nausea, diaphoresis, and
SOB,
although she does endorse worsening dyspnea on exertion, lower
extremity swelling in her right extremity more than her left
over
the past week. She denied hemopytsis, recent travels, abdominal
pain, back pain, fevers, chills, urinary or bowel symptoms. Her
blood pressure was barely palpable at 80 systolic. Her pulse was
irregular at about 50. Her O2 saturation was normal at 100%. On
exam, she had chronic leg swelling in R leg. She had an EKG
which
reportedly showed frequent PVCs with episodes of ventricular
bigeminy which was not present on prior EKG yesterday on ___. She last took xarelto at 5 pm last night and states and
has not missed any doses. She received ___ and 2 SL nitro and
was
sent to the ___ ED.
- In the ED, initial vitals were:
97.6 94 126/71 18 100% RA
- Exam was notable for:
General: Obese, no apparent distress
HEENT: Atraumatic, Moist mucous membranes, pupils equal and
reactive bilaterally, no JVD
Cardiovascular: Regular rate and rhythm no murmurs rubs or
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft nontender nondistended, no rebound or guarding
Extremities: Right leg slightly more edematous than the left
Neuro: ___ strength bilaterally in UE and ___. SLTIT.
- Labs were notable for:
Na 141, K 3.8, BUN 21, Cr 1.0
Ca 9.3, Mg 1.8, Phos 4.6
trop <0.01 x2
proBNP 443
hgb 9.6 with MCV of 77
- Studies were notable for:
CTA Chest with: No evidence of pulmonary embolism to the
segmental level. No other acute abnormality in the chest.
R ___ with: No evidence of deep venous thrombosis in the right
lower extremity veins.
- The patient was given:
IV Morphine Sulfate 4 mg
IV heparin drip
IV Ondansetron 4 mg
IV Morphine Sulfate 4 mg
SL Nitroglycerin SL .4 mg
IV Morphine Sulfate 4 mg
IV Ondansetron 4 mg
PO/NG Atorvastatin 10 mg
IV HYDROmorphone (Dilaudid) 1 mg
Atrius cardiology was consulted and agreed with admission.
On arrival to the floor, the patient states her current chest
pain is an ___ whereas on ___, it was a 10 plus out of 10.
She
has had chest pain daily since her stent placement. She denies
any current nausea, diaphoresis, shortness of breath, or
palpitations. She does endorse BRBPR with internal hemorrhoids
that has been stable. Her last bowel movement was 1 day PTA. She
has pain in her RLE which is chronic and stable.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Bursitis, trochanteric
Obesity
Pain syndrome, chronic
GERD (gastroesophageal reflux disease)
Hypertension, essential
IBS (irritable bowel syndrome)
HSV-2 infection
Shoulder impingement
Hypothyroidism
Hypercholesterolemia
Obstructive sleep apnea
Somatization disorder
Borderline intellectual functioning
OPIOID AGREEMENT violated ___ with neg urine tox screen,
Chondromalacia patellae of left knee
Nonalcoholic steatohepatitis (___)
Panic disorder with agoraphobia, mild agoraphobic avoidance and
moderate panic attacks
Superficial thrombophlebitis of leg
Pulmonary emboli ___
Depression with anxiety
Tobacco use disorder, moderate, dependence
Generalized anxiety disorder
Major depressive disorder, recurrent, mild
Alcohol abuse
Type 2 diabetes mellitus with diabetic nephropathy, with
long-term current use of insulin
DVT femoral (deep venous thrombosis) with thrombophlebitis,
right s/p insertion of IVC (inferior vena caval) filter
Other hemorrhoids
Gastroesophageal reflux disease without esophagitis
Nonintractable migraine
Primary insomnia
Atelectasis
Bradycardic cardiac arrest
Mild persistent asthma without complication
Coronary artery disease involving native coronary artery of
native heart without angina pectoris
Costochondritis
Labile hypertension
Chronic diastolic congestive heart failure
Social History:
___
Family History:
Reviewed and found to be noncontributory to current
hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.5 PO 125 / 59 65 18 95 Ra
GENERAL: Alert and interactive. In no acute distress. obese
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD although difficult to
assess with habitus
CARDIAC: decreased heart sounds but regular rhythm, normal rate.
Audible S1 and S2. No murmurs/rubs/gallops. tenderness to
palpation over central chest wall
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 1+ pitting edema in b/l lower extremities. Pulses
DP/Radial 1+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously.
DISCHARGE EXAM:
===============
___ 1523 Temp: 97.8 PO BP: 109/76 HR: 77 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: Lying comfortably in bed on her left side
HEENT: MMM, anicteric
NECK: No JVD although difficult to assess with habitus
CARDIAC: regular rate & rhythm, no murmurs. chest pain
reproducible with palpation
LUNGS: Clear to auscultation bilaterally.
BACK: No CVA tenderness.
ABDOMEN: softly obese, NT, ND
EXTREMITIES: no edema, warm. R radial pulse +1, dopplerable,
hand strength and sensation intact
SKIN: Warm. Cap refill <2s. No rashes.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:20PM BLOOD WBC-6.9 RBC-4.20 Hgb-9.6* Hct-32.5*
MCV-77* MCH-22.9* MCHC-29.5* RDW-16.9* RDWSD-47.3* Plt ___
___ 04:20PM BLOOD Glucose-205* UreaN-22* Creat-1.0 Na-140
K-3.9 Cl-101 HCO3-25 AnGap-14
___ 08:45PM BLOOD ALT-232* AST-529* LD(LDH)-563*
AlkPhos-421* TotBili-0.7
___ 04:20PM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.6* Mg-1.8
DISHARGE LABS:
==============
___ 06:47AM BLOOD WBC-7.4 RBC-4.03 Hgb-9.1* Hct-31.5*
MCV-78* MCH-22.6* MCHC-28.9* RDW-17.6* RDWSD-48.6* Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD ___ PTT-70.9* ___
___ 06:59AM BLOOD Glucose-191* UreaN-18 Creat-1.1 Na-140
K-4.3 Cl-98 HCO3-25 AnGap-17
___ 06:47AM BLOOD Glucose-306* UreaN-17 Creat-1.0 Na-137
K-4.3 Cl-101 HCO3-23 AnGap-13
___ 04:22AM BLOOD ALT-139* AST-30 LD(LDH)-174 AlkPhos-287*
TotBili-0.2
___ 01:25AM BLOOD CK(CPK)-44
___ 01:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:05PM BLOOD cTropnT-<0.01
___ 04:11AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:59AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.0
IMAGING RESULTS:
================
___ Cardiac Catheterization
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. The Diagonal, arising from the
proximal segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. The ___ Obtuse Marginal, arising from the
proximal segment, is a medium caliber vessel. The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RCA: The Right Coronary Artery, arising from the left cusp, is a
large caliber vessel. The Right Posterior Descending Artery,
arising from the distal segment, is a medium caliber vessel. The
Right Posterolateral Artery, arising from the distal segment, is
a medium caliber vessel.
Interventional Details
Complications: There were no clinically significant
complications.
Findings
Normal left and right heart filling pressures.
No angiographically apparent coronary artery disease.
Recommendations
Maximize medical therapy
___ Cardiovascular STRESS
IMPRESSION: Atypical type symptoms in the absence of significant
ST
segment changes. Appropriate hemodynamic response to vasodilator
stress.
Nuclear report sent separately.
Cardiac Perfusion Portion
FINDINGS:
Left ventricular cavity size is enlarged with a LVEV of 158 ml.
Rest and stress perfusion images reveal moderate-sized mid and
apical inferior
wall moderate reversible defect.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 48%.
IMPRESSION: Moderate reversible defect with mildly decreased
ejection fraction and large left ventricle.
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
No focal suspicious hepatic lesions. No intrahepatic bile duct
dilatation. The portal vein is patent with hepatopetal flow.
Splenomegaly unchanged.
___ Imaging UNILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Imaging CTA CHEST
IMPRESSION:
No evidence of pulmonary embolism to the segmental level. No
other acute
abnormality in the chest.
Brief Hospital Course:
___ female medically complex pt with h/o CAD s/p LAD DES
___, recurrent PE ___ on Xarelto and IVC filter ___
in ___, severe vaginal bleeding on anticoagulation
requiring hysterectomy at ___ ___, cx'd by vaginal cuff
infection, with abx d/c'd ___, insulin dependent diabetes,
chronic pain, panic disorder, intellectual disability, and HTN
who presents today with chest pain of unclear etiology but
thought to be from ___ strain.
Transitional Issues:
=====================
[]Consider starting ACE ___ if SBPs tolerate (renal
protection iso poorly controlled diabetes)
[]Consider increasing atorvastatin 40 mg to 80 mg though caution
LFT abnormalities
[]Transaminitis on presentation, RUQ u/s unrevealing. Recommend
repeat LFTs and further work up as indicated
[]Uncontrolled blood sugars during hospitalization despite
increasing home insulin. Recommend optimization of glucose and
consideration of an SGLT2 inhibitor given benefit in HFpEF.
[]F/u dizziness
[]Script for custom made TEDs/compression stockings
[]Iron deficient, recommend oral vs IV iron infusions
[]F/u methylmalonic acid given borderline B12 deficiency
[]Opioid dependence likely, wean if able
ACUTE/ACTIVE ISSUES:
====================
#Atypical, non-cardiac chest pain
Patient with substernal chest pressure s/p aspirin that
persisted despite sublingual nitro and morphine. EKG without
ischemic changes. CTA was negative for PE and ___ negative for
DVT. She was placed on a heparin drip in the ED for concern for
ACS in setting of DES but patient denies missing Plavix dose.
Underwent MIBI which was notable for moderate-sized mid and
apical inferior wall moderate reversible defect. Subsequent
coronary catheterization (___) did not demonstrate
angiographically apparent coronary artery disease. Of note, she
has had multiple provider ___ in the past month.
Possible that symptoms are related to anxiety/inability to cope
at home especially in the setting of her father's recent
passing. Given tenderness to palpation and otherwise reassuring
cardiac and pulmonary workup, pain likely has a component of
chostochondritis vs esophageal spasam or reflux. Heparin gtt was
discontinued and patient was deemed safe for discharge on the
following regimen: atorvastatin 40, Toprol 12.5 ___ +
Plavix, Rivaroxaban 20 ___. Arrangements were made for follow up
with outpatient cardiology at ___.
#frequent PVCs:
Recommended to have Zio patch at prior admission and discharged
on low dose metoprolol. There was some discussion regarding a
cardiac MRI to uncover etiology of PVCs vs ablation to treat.
Noted to have frequent PVCs on telemetry thoughout
hospitalization, do not believe they were causing any symptoms.
#orthostatic hypotension:
On last admission, cardiology recommended 24-hour urine
collection to rule out pheochromocytoma to be collected when
patient not on beta blockers. TSH WNL last admission and am
cortisol high. Unclear etiology of labile BPs. SBPs stable
100-140s throughout admission while on home medications.
Orthostatics negative prior to discharge.
# Microcytic anemia:
#BRBPR:
B/l Hgb ___ currently at baseline but with BRBPR thought to be
due to hemorrhoids. No recurrence of bleeding while on heparin,
Plavix, and received aspirin ___. Also with history of chronic
abnormal uterine bleeding, now s/p TVH, with no e/o active GU
bleeding.
# Chronic pain:
Patient with chronic pain reportedly taking oxycodone 10qam,
5qpm, 10 qhs, and 5 prn breakthrough. Briefly given ___ po
dilaudid, transitioned to home dose. Likely has chronic pain
related to morbid obesity and deconditioning, however now seems
to have a narcotic dependence. Discharged with instructions to
take 5 ___.
#HFpEF:
Diuretics and hypertension control limited by reported
orthostasis and hypotension as an outpatient. Patient states her
dry weight is 315 lbs and she was 332lb this morning on her
scale. Discharge weight of 328 lbs last admission. Standing
weight on admission was 312lb. CTA chest unremarkable for
vacular congestion and she remained stable on RA. Not believed
to have been in acute heart failure and was continued on home
diuretic regimen without incident. Discharge weight: 341 lbs.
Discharge Cr: 1.1
# DM:
Hyperglycemic throughout admission with sugars 200-350s on
glargine 70 qam, standing Humalog 7 w/ b/l/d, and ISS. Resumed
home lantus on discharge.
Recommend optimization of glucose and consideration of an SGLT2
inhibitor given benefit in HFpEF.
# RLE DVT:
# Recurrent PE s/p IVC filter:
___ negative for DVT and CTA negative for PE.
CHRONIC ISSUES:
==============
# Anxiety:
- continue home buspirone, Lorazepam, trazodone
- consider weaning as outpatient
# Insomnia:
- continue home trazodone and zolpidem
- consider weaning both as outpatient
# COPD:
- continue home spiriva and prn albuterol
# OSA:
- continuous pulse oximetry
- being evaluated as outpatient for appropriately-fitting CPAP;
declining inpatient CPAP
# Hypothyroidism:
- continue home levothyroxine
# GERD:
- continue home PPI
# Developmental delay:
AOx3, but per brother has cognitive capacity of ___.
Currently at baseline. Lives home alone with assistance from
aunt
and friend ___.
Code status: Full
Contact: ___, mother, ___
Discharge weight: 155 kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Clopidogrel 75 mg PO DAILY
3. BusPIRone 15 mg PO TID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. LORazepam 1 mg PO DAILY
6. LORazepam 1 mg PO DAILY:PRN anxiety
7. Ondansetron ODT 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
9. Pantoprazole 40 mg PO Q12H
10. Rivaroxaban 20 mg PO DINNER
11. Tiotropium Bromide 1 CAP IH DAILY
12. Tizanidine 4 mg PO TAKE 1 TAB IN AM AND 1 TAB MIDDAY AND 3
TABLETS AT BEDTIME AS NEEDED FOR MUSCLE SPASM
13. Torsemide 10 mg PO 5X/WEEK (___)
14. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
15. TraZODone 200 mg PO QHS
16. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
17. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous 55U qam
18. Metoprolol Succinate XL 12.5 mg PO DAILY:PRN SBP>120/130
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
20. Atorvastatin 40 mg PO QPM
21. Torsemide 20 mg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Atorvastatin 40 mg PO QPM
3. BusPIRone 15 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous 55U qam
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 1 mg PO DAILY:PRN anxiety
9. LORazepam 1 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY:PRN SBP>120/130
11. Ondansetron ODT 4 mg PO Q6H:PRN Nausea/Vomiting - First
Line
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
13. Pantoprazole 40 mg PO Q12H
14. Rivaroxaban 20 mg PO DINNER
15. Tiotropium Bromide 1 CAP IH DAILY
16. Tizanidine 4 mg PO TAKE 1 TAB IN AM AND 1 TAB MIDDAY AND 3
TABLETS AT BEDTIME AS NEEDED FOR MUSCLE SPASM
17. Torsemide 10 mg PO 5X/WEEK (___)
18. Torsemide 20 mg PO 2X/WEEK (MO,TH)
19. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
20. TraZODone 200 mg PO QHS
21. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-------------------
Atypical, non-cardiac chest pain
SECONDARY:
-------------------
Coronary artery disease
Heart failure with preserved EF
Diabetes mellitus, II
Transaminitis
History of PE and RLE DVT w/ IVC filter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a cardiac catheterization which was normal and did not
show a blockage in the arteries of your heart.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please bring this discharge paperwork with you to your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
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DS
| 7 |
2183-04-14 00:00:00
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2183-04-15 02:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
Nausea/vomiting; weakness.
Major Surgical or Invasive Procedure:
None during this admission.
History of Present Illness:
Ms. ___ is a ___ year old female with unknown past medical
history due to baseline dementia who presented to an outside
hospital with nausea, vomiting, and generalized weakness. A
non-contrast head CT revealed a 2cm medullary mass and the
patient was transferred to ___ for further evaluation. Upon
history taking the patient was confused about reason for being
in this hospital and her symptoms however she did deny pain,
nausea, vomiting, falls, constipation, or diarrhea. She reported
having dizziness, bilateral hand numbness, and is occasionally
incontinent of urine.
Past Medical History:
-Dementia
-Hard of hearing
-Osteogenesis imperfecta
Social History:
___
Family History:
NC.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: Comfortable lying on stretcher.
T: 98.2 BP: 141/78 HR: 90 R: 16 O2Sats: 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Anisocoric R>L EOMs: intact without nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, ___, Mass, ___, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils round and reactive to light, R pupil ___, L pupil 4.5
-4mm. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Slight L ptosis.
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. Intentional tremors in
bilateral upper extremities. Strength full power ___ throughout.
Right pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger (tremulous), rapid
alternating movements.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented to self, ___, and ___.
Right pupil surgically irregular, 5mm-4mm briskly reactive.
Left pupil, 5mm-4mm briskly reactive.
CN II-XII grossly intact.
Motor Examination:
Upper and lower extremity strength ___ bilaterally with
encouragement.
Pertinent Results:
==========
IMAGING
==========
___ CT HEAD W/O CONTRAST
1. A 2.0 cm mass is identified in the medulla. Consider MRI of
the cervical spine with and without contrast for further
evaluation.
RECOMMENDATION(S): Partially evaluated hypodense lesion in the
medulla
oblongata as described above, correlation with MRI of the
cervical spine with and without contrast is recommended for
further characterization.
___ CHEST (PA & LAT)
No acute cardiopulmonary process.
___ CT HEAD W/O CONTRAST
1.7 cm medullary lesion is similar to prior. No significant
changes are
demonstrated in comparison with the prior head CT.
RECOMMENDATION(S): MRI of the cervical spine with and without
contrast is
recommended for further characterization.
___ CT CERVICAL W&W/O CONST
1. No evidence of enhancement within the 1.9 x 1.6 x 1.6 cm
hypodense
medullary lesion.
2. Cervical cord at the level of C2 superiorly is not well
assessed due to
streak artifact. However, a hypodense lesion is again seen
extending from the inferior aspect of spinal cord at C2 through
at least C7, again without evidence of enhancement. It is
unclear whether the above two lesions are continuous or whether
there is a short intervening segment of
uninvolved/minimally involved cord at C2. Again these findings
would be
better assessed by MRI.
3. Mild multilevel degenerative changes, resulting in up to mild
spinal canal stenosis at C3-C4. There is also multilevel neural
foraminal stenosis, most pronounced at C4-C5 where there is
moderate narrowing on the right and mild narrowing on the left.
RECOMMENDATION(S): Point 2. Correlation with MRI of the
cervical spine with and without contrast is recommended for
further characterization.
___ MR HEAD W & W/O CONTRAS
1. Cystic expansion of the craniocervical and upper cervical
spinal cord with postcontrast enhancement. Differentials
include spinal cord glioma and hemangioma, as well as metastatic
disease. MRI of the cervical, thoracic and lumbar spine is
recommended for complete evaluation.
2. Spinal canal narrowing at C3-4 due to posterior osteophyte,
indenting the thecal sac and narrowing the cystic expansion of
the cord.
___ CT TORSO
1. Incompletely characterized 1 cm left upper pole renal
hyperdense lesion
likely represents a hemorrhagic/ proteinaceous cyst or may be
secondary due to partial volume averaging.
2. No evidence of primary malignancy or metastatic disease
within the abdomen or pelvis
3. Severe dextroscoliosis.
4. Chronic findings including diverticulosis, renal cysts, and
biliary ductal ectasia.
CHEST:
1. No evidence of primary thoracic malignancy.
2. Healing right anterior fourth and fifth rib fractures.
3. Two 2 mm subpleural pulmonary nodules, attention on followup
suggested.
___ KIDNEY ULTRASOUND
1. Bilateral simple renal cysts.
2. 6 mm echogenic lesion within the upper pole of the left
kidney is
sonographically likely an angiomyolipoma although this lesion
was not well
seen on the prior CT.
___ MRI Spine:
1. Limited examination due to lack of axial and post-contrast
images in the
setting of patient discomfort during exam.
2. Expanded medulla, cervicomedullary junction, and cervical
spinal cord
containing at least two gently lobulated cystic areas, as above.
The
intervening upper cervical spinal cord is expanded demonstrates
heterogeneous
signal, and was demonstrated to be heterogeneously enhancing on
prior brain
MR. ___ concerning for underlying mass at this location.
Although
differential includes metastasis, hemangioblastoma, astrocytoma,
and
ependymoma, given patient's age, lack of additional lesions,
lack of brain
lesions, and appearance, ependymoma or astrocytoma are felt to
be most likely.
3. More inferior cervical spinal cord is expanded and edematous.
Thoracic and
lumbar spinal cord, and cauda equina, is normal. No additional
lesions seen.
4. Thoracolumbar S-shaped scoliosis and mild lumbar spine
discogenic
degenerative changes, as above.
Brief Hospital Course:
On ___, Ms ___ presented to an OSH for complaints of nausea,
vomiting and generalized weakness. ___ revealed a 2cm
medullary mass. She was transferred to ___ for further
evaluation. ___ and CT Cervical spine with contrast were
performed for evaluation. Electrophysiology was consulted for
MRI due to presence of pacemaker, which was scheduled for
___.
From ___ to ___, the patient remained inpatient for close
neurologic monitoring. She remained neurologically and
hemodynamically stable.
On ___, MRI brain with and without contrast was performed under
the guidance of the electrophysiology team.
On ___, patient is neurologically stable. In reviewing MRI
Brain, there is concern for spinal metastatic disease, thus MRI
of total spine ordered. Renal ultrasound was ordered to better
characterize left renal hyperdensity.
On ___, patient is neurologically stable. MRI Total Spine is
pending with EP.
On ___, the patient underwent a MRI of the cervical, thoracic
and lumbar spine. Dr. ___ met with the family in the
afternoon. She was evaluated by EP and her pacemaker is
appropriately set after undergoing the MRI. It was determined
she would be discharged to home with ___ services. Physical
therapy recommended rehabilitation, but her family would like to
take her home. Dr. ___ is in agreement with this plan.
Prior to discharge, the patient experienced a 17-beat run of
SVT. She remained asymptomatic. An EKG was performed and
compared to prior. The Cardiac Fellow, ___, MD was
contacted and reviewed the EKG. It was determined no further
cardiac intervention would be necessary and she was cleared for
home. A set of lytes and troponins were sent and were within
normal limits. Troponin was negative.
At the time of discharge she was tolerating a regulat diet,
ambulating with and assistive device, afebrile with stable vital
signs.
Medications on Admission:
acetaminophen, Colace, oxycodone, miralax, amlodipine, baclofen,
escitalopram, vitamin d3, Claritin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
2. amLODIPine 2.5 mg PO DAILY
3. Baclofen 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN nausea/GERD
5. Docusate Sodium 100 mg PO BID
6. FLUoxetine 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Loratadine 10 mg PO DAILY
9. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Medullary Lesion.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with nausea and vomiting and found to have a
1.7cm medullary lesion. You will follow-up with Dr. ___ in
the outpatient office to discuss potential surgical
intervention.
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.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin).
You have been discharged on salt tabs as your sodium level was
found to be low. You will follow-up with your primary care
physician ___ ___ days from the day of discharge for a sodium
check.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
Nausea and/or vomiting
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:
___
|
19620779-DS-8
| 19,620,779 | 24,492,056 |
DS
| 8 |
2183-04-26 00:00:00
|
2183-04-26 16:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
Nausea/UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female patient known to our service who was recently
admitted with nausea, paresthesias, and incontinence. She was
found to have a cystic mass in her medulla, as well as, C2/3
with cervical stenosis. Surgery was offered, but patient
initially declined and was discharged home under the care of her
family. She returned ___ morning with worsening nausea and
fevers. Work up revealed UTI and she was admitted for further
work up and surgical discussion as the patient and family are
now considering surgical intervention.
Past Medical History:
-Dementia
-Hard of hearing
-Osteogenesis imperfecta
Social History:
___
Family History:
NC.
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Anisocoric R>L EOMs: intact without nystagmus
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, ___, Mass, ___, and
date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils round and reactive to light, R pupil ___, L pupil 4.5
-4mm. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Slight L ptosis.
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. Intentional tremors in
bilateral upper extremities. Strength full power ___ throughout.
Right pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Decreased sensation bilateral hands.
Coordination: normal on finger-nose-finger (tremulous), rapid
alternating movements.
ON DISCHARGE:
Patient is awake and oriented to self, ___, ___. + Hard
of hearing. Speech is clear/appropriate. Patient easily follows
commands. Motor ___ grossly, + decreased sensation in bilateral
hands, denies other sensory changes. L>R dysmetria. R Pupil ___,
L pupil ___ (at times can be both ___.
Pertinent Results:
___ Head CTA
CT head: The known 1.7 x 1.6 cm hypodense lesion in the medulla
is unchanged from prior studies. No acute intracranial
hemorrhage detected.
CTA head: Images are limited by streak artifact from the dental
amalgam. The circle of ___ and its principal intracranial
branches appear patent, without evidence of occlusion,
flow-limiting stenosis, or aneurysm greater than 3 mm. Mild to
moderate cavernous carotid calcifications are noted. The
visualized vertebral arteries are also patent, without evidence
of occlusion or dissection.
Brief Hospital Course:
___ yo female with known C2/3 and Medulla cystic lesions and
cervical stenosis who presented form home with worsening nausea
and fever. She was found to have a UTI and was started on
Cipro. Additionally the patient and family are now considering
surgical intervention.
GU/ID
UTI - currently on Cipro 500mg BID x 3 days. Patient now with
improved symptoms and mental status, nausea resolved.
Neuro
Cystic mass - Medulla/C2-3 - Cervical Stenosis - Decadron 4mg Q
6 hours.
F/E/N
Hyponatremia - Na of 130 on admission, improved to 133. Sodium
Chloride tablets increased on ___.
On ___, it was discussed with the patient and patients husband
re: surgical plan. There is concern from the patients husband
regarding surgery, recovering and if that is in the patients
best interested. The patient and husband were educated and
counseled regarding the goals of the planned surgery to include
biopsy for medulla lesion and to treat cervical stenosis due to
patient complaints of decreased sensation in bilateral hands.
All questions and concerns answered. The patient and husband
decided to be discharged home and follow up in the office.
The husband was also counseled on involving elder care to help
with care of the patient, he agrees to involve them for
assistance.
Medications on Admission:
amlodipine, loratadine, salt tabs, baclofen, calcium carb,
colase, senna, lexapro
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
3. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*112 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*40
Tablet Refills:*0
6. Sodium Chloride 2 gm PO TID
RX *sodium chloride 1 gram 2 tablet(s) by mouth twice a day Disp
#*168 Tablet Refills:*0
7. amLODIPine 2.5 mg PO DAILY
8. Baclofen 10 mg PO DAILY
9. Escitalopram Oxalate 20 mg PO DAILY
10. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Stenosis
Medulla lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)/standby assistance.
Discharge Instructions:
Discharge Instructions
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may experience headaches.
· 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:
· 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:
___
|
19620795-DS-16
| 19,620,795 | 28,980,962 |
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| 16 |
2113-03-10 00:00:00
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2113-03-10 19:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a ___ with hx of ETOH cirrhosis, recent
admission for cryptococcal meningitis, transferred from ___ for right-sided weakness and aphasia followed by
witnessed focal seizure resolving with Ativan.
History is obtained via the patient who may be unreliable due to
mental status, ___ records, and sign out from the tele-stroke
fellow who spoke to the husband prior to transfer. I attempted
to reach her husband for additional history but the number and
is
outside hospital paperwork went to a machine and the number that
the patient provided was incorrect.
The patient reports that today, at around 12 ___, she had gradual
onset of paresthesias and numbness in her right hand followed by
weakness that led to her dropping objects. The symptoms
developed over minutes and were not associated with any pain or
headache. At around 1 ___, she started having trouble with her
speech characterized by inability to produce any speech. She
reports she did understand whether people were saying to her.
She was taken to ___. At this point, she does
not remember what happened and only remembers being transferred
to our hospital subsequently. Per outside hospital
documentation
and sign out, she initially underwent a code stroke for right
upper extremity weakness and aphasia with ___ stroke scale of
15.
Tele-stroke was contacted and CT and CTA head and neck was
remarkable for only large ventricles. She proceeded to have
right arm jerking movements consistent with focal seizure that
resolved with "several milligrams of Ativan". Given all the
above, TPA was not recommended. ___ stroke scale only improved
to 13 after Ativan. She was transferred for further workup and
management of focal seizure.
More regarding her neurologic history: (The patient gives
correct
timing of the following history but is unable to give a detailed
history and reports inaccurately that she presented with
generalized weakness, headache, and fever)
Per the neurology consult at ___, she had a history of
intermittent headaches associated with speech difficulty in the
past. On ___, she had onset of right arm weakness leading
to
her dropping a shopping bag as well as slurred speech. After
getting into her car, she had difficulty turning the car on.
Bystanders noticed her difficulty and the patient presented to
the ___ ED where her symptoms resolved. She endorsed
significant
headaches over the last several days. MRI/MRA of the brain was
performed which showed no acute infarction and normal MRA head.
Noncon head CT reported mildly prominent lateral ventricles
which
may have slightly increased from prior study with slightly
prominent third ventricle. Echo showed EF of 60% with no wall
motion abnormalities, no clots. Because her workup for stroke
was
unremarkable she was discharged with the possible diagnosis of
migraine.
Per sign out from stroke fellow in combination ___ some
confirmation from the patient, she had recurrent symptoms
several
weeks later and was this time taken to ___ where
she reportedly also had right-sided jerking movements concerning
for focal seizure. She had a lumbar puncture that diagnosed
cryptococcal meningitis and she was started on antiepileptic
therapy and fluconazole. Per the OMR medications tab, she was
initially prescribed Keppra 500 mg twice daily. Presumably,
after seeing neurology in ___ (this note not available),
she was switched to Vimpat with up titration to 100 mg twice
daily. The patient incorrectly reports that she has remained on
the same AED since admission. She also reports that she takes
200 mg 4 times a day of a seizure medication beginning with
"VI".
Therefore, it is unclear if she is taking her medication
correctly. She correctly gives the fluconazole dose as 1 tab
per
day.
At the time of transfer, she was noted to be mildly somnolent
likely due to Ativan. Neurologic exam per ED note:
"Neurological alert, nonverbal. Does not hold her right arm
against gravity. Follows some commands but minimally, able to
hold the right lower extremity against gravity. Response
appropriately with sensory challenge to the left, not the right.
Pupils are equal and appears to track across the midline. Uvula
elevates in the midline"
On arrival in the ED, she told the nurse that she was having
intermittent numbness in her right hand. On my evaluation, she
says that she is asymptomatic - with normal speech and normal
sensation/strength in her right hand.
Past Medical History:
ETOH Cirrhosis
History of ETOH abuse sober for ___ years
Cryptococcal meningitis c/b right focal motor seizures ___
Social History:
___
Family History:
No family hx of neurologic disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7F, HR 70-74, 96-119/57-63, RR ___, 98% RA
FSG 100
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl.
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: Warm to the touch. No rashes or lesions noted.
Neurologic:
-Mental Status: Somnolent closing her eyes when not stimulated,
arousing with gentle tactile stimulation, oriented to ___
(one day off the date), reported initially at "an OR somewhere"
corrected to BI and when asked after exam where she was, she
answered correctly. Able to relate history some history with
some
inaccuracies. Mildly inattentive, could not perform ___
backwards - got from ___ to ___ and then started
going
in random order. Could perform ___ backwards. Language is fluent
with intact repetition and comprehension. Normal prosody. There
was some mild dysarthria vs very mild paraphasic errors. Pt was
able to name both high and low frequency objects. Able to read
without difficulty. Able to follow both midline and appendicular
commands - could do two step commands on second try. On the
first
attempt, she initially extinguished to DSS - both sensory and
visual but then corrected on repeated stimulation.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with bilateral
end gaze nystagmus left more than right which does not fatigue -
no double vision. Hypometric saccades. Saccadic breakdown of
smooth pursuit. VFF to confrontation - extinguished once to DSS,
corrected with repeated testing. Fundoscopic exam revealed no
papilledema on the right, left difficult to visualize though
lateral edge was visualized as sharp.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. On testing of drift, her
right fingers cup and she pronates the right hand. Mildly slowed
finger tap on the right compared to the left.
++Asterixis
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5- 5- 5 4 4
R 5 ___ 4+ ___- 5 4+ 5- 5 --- Not
tested due to recent orthopedic toe surgery.
-Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. Extinguished once to DSS, did not on
repeated attempt.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
No hoffmans.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Able to stand independently and take a small step. Mildly
unsteady when standing and then wanted to sit down. Mild sway
with feet together.
======================================
DISCHARGE PHYSICAL EXAM:
Neurological exam reveals her to be alert, oriented to time,
place and person. Speech and language are normal. She may have
mild word finding difficulty for low frequency words such as
cuticle but she seem to make a paraphasic error and then
eventually got the word correctly. She has a pronator drift on
the right side, otherwise full. Sensory exam is normal including
cortical
sensation. She was able to walk with a steady gait.
Pertinent Results:
ADMISSION LABS:
___ 06:30PM BLOOD WBC-3.5* RBC-3.99 Hgb-12.1 Hct-35.2
MCV-88 MCH-30.3 MCHC-34.4 RDW-11.8 RDWSD-37.9 Plt ___
___ 06:30PM BLOOD Neuts-66.1 ___ Monos-5.8 Eos-4.3
Baso-0.6 Im ___ AbsNeut-2.28 AbsLymp-0.79* AbsMono-0.20
AbsEos-0.15 AbsBaso-0.02
___ 06:30PM BLOOD ___ PTT-29.4 ___
___ 06:30PM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-141
K-4.2 Cl-101 HCO3-28 AnGap-12
___ 06:30PM BLOOD ALT-12 AST-23 AlkPhos-53 TotBili-0.2
___ 06:30PM BLOOD Lipase-88*
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.6 Mg-2.1
___ 09:00PM BLOOD Ammonia-35
___ 09:00PM BLOOD TSH-0.74
___ 09:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:00PM BLOOD CRP-0.3
___ 09:00PM BLOOD HIV Ab-NEG
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:45PM BLOOD Lactate-1.3
IMAGING:
MRI BRAIN WITH AND WITHOUT:
1. Small areas of leptomeningeal enhancement, most consistent
with meningitis given patient history. Other etiologies,
including inflammatory or neoplastic process could have similar
appearance.
2. No evidence of subarachnoid hemorrhage on MRI or CT.
3. Stable, borderline ventricular size. Linear linear
periventricular T2 signal abnormality, likely represents mild
chronic small vessel ischemic changes, component of mild
periventricular edema cannot be excluded. No ventriculitis.
4. Paranasal sinusitis.
EEG FINAL READS PENDING. Prelim notable for periodic lateralized
epileptiform discharges over the left temoporal reiong ___
Hz).
Brief Hospital Course:
Ms. ___ is a ___ y/o F with hx of ETOH cirrhosis, sober for the
past ___ years, recent admission to ___ in ___ for cryptococcal meningitis thought to be secondary to bird
dropping exposure complicated by seizures who was transferred
from ___ for right-sided weakness and aphasia followed
by witnessed focal seizure. Her exam on admission was non-focal
except for mild paraphasias with low frequency words. She had
been on Vimpat at home, but it was unclear what dose what was
taking. Per pharmacy, she was written for 100mg BID, but patient
reported taking 200mg QID. She was continued inpatient on 200mg
BID. She had previously tried Keppra but reported that this
caused peripheral edema, so it was switched to Vimpat. She was
monitored on continuous EEG, which showed ___ hertz
epileptiform discharged which did not progress to seizure
activity. Given the breakthrough event and PLEDs, Zonisamide was
chosen. This was chosen since she has pancytopenia and a history
of cirrhosis, which limited AED choices. Continuous EEG showed
improvement in lateralized discharges with the addition of
Zonisamide.
With regard to her cryptococcal meningitis, records were
obtained from ___. She was deemed relatively
immunosuppressed given her history of alcoholic cirrhosis and
pancytopenia (unclear etiology) in the setting of bird dropping
exposure. She underwent LP there, which showed a lymphocytic
pleocytosis with low glucose and high protein (no exact values
sent). Opening pressure was not measured until after she was
started on medication, and then repeat LP showed a value of 6 cm
H20. MRI showed left and right parietal leptomeningeal
enhancement consistent with infectious process. Cryptococcal
antigen positive. She was treated with Ambisome then Flucytosine
and now on suppressive Fluconazole.
She did have a repeat MRI brain here, which showed small areas
of linear and nodular enhancement in the subarachnoid space at
inferior left central and inferior postcentral sulcus, left
frontal operculum, which, given her history, were most
consistent with meningitis. As above, repeat LP did not show
evidence of ongoing infection (opening pressure 13, 3 WBC w/
lymphocytic predominance (84%), Protein 38, Glucose 51. CSF
cultures were negative. Notably, repeat cryptococcal antigen was
negative.
Lastly, she was noted to have pancytopenia, which has been seen
back in ___ records as early as ___, though WBC on
discharge was 1.9. This is likely secondary to Fluconazole. She
has weekly labs drawn by her ID specialist and will follow-up
with them regarding medication changes.
She has appointments with neurology and ID next week in ___.
Transitional issues:
-Increase Zonisamide as needed
-repeat labs to ensure stabilization of cbc
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluconazole 200 mg PO Q24H
2. LACOSamide 200 mg PO BID
Discharge Medications:
1. Zonisamide 100 mg PO QHS
RX *zonisamide 100 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*1
2. Fluconazole 200 mg PO Q24H
3. LACOSamide 200 mg PO BID
RX *lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with difficulty speaking, right sided
weakness and shaking concerning for seizure.
You were monitored on EEG which showed an area of the brain
which has the potential for generating more seizures. Therefore,
we continued your home Vimpat and added a second agent,
Zonisamide.
You had a repeat lumbar puncture which did not show any evidence
of ongoing infection. Cryptococcal antigen was negative which
means the infection is being treated appropriately by the
Fluconazole.
Notably, your white blood cell count was quite low. You should
touch base with your infectious disease doctor next week to
discuss any changes needed to your medications.
You should continuing taking all medications as prescribed
below.
Of note, in the state of MA, you are not allowed to drive for 6
months after a seizure with alteration of consciousness. Would
not recommend driving until your follow-up with your neurology
next week. He can make further recommendations based on your
history and the laws in ___.
Please follow-up with your PCP and neurologist in the next week.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
19620892-DS-11
| 19,620,892 | 22,376,148 |
DS
| 11 |
2126-04-28 00:00:00
|
2126-04-29 18:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cerebellar mass
Major Surgical or Invasive Procedure:
___: Suboccipital craniotomy for tumor resection
___: Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ female with history of
metastatic breast cancer status post lumpectomy and chemotherapy
with negative PET scan 3 months ago presents today as a referral
for 4 cm cerebellar mass.
Patient reports that she was diagnosed just last year with
breast cancer. She states that she underwent a lumpectomy and
chemotherapy in ___ and ___ ___ year ago. She has had follow
up since that time, and states that she had a negative PET-CT of
her entire body, including head, 3 months ago. Over the last
year, patient has noted intermittent headaches. Patient noticed
acute worsening ___ days ago, with pain that radiates to the
right side of her neck. Endorsed feelings of lightheadedness and
vertigo, with the room spinning, with some nausea. Woke up
yesterday with constant vertigo and presented to the ED. Not
positional. Denies any fevers, chills, vomiting, abdominal pain,
urinary or bowel symptoms. Patient was evaluated at ___
___, was found to have a 4 cm cerebellar mass. She was
therefore transferred to ___ for further eval.
In the ED, initial vitals: T 97.0, HR 72, BP 135/91, RR 16, 100%
RA
Labs were significant for
- normal CBC
- normal lytes
- LFTs with ALT 78, AST 57, otherwise normal
Imaging with CXR with no acute intrathoracic process
She was seen by neurosurgery, who recommended IV dexamethasone.
In the ED, pt received:
___ 23:51 IV Dexamethasone 10 mg
___ 06:06 IV Dexamethasone 4 mg
___ 13:00 IV Dexamethasone 4 mg
Vitals prior to transfer: T 98.5, HR 90, BP 127, RR 17, 98% RA
Currently, patient states that her headache has improved, with
no vertigo. She is scared about what will be found and what the
next steps are. She states that her husband died ___ years
ago, and she has three children. She knows that they are very
worried as well.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
- Metastatic Breast cancer (CMS/HCC) s/p lumpectomy and
chemotherapy
- Cataracts
Social History:
___
Family History:
- Father - hypertension
- Mother - hypertension
Physical ___:
==========================
ADMISSION PHYSICAL EXAM
==========================
VS: T 98.6, HR 101, BP 123/75, RR 18, 99%RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
normal finger-nose-finger, normal heel to shin
==========================
DISCHARGE PHYSICAL EXAM
==========================
VS: ___ 0818 Temp: 98.5 PO BP: 121/81 HR: 67 RR: 16 O2 sat:
98% O2 delivery: RA FSBG: 160
GEN: Sitting up in bed, well-appearing
HEENT: surgical incision with staples in place back of head, no
erythema or drainage
PULM: CTAB
COR: RRR (+)S1/S2 no m/r/g
ABD: Normal bowel sounds. Soft, nontender, nondistended
EXTREM: Warm, well-perfused, no edema
NEURO: alert and oriented x3, CN ___ grossly intact, ___
strength in upper and lower extremities, gait not assessed.
Pertinent Results:
================================
LABS ON ADMISSION
================================
___ 10:30PM BLOOD WBC-4.6 RBC-3.78* Hgb-12.3 Hct-36.7
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.3 RDWSD-47.5* Plt ___
___ 10:30PM BLOOD Neuts-45.1 ___ Monos-8.6 Eos-1.9
Baso-0.6 Im ___ AbsNeut-2.08 AbsLymp-2.00 AbsMono-0.40
AbsEos-0.09 AbsBaso-0.03
___ 10:30PM BLOOD ___ PTT-29.5 ___
___ 10:30PM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-143
K-4.0 Cl-106 HCO3-25 AnGap-12
___ 10:30PM BLOOD ALT-79* AST-57* AlkPhos-99 TotBili-0.5
___ 10:30PM BLOOD Albumin-4.1 Calcium-9.8 Phos-3.5 Mg-1.8
================================
PERTINENT INTERVAL LABS
================================
___ 05:35AM BLOOD ALT-59* AST-23 AlkPhos-94 TotBili-0.4
___ 05:58AM BLOOD %HbA1c-6.8* eAG-148*
___ 09:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:45PM BLOOD HIV Ab-NEG
___ 09:45PM BLOOD HCV Ab-NEG
================================
LABS ON DISCHARGE
================================
___ 05:15AM BLOOD WBC-6.2 RBC-3.59* Hgb-11.7 Hct-34.7
MCV-97 MCH-32.6* MCHC-33.7 RDW-13.0 RDWSD-46.5* Plt ___
___ 05:15AM BLOOD Glucose-152* UreaN-18 Creat-0.8 Na-141
K-4.5 Cl-101 HCO3-30 AnGap-10
___ 05:15AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.1
================================
MICROBIOLOGY
================================
- ___ urine culture - negative
- ___ CSF culture - pending at discharge
================================
IMAGING
================================
## ___ CXR (Pa and Lat) - No acute intrathoracic process.
## ___ CT chest w/ contrast
- No definitive evidence of intrathoracic metastatic disease.
- Postradiation changes in the right upper lobe dot.
- Several pulmonary nodules as described, that alternatively
might represent small areas of atelectasis in can be reassessed
on the subsequent study. They do not have typical metastatic
features.
- Status post right breast surgery and right axillary surgery.
## ___ CT a/p w/ contrast
1. No findings of metastatic disease in the abdomen or the
pelvis.
2. Hepatic steatosis. Fibroid uterus.
3. Please refer to the chest CT report from the same day for
details on intrathoracic findings.
## ___ MRI head w/ and w/o contrast
1. 31 mm right cerebellar hemisphere enhancing mass with
surrounding edema and leptomeningeal spread of tumor.
2. Mild deformity of the inferior fourth ventricle without
hydrocephalus.
## ___ Chest xray Pa and Lat - No acute cardiopulmonary
abnormality.
## ___ CT head w/o contrast:
1. Status post right suboccipital craniotomy and resection of
right cerebellar mass, with postoperative changes including
right cerebellar edema and pneumocephalus at the surgical bed.
Given the wedge-shaped appearance of the right cerebellar
hypodensity, a superior cerebellar arterial infarct should also
be considered and close attention on follow-up imaging is
recommended.
2. No evidence of intraparenchymal hemorrhage.
3. Persistent mild-to-moderate mass effect on the fourth
ventricle is similar to most recent ___ head MR,
without evidence of obstructive hydrocephalus.
## ___ MR head w/ and w/o contrast:
1. Status post right suboccipital craniotomy for right
cerebellar tumor resection with residual enhancement along the
lateral greater than medial aspect of the resection bed is
compatible with residual leptomeningeal disease.
Brief Hospital Course:
Ms. ___ is a ___ female with history of
metastatic breast cancer status post lumpectomy and chemotherapy
with negative PET scan 3 months ago who presented as a referral
for 4 cm cerebellar mass.
=================================
ACUTE MEDICAL ISSUES ADDRESSED
=================================
# Cerebellar mass: Patient initially presented as transfer from
___ after being found to have a cerebellar mass
on MRI. She was evaluated by neurosurgery, and started on
dexamethasone. Her symptoms of vertigo improved. A CT torso with
contrast did not show any other evidence of metastatic disease.
Multiple discussions were held regarding best plan of care given
that patient was visiting in the ___ and does not have
insurance, and is not a resident. Ultimately, it was decided
that given no safe discharge plan, patient should undergo
debulking surgery in house. She went to the OR on ___ and
underwent a suboccipital craniotomy for tumor resection without
complications. She recovered well post-surgically. She underwent
an LP on ___ to evaluate for spread into the CSF for staging.
She was seen by physical therapy, and cleared for discharge home
on dexamethasone 2mg daily with plan for follow up in Brain
Tumor Clinic on ___.
# Thrombocytopenia: Platelets 168 on admission, decreased to
110s following surgery and remained stable. 4T score calculated
to be 3, low risk of HITT. Discharge platelets 117.
# Hyperglycemia
Patient noted to be hyperglycemic in the setting of
dexamethasone. Was placed on an insulin sliding scale. On two
days prior to discharge, max FBSG 256. Given that patient being
discharged home on smaller dose of dexamethasone (2mg daily)
felt that patient will not need further treatment of her
hyperglycemia as an outpatient.
=================================
TRANSITIONAL ISSUES
=================================
[] Patient will have follow up in the Brain Tumor Clinic on ___ at 12:00 with Dr. ___. Final pathology results and CSF
results will be followed up at this time.
[] Discharged on dexamethasone 2mg daily, to be continued until
at least appointment with Brain Tumor Clinic.
[] Patient's staples to be removed at Brain Tumor Clinic
appointment.
[] Could consider repeat CBC at next appointment to monitor
thrombocytopenia
[] Discharged on pantoprazole while on dexamethasone - can be
stopped once completes course of dexamethasone.
[] A1c 6.8% - should consider further follow up and evaluation
in outpatient setting
[] Patient noted to have several pulmonary nodules on CT chest,
"Nodular potentially atelectasis in the left upper lobe is 7 mm,
series 302, image 56. Right middle lobe nodule, 5 mm, series
302, image 136 also represent minimal atelectasis or
postradiation changes." No clear guidelines on need for follow
up of these findings, but would consider repeat CT chest in ___
months to assess for change.
# Code: Full
# Contact: Name of health care proxy: ___
___: Daughter
Phone number: ___
___ on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 2 mg PO Q12H
This is the maintenance dose to follow the last tapered dose
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- cerebellar mass
Secondary Diagnosis
- history of breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
after you were found to have a brain tumor. You underwent a
surgery to have this removed. You also had a lumbar puncture
(spinal tap) to look for possible spread of the cancer. We do
not have the results from this yet. You will have a follow up
appointment next ___ at 12:00 (noon) where we will
discuss these results with you and make plans for the next
steps.
For your incision, you do not need to clean this area. Please
try to keep it dry. If it does get wet, please pat it dry with a
soft towel. You will have your staples removed at your Brain
Tumor Clinic appointment.
You are also being discharged on dexamethasone (decadron) to
help reduce any swelling. You should take half a pill (2mg)
every morning at least until your appointment next week. You
should also take pantoprazole every day to help protect your
stomach.
You had some high blood sugars when you were in the hospital and
were getting insulin to help lower these levels. These were
probably related to the dexamethasone. However, your sugars were
not at a dangerously high level and you will be on a smaller
dose of dexamethasone at home, so you will not need to check
your blood sugar at home or take a medication for your sugars.
It was very nice to meet you and your family, and we wish you
the best.
Sincerely,
Your ___ Care Team
============================
SURGICAL INSTRUCTIONS
============================
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You 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 may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is 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.
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:
___
|
19620892-DS-12
| 19,620,892 | 20,891,796 |
DS
| 12 |
2126-05-31 00:00:00
|
2126-05-30 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Metastatic Breast Cancer (c/b brain mets, s/p
resection of cerebellar mass, c/b leptomeningeal disease, s/p
radiation, awaiting establishment of care with medical
oncology),
who presents for left back and leg pain.
As per review of notes, patient recently admitted for resection
of her cerebellar mass (pathology c/w breast origin), and LP
which revealed leptomeningeal disease. She was seen in radiation
___ clinic afterward where she is undergoing whole brain
radiation and was noted to have left shoulder pain. CT chest
from
___ was reviewed and patient was not known to have any lytic
lesions. MRI was suggested given known leptomeningeal disease
but
patient's insurance did not cover outpatient scans so was not
possible. Of note, patient is also awaiting her initial oncology
appointment.
On this admission, patient presents with left sided back pain
and
leg pain. While patient is listed as ___ speaking she
actually speaks fluent ___ which the interview was conducted
in.
She reports that 10 days ago she developed left back pain that
is
4 inches lateral to spine on left at level of scapula which is
non radiating occurs relatively persistently throughout the day,
up to ___ at its worst, slowly worsening day by day, not
related
to movement, goes down to ___ with ibuprofen, massage, and
lidocaine patch. Denied sensation/strength changes in her b/l
upper extremities.
Left leg pain started ___ days ago, is worse with sitting during
long periods, unchanged by movement, shooting from her left
buttock down to her calf. Noted that it occurs independent of
left back pain. Denied any leg weakness, bowel/bladder
incontinence, saddle anesthesia, changes in sensation of lower
legs.
Denied fever, chills, nausea, vomiting, headache. Reported that
she is planning to see Dr ___ in clinic in early ___ then
go back to ___ for good.
In the ED, initial vitals: 99.1 80 144/87 18 100% RA. Labs
significant for plt of 141, normal WBC/Hgb, normal CHEM, UA
negative. Left duplex with no evidence of deep venous thrombosis
in the left lower extremity veins. EKG sinus with TWI in AVR/V1,
unchanged from prior. Patient was given Tylenol, lidocaine
patch,
ketorolac, dexamethasone, gabapentin.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- Metastatic Breast cancer (CMS/HCC) s/p lumpectomy and
chemotherapy with metastatic spread to brain and leptomeningeal
disease s/p WBRT
- Cataracts
Social History:
___
Family History:
- Father - hypertension
- Mother - hypertension
Physical ___:
ADMISSION:
==========
Vitals: ___ Temp: 98.0 PO BP: 117/79 HR: 63 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: laying in bed, calm, NAD, pleasant, appears comfortable
EYES: PERRLA, anicteric
HEENT: OP clear, MMM
NECK: supple
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR
CV: RRR no m/r/g, normal distal perfusion
ABD: soft, NT, ND, normoactive BS
GENITOURINARY: no foley
EXT: points to area overlying scapula on left as area which is
painful, but is non tender to palpation, no visual or palpable
abnormalities, no spinal processes tenderness, no pain with ROM
or strength testing of left arm. b/l upper extremity strength is
___. Lower extremity strength ___. Patient has positive straight
leg test on right at 45 degrees. Normal ROM of left hip. No
visual or palpable abnormalities of left leg. Sensation to touch
intact throughout arms and legs
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech, strength documented above
DISCHARGE:
==========
Patient examined on day of discharge. AVSS. She ambulated
without difficult obn day of discharge, with no assistive
decide. ___- and plantar flexion are ___ in RLE. She had
tenderness in the right cervical paraspinal muscles, but no
tenderness over the spine.
Pertinent Results:
LABORATORY RESULTS:
___ 08:00AM BLOOD WBC-4.6 RBC-3.58* Hgb-11.5 Hct-34.3
MCV-96 MCH-32.1* MCHC-33.5 RDW-14.3 RDWSD-49.4* Plt ___
___ 08:00AM BLOOD ___ PTT-27.4 ___
___ 07:30PM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-24 AnGap-13
___ 08:00AM BLOOD Calcium-10.1 Phos-4.0 Mg-1.8
MRI:
1. Study is mildly degraded by motion.
2. No definite evidence of paraspinal or paravertebral mass.
3. No definite evidence of spinal cord lesion or enhancement.
4. Multilevel cervical, thoracic and lumbar spine degenerative
changes as
described, most pronounced at L5-S1 where there is disc bulge
with annular
fissure contacting bilateral transiting S1 nerve roots with
mild-to-moderate
vertebral canal and moderate bilateral neural foraminal
narrowing.
5. C5-6 and C6-7 moderate right neural foraminal narrowing.
6. Otherwise, no definite evidence of moderate or severe
vertebral canal or
neural foraminal narrowing.
7. Limited imaging of the suboccipital soft tissues demonstrate
postoperative
changes related to patient's known posterior fossa mass
resection, with
suggested 3.4 x 1.1 x4.2 cm nonspecific fluid collection
adjacent to surgical
site. While finding may represent evolving postoperative
change, CSF cyst
formation is not excluded on the basis of this examination.
Brief Hospital Course:
___ w/ Hx of triple negative breast CA s/p lumpectomy and
chemo/XRT, recent admission for cerebellar mass s/p suboccipital
craniotomy, found to be metastatic triple negative breast CA
with leptomeningeal disease, s/p whole brain radiation admitted
with back pain. MRI C/T/L spine negative for new metastases;
her pain is most likely consistent with an L5-S1 disc
herniation, seen on MRI. Oncology evaluated her for assistance
with initial treatment planning and recommended Capecitebine,
which she will start when she returns to ___. When she was
feeling better, she was discharged home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth Three times daily
as needed Disp #*42 Tablet Refills:*0
3. Diazepam 5 mg PO TID back spasm
RX *diazepam 5 mg 1 tab by mouth Three times daily as needed
Disp #*21 Tablet Refills:*0
4. Diclofenac Sodium ___ 50 mg PO BID
RX *diclofenac sodium 25 mg 1 tablet(s) by mouth Twice daily as
needed Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Sciatica, musculoskeletal back pain
SECONDARY: metastatic breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___. You were admitted
with back pain. We did an MRI of your spine to determine
whether your pain was due to your cancer, and it does not appear
to be. It appears to be most consistent with a herniated disc
at the L5-S1 level. We gave you medications to treat your
symptoms, and your symptoms improved. Our oncologists also
evaluated you to determine the treatment plan for your breast
cancer when you go back to ___. When you were feeling better,
you were discharged home. Their recommendations are:
In assessment, Ms ___ is a ___ woman who
now presents with a metastatic recurrence of triple negative
breast cancer. She is now status post resection of a right
cerebellar lesion. She has radiographic evidence of
leptomeningeal spread of her tumor as well as positive CSF
cytology.
Based on the findings of leptomeningeal disease, we do recommend
that she initiate systemic chemotherapy. Leptomeningeal disease
is rare, but case report suggests capecitabine monotherapy may
have some efficacy. ___ et al. "Durable response of breast
cancer leptomeningeal metastasis to capecitabine monotherapy."
Neuro Oncol ___
She sure that she strongly prefers to begin her treatment and
___. Her daughter shared that they are unable to
purchase chemotherapy in ___, and they must travel to ___ to
do this. Given this requirement, they request that a dosing
schedule of capecitabine be provided.
We recommend the following:
CAPECITABINE 1,800 mg twice daily on days 1 to 14 of a 21-day
treatment cycle for at least 2 and up to 6 cycles or longer.
Capecitabine dosing is based on a dose of 1000 mg/m2. Her BSA is
approximately 1.8 m2.
She will need to have periodic imaging at the discretion of her
oncologist to assess her response to treatment.
If she developed bony metastases, we recommend that she be
initiated on bisphosphonate therapy with zoledronic acid 4mg
monthly.
We anticipate that she will need supportive antiemetics
including:
Ondansetron 8mg every 8 hours as needed
Prochlorperazine 10mg every 6 hours as needed.
We discussed that she should not initiate chemotherapy treatment
until she is reestablished under the care of an oncologist in
___. We emphasized that she must have frequent oncology
visits
to monitor her blood counts and potential toxicities from
capecitabine. The family was provided with written information
reviewing the common side effects of capecitabine.
-------
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19621207-DS-18
| 19,621,207 | 29,141,635 |
DS
| 18 |
2183-06-29 00:00:00
|
2183-06-30 20:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F h/o HTN, hypothyroidism, MR, AI p/w fever, confusion,
generalized weakness found to be flu positive. She lives at
home independently, caretaker found her this morning sitting on
the floor in a pool of urine (no baseline incontinence),
confused, low suspicion for fall. She usually ambulates with a
cane but was unable to stand up on her own today, no focal
weakness. Per niece, patient reported chills but otherwise was
asymptomatic. Patient currently alert to self, "hospital," and
___ but not to time (not baseline per niece). She endorses
fatigue and weakness but denies fever/chills, headache, chest
pain, shortness of breath, cough, abd pain, dysuria, nausea,
diarrhea. Her niece and main caretaker have recently been ill
with influenza-like illness.
In the ED initial vitals were: 100.7 84 200/90 18 95%
- Labs were significant for positive flu swab, normal WBC,
Chem-7, UA, lactate.
- Head CT showed no acute process.
- CXR showed sm b/l effusions, dense retrocardiac opacity on
frontal view (not seen on lateral), atelectasis vs. infection
- Patient was given home lisinopril 12.5, tamiflu 75, iv
labetalol 10mg x 3, APAP 650mg pr.
- Her BP was then rechecked manually in the 150s
- Oriented only to hospital, not month and year (per niece
baseline is AOx3 with mild dementia)
Vitals prior to transfer were: 100.0 90 159/46 15 100% RA
On the floor, she denies any pain, sob, or other symptoms
Past Medical History:
AORTIC INSUFFICIENCY +2 tte ___
DEPRESSION ___ mania in youth.
HYPERTENSION
HYPOTHYROIDISM
PELVIC FRACTURE
BACK PAIN
chronic thoracic spine fxs, aortic insufficiency,
cervical arthritis
dyspnea
renal cyst
leg pain
Social History:
___
Family History:
She has no children. Her siblings have cardiac
disease and her parents both had cardiovascular disease. No
first-degree relatives with pulmonary disease.
Physical Exam:
Vitals - T:100.1 BP:132/40 (with pediatric cuff) HR:85 RR:16 02
sat:96% RA
GENERAL: NAD, cachetic, alert, oriented to ___ and
___, didn't know month, year, or why she was in the hospital
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 2+ pitting edema to midshins bilaterally, moving
all 4 extremities with purpose
NEURO: CN II-XII intact, strength ___ in all extremities both
proximally and distally
SKIN: warm and well perfused, bruising to shins, no rashes
Discharge:
Vitals - overnight BP 190/60, previously 160/68-190/60 last 24h
(these BP's are suspect as no pediatric cuff was available so
they were taken with an ill fitting cuff) Tm 98.0, HR 70's, RR
18, 95%RA. Orthostatics negative.
GENERAL: NAD, cachetic, more alert, oriented to person, ___
___, not date
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 2+ pitting edema to midshins bilaterally, moving
all 4 extremities with purpose
NEURO: CN II-XII intact, strength ___ in all extremities both
proximally and distally
SKIN: warm and well perfused, bruising to shins, no rashes
Pertinent Results:
___ 04:00PM BLOOD WBC-6.4 RBC-3.65* Hgb-11.6* Hct-32.4*
MCV-89 MCH-31.9 MCHC-35.9* RDW-16.1* Plt ___
___ 05:54PM BLOOD ___ PTT-24.3* ___
___ 04:00PM BLOOD Glucose-110* UreaN-20 Creat-0.7 Na-135
K-4.0 Cl-99 HCO3-26 AnGap-14
___ 05:30PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
On discharge:
___ 07:17AM BLOOD WBC-4.2 RBC-3.14* Hgb-10.0* Hct-28.0*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.8* Plt ___
CXR
The lungs are well expanded. Blunting of the posterior
costophrenic angles
suggests small bilateral pleural effusions are identified. On
the frontal view there is more dense opacity at the left lung
base without correlative finding on the lateral view suggesting
at least some component of atelectasis. Superiorly, the lungs
are clear. The cardiac silhouette there is mildly enlarged.
Atherosclerotic calcifications noted within the aorta.
Degenerative changes seen at the shoulders bilaterally. No
displaced fractures there noted. Compression deformities in the
mid thoracic spine are unchanged.
IMPRESSION:
Small bilateral effusions. More dense retrocardiac opacity on
the frontal view suggests component of atelectasis as it is not
clearly delineated on the lateral view although component of
infection is possible.
Head CT
No acute intracranial abnormality.
Brief Hospital Course:
___ F h/o HTN, hypothyroidism, MR, AI p/w fever, confusion,
generalized weakness, influenza a positive on tamiflu
#Hypertension: Pressures as high as SBP 220's measured
automatically in arm with small adult cuff this admission,
however manual pressures with pedi cuff in 130's. Unable to
obtain pedi cuff on floor, so taking pressures in thigh with
small adult cuff, genearlly SBP<160 but with some persistently
elevated BP. Patient is asymptomatic with higher blood pressure
readings. Lisinopril was increased from 12.5mg to 25mg, she was
not orthostatic. SBP on discharge taken manually was
120's-130's. Continued metoprolol.
#Influenza: Positive flu swab in the ED, + sick contacts. No
prominent respiratory symptoms or metabolic abnormalities, but
off her baseline mental status and weak. Was treated with 5 days
of tamiflu (q48h dosing).
#Encephalopathy: Currently AAOx2, off her baseline of some
memory problems but completely oriented per niece. Head CT
negative, no focal neuro deficits, no metabolic abnormalities.
Likely due to influenza infection. Improving, but ___
recommended 24 hour care at home for safety due to her impaired
cognition. Discussed risks/benefits of home vs. rehab with
niece/HCP ___ and she would like to take the patient home.
She will have 24h care at least for the time being, if this
turns out to be necessary long term she will arrange other
living arrangements.
#Malnutrition: Nutrition consulted, recommended supplements with
meals and ideally 1:1 assist to help her eat.
#Hypothyroidism: continued levothyroxine
# Code: DNR/DNI (confirmed w/ HCP)
# Communication: Patient
# Emergency Contact: ___ (niece, HCP) ___, she
confirmed that patient is DNR/DNI
Transitional:
-will get home ___ for cardiovascular and respiratory monitoring
-if still requiring 24 hour care after a few weeks family will
likely consider other living arrangements
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 12.5 mg PO DAILY
5. Ibuprofen 400 mg PO DAILY:PRN headache
6. Multivitamins 1 TAB PO DAILY
7. Fish Oil (Omega 3) Dose is Unknown PO DAILY
8. Ascorbic Acid Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Lisinopril 25 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Influenza
Delerium
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:
You were admitted to the hospital because you had the flu. This
made you weak and confused. We treated you for the flu and your
respiratory symptoms and fever resolved. You are still a little
bit confused, but this should improve gradually at home. You
were seen by physical therapy and occupational therapy and
although you are strong enough to climb stairs now with
assistance, because of your confusion you will need 24 hour
supervision at home for the time being.
Followup Instructions:
___
|
19621207-DS-19
| 19,621,207 | 25,133,541 |
DS
| 19 |
2185-03-14 00:00:00
|
2185-03-15 11:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of valvular disease (MR, AI), HTN, HFpEF (EF >75% in
___ who presents with several day history of abdominal pain.
Per her caretaker (___), patient has reported abdominal
pain over the past 2 days with resultant poor PO intake. Her
caretaker also reports elevated blood pressures at home with
SBPs to 200s over the same time period. She reports compliance
with medication administration and had increased her lisinopril
on morning of admission due to her increased SBPs.
Of note, her PCP recently ___ amlodipine in ___ and
reduced her lisinopril to 5 mg qd due to low SBP. Per OMR
medications, it appear her amlodipine was recently re-renewed.
In the ED, initial VS were 98 72 205/66 18 99% RA.
Exam notable for AOx 2, diminished breath sounds w/ crackles in
elft base, diastolic murmur, no abdominal tenderness.
Labs showed
- 5.3 > 11.2/32.4 < 173
- 138| 105 | 18
---------------< 101
4.3 | 23 | 0.6
- Troponin < 0.01 -> < 0.01 (@1900)
- Lactate 1.0
- UA with mod leuk, 20 WBC, (-) nit, (-) bacteria
- proBNP 2699
Imaging showed
- CXR: Grossly stable small to moderate left pleural effusion
with overlying atelectasis, underlying consolidation is not
excluded in the appropriate clinical setting.
- CT Head: No acute intracranial abnormality. Involutional
changes and minimal likely chronic microvascular ischemic
change.
- CT A/P
1. Examination of the lower abdomen and pelvis is limited by
patient's body habitus. Within these limitations, there is no
evidence of diverticulitis, bowel obstruction or perforation.
2. There is trace free fluid in the pelvis of unclear etiology.
3. The uterus contains a non-specific 0.6 cm hypodensity which
could represent a small fibroid. If clinically appropriate, this
could be re-assessed with pelvic ultrasound on a non-emergent
basis.
4. No definite CT findings to explain patient's symptoms.
Received amlodipine 5 mg, levofloxacin 500 mg, captopril 25 mg
Transfer VS were 98.7 81 138/63 19 96% RA
Decision was made to admit to medicine for further management.
On the floor, patient reports dull lower abdominal pain over
the past few days. She is still able to tolerate PO, no n/v/d,
fever/chills, dysuria, increased urinary frequency,
hematocheiza, melena, HA, CP, SOB. She does report constipation
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
AORTIC INSUFFICIENCY +2 tte ___
DEPRESSION ___ mania in youth.
HYPERTENSION
HYPOTHYROIDISM
PELVIC FRACTURE
BACK PAIN
chronic thoracic spine fxs, aortic insufficiency,
cervical arthritis
dyspnea
renal cyst
leg pain
Social History:
___
Family History:
She has no children. Her siblings have cardiac
disease and her parents both had cardiovascular disease. No
first-degree relatives with pulmonary disease.
Physical Exam:
ON ADMISSION PHYSICAL EXAM
=========================
VS 98.1 152/83 84 16 98% on RA
GENERAL: NAD, AO x 2
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
CARDIAC: RRR, ___ diastolic murmur loudest at ___ with
palpable heave, ___ systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness to palpation in
LLQ, suprapubic. No rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE PHYSICAL EXAM
=========================
VS 99.5 92-161/30-62 ___
GENERAL: Pleasant in NAD, AO x 2
HEENT: EOMI, PERRL, anicteric sclera
CARDIAC: RRR, ___ diastolic murmur loudest at ___, ___
systolic murmur
LUNG: Decreased breath sounds at left base. Otherwise CTA
ABDOMEN: +BS. Soft, nontender, nondistended. No
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, dry skin over anterior tibial
surface b/l
Pertinent Results:
ON ADMISSION/PERTINENT LABS
============================
___ 12:30PM BLOOD WBC-5.3 RBC-3.56* Hgb-11.2 Hct-32.4*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.5 RDWSD-48.9* Plt ___
___ 12:30PM BLOOD Neuts-71.9* Lymphs-14.0* Monos-9.5
Eos-3.2 Baso-0.6 Im ___ AbsNeut-3.81 AbsLymp-0.74*
AbsMono-0.50 AbsEos-0.17 AbsBaso-0.03
___ 12:30PM BLOOD Glucose-101* UreaN-18 Creat-0.6 Na-138
K-4.3 Cl-105 HCO3-23 AnGap-14
___ 12:30PM BLOOD proBNP-269___*
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 07:10AM BLOOD VitB12-404 Folate-15.9
DISCHARGE LABS
====================
___ 05:39AM BLOOD WBC-3.3* RBC-3.36* Hgb-10.4* Hct-30.4*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.0 RDWSD-49.0* Plt ___
___ 05:39AM BLOOD Glucose-100 UreaN-19 Creat-0.6 Na-138
K-3.2* Cl-105 HCO3-24 AnGap-12
___ 05:39AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
MICRO
==========
___ 2:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
___ 12:30 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE.
Blood Culture, Routine (Preliminary):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
Reported to and read back by ___ (___)
___ ___.
IMAGING
=============
IMAGING:
- CXR (___): Grossly stable small to moderate left pleural
effusion with overlying atelectasis, underlying consolidation is
not excluded in the appropriate clinical setting.
- CT Head (___): No acute intracranial abnormality.
Involutional changes and minimal likely chronic microvascular
ischemic change.
- CT A/P (___)
1. Examination of the lower abdomen and pelvis is limited by
patient's body habitus. Within these limitations, there is no
evidence of diverticulitis, bowel obstruction or perforation.
2. There is trace free fluid in the pelvis of unclear etiology.
3. The uterus contains a non-specific 0.6 cm hypodensity which
could represent a small fibroid. If clinically appropriate, this
could be re-assessed with pelvic ultrasound on a non-emergent
basis.
4. No definite CT findings to explain patient's symptoms.
Brief Hospital Course:
___ yo F w/ PMH of valvular disease (MR, AI), HTN, HFpEF (EF >75%
in ___, hypothyroidism, depression who presented with several
day history of abdominal pain, found to have urinary tract
infection and elevated SBP in 200's. UA was suspicious of UTI
and she was started on ceftriaxone. Urine culture was positive
for enterococcus, so she was transitioned to ampicillin. Her
blood pressure medication was adjusted to amlodipine 5mg and
2.5mg lisinopril BID. Of note, her blood culture was positive
for gram positive rods. Although patient has been afebrile, she
does not look toxic. We asked our ID team, and we suspect that
the gram positive rod is a contamination. She had repeat blood
culture pending on discharge.
# ABDOMINAL PAIN
CT abdomen without acute process. Pt did not complain of
abdominal pain, and no tenderness on exam on admission. ___ be
secondary to UTI as below or depression given vague nonspecific
complaint or constipation. Patient was monitored and did not
complain of any abdominal pain throughout hospitalization
# UTI:
Patient asymptomatic, however may be possibly be altered and
contributed to patient's original abdominal pain. Received
levofloxacin (___), ceftriaxone (___). Ucx positive for
enterococcus and she was transitioned to ampicillin (___) and
will complete a ___s outpatient
#Labile BPs: SBPs 200s on admission with caretaker stating that
her BP is sometimes in the 200s. Reviewing old notes, it appears
that she has very labile BPs with at times hypotension possibly
in the setting of poor PO intake. Most recently, her PCP has
been adjusting her BP regimen. Pt has isolated systolic HTN,
typically seen in the elderly. She was also severely
orthostatic, likely in the setting of poor PO intake. She was
continued on amlodipine 5mg, and lisinopril was changed to 2.5mg
BID due to high BPs in the evenings. Given that caretaker checks
BP at home, can have more tailored therapy for
anti-hypertensives that is outlined below in transitional
issues.
#Positive Blood Cx
Patient with 1 bottle that grew gram positive rods. However,
patient has been afebrile and does not appear toxic. Suspected
that positive blood culture is a contaminant. She had repeat
blood blood cultures drawn on discharge which will be followed
up.
#Dementia:
___ was consulted to assist with ambulation. Speech and swallow
evaluated patient, found no evidence on aspiration on bedside
evaluation.
#Nutrition:
Patient with poor PO intake, may be related to UTI. B12/folate
wnl. Nutrition consulted recommended supplemental ensure to
assist with nutrition
# Valvular Disease/HFpEF:
Known severe AR, moderate MR seen on TTE in ___ that was
monitored and stable. She was continued on fractionated
metoprolol tartrate
# Hypothyroidism
TSH of 2.6 on ___. She was continued on home levothyroxine
***TRANSITIONAL ISSUES:***
- Patient should complete treatment of urinary tract infection
with ampicillin for a total duration of 5 days (day ___,
last ___.
- Patient has extremely LABILE blood pressure, she has systolic
hypertension with SBP up to 200's and down to the 90's. We made
the following changes in her medications, please monitor blood
pressure and adjust as needed:
IN THE MORNING:
-----If the systolic blood pressure is >150, take lisinopril 5
mg PLUS amlodipine 5 mg.
-----If the systolic blood pressure is between 120 and 150, take
lisinopril 5 mg only and hold the amlodipine.
-----If the systolic blood pressure is <120, hold both
lisinopril and amlodipine.
IN THE EVENING:
-----If the systolic blood pressure is >150, take lisinopril 2.5
mg in the afternoon.
-----If the systolic blood pressure is <150, DO NOT take
lisinopril 2.5 mg in the afternoon.
- F/U pending blood cultures.
CODE: DNR/DNI (confirmed with HCP)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
___: niece
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Ibuprofen 400 mg PO DAILY:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*14 Capsule Refills:*0
2. Lisinopril 2.5 mg PO QPM
If BP>150 in afternoon, give 2.5mg lisinopril
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Ibuprofen 400 mg PO DAILY:PRN Pain - Mild
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Urinary tract infection
Labile Blood Pressure
SECONDARY DIAGNOSES:
Aortic Insufficiency
Mitral Regurgitation
Heart failure with preserved ejection fraction
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you.
Why you were admitted?
- You were admitted because you had abdominal pain and labile
blood pressures.
What we did for you?
- You were found to have a urinary tract infection, for which
you were treated with antibiotics.
- We adjusted your blood pressure medications to stabilize your
blood pressure, the goal is to keep your systolic blood pressure
between 120 and 180.
What you should do when you go home
1) Continue taking ampicillin for the treatment of urinary tract
infection for a total duration of 5 days (day ___, last
___.
2) Check your blood pressure every morning, and take your blood
pressure medications as follows:
-----If the systolic blood pressure is >150, take lisinopril 2.5
mg PLUS amlodipine 5 mg.
-----If the systolic blood pressure is between 120 and 150, take
lisinopril 2.5 mg only and hold the amlodipine.
-----If the systolic blood pressure is <120, hold both
lisinopril and amlodipine.
3) Check your blood pressure in the afternoon:
-----If the systolic blood pressure is >150, take lisinopril 2.5
mg in the afternoon.
-----If the systolic blood pressure is <150, DO NOT take
lisinopril 2.5 mg in the afternoon.
Please follow up with your primary care doctor within one week.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19621207-DS-20
| 19,621,207 | 21,283,419 |
DS
| 20 |
2185-03-25 00:00:00
|
2185-03-25 20:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PER ADMITTING NOTE: This is a ___ year-old with the history below
who presented to ED with weakness and fatigue. Patient unable to
give a history due altered mental status. Very limited
information below was gathered from chart and with help of HCP.
She has been progressively weaker and altered for last couple of
weeks. She has been admitted recently at the ___ in the
begging of ___ for abdominal pain and poor PO intake but the
work up including CT A/P, abdominal US was negative. She lives
alone at her own with help of person who spends with her 8 hours
a day. Her food intake has diminished significantly and she was
visibly loosing
weight. Last week has black diarrhea with last episode on
___. No history of hematochezia or hematemesis. She
presented to ER hemodynamically stable. Per report had being
exam with normal stool in the rectum. Her Hb came back at 5.1
from 10 week ago. Put 314, no coags. BMP showed elevated BUN but
otherwise unremarkable. Orthostatic vital signs were negative.
Laying 78, 137/45, sitting 76, 128/42, standing 74, 145/74. She
received 1 unit of pRBCs and no acid suppression therapy. I have
discussed at length if she is suitable candidate for admission
to the floor but in the view of hemodynamic stability, negative
orthostatic vital signs and no evidence of active bleeding we
made a decision to admit to the floor. Per ED report GI was
notified but they did not leave specific recommendations.
I have discussed over the phone situation with HCP and she
stated that Mrs ___ is DNR/DNI and would not wish any
invasive procedures. In fact she says that she would not want to
be admitted to hospital. The plan after last hospitalization was
not to readmit. HCP was supposed to meet with PCP ___ ___ to
discuss palliation.
Past Medical History:
AORTIC INSUFFICIENCY +2 tte ___
DEPRESSION ___ mania in youth.
HYPERTENSION
HYPOTHYROIDISM
PELVIC FRACTURE
BACK PAIN
chronic thoracic spine fxs, aortic insufficiency,
cervical arthritis
dyspnea
renal cyst
leg pain
Social History:
___
Family History:
She has no children. Her siblings have cardiac
disease and her parents both had cardiovascular disease. No
first-degree relatives with pulmonary disease.
Physical Exam:
ADMISSION EXAM:
VS: Afebrile and vital signs stable. Temp 98.1 BP 147 / 46, HR
84, RR 18, O2 sat 96 RA
General Appearance: pleasant, comfortable, no acute distress
Eyes: no conjuctival injection, anicteric
ENT: no supraclavicular or cervical lymphadenopathy, no JVD, no
carotid bruits
Respiratory: CTA b/l with poor air movement throughout
Cardiovascular: RRR, S1 and S2 wnl, ___ systolic murmur LLSB,
___ diastolic murmur RUSB, no rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Awake, alert, oriented to self only
GU: no catheter in place
Rectal: deferred
DISCHARGE EXAM:
97.4 Axillary 143 / 69 Sitting 69 18 100 ra
delightful, comfortable
anicteric, MMM without blood
RRR, II/VI HSM at ___, JVP <8cm
sntnd, NABS
wwp, neg edema
A&Ox2, when asked about date says "I didn't have an appointment
today, so I didn't worry about it", oriented to president, ___
BUE/BLE, SILT BUE/BLE, able to recount days of week backwards
Pertinent Results:
ADMISSION LABS:
___ 01:25PM WBC-7.1 RBC-1.64* HGB-5.1* HCT-16.0* MCV-98
MCH-31.1 MCHC-31.9* RDW-16.1* RDWSD-51.8*
___ 09:50PM HCT-20.9*#
___ 01:25PM NEUTS-73* BANDS-1 LYMPHS-18* MONOS-5 EOS-3
BASOS-0 ___ MYELOS-0 NUC RBCS-1* AbsNeut-5.25
AbsLymp-1.28 AbsMono-0.36 AbsEos-0.21 AbsBaso-0.00*
___ 12:45PM GLUCOSE-113* UREA N-29* CREAT-0.5 SODIUM-142
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
___ 12:45PM WBC-7.5 RBC-1.75*# HGB-5.4*# HCT-17*# MCV-97
MCH-30.9 MCHC-31.8* RDW-16.4* RDWSD-52.0*
___ 12:45PM NEUTS-74* BANDS-0 LYMPHS-14* MONOS-10 EOS-2
BASOS-0 ___ MYELOS-0 AbsNeut-5.55 AbsLymp-1.05*
AbsMono-0.75 AbsEos-0.15 AbsBaso-0.00*
RELEVANT INTERVAL RESULTS AND DISCHARGE STUDIES:
___ 05:16AM BLOOD WBC-7.3 RBC-2.70*# Hgb-8.2*# Hct-24.5*
MCV-91# MCH-30.4 MCHC-33.5 RDW-17.6* RDWSD-54.9* Plt ___
___ 09:40AM BLOOD Hct-26.1*
___ 03:10PM BLOOD Hct-22.4*
___ 05:16AM BLOOD Glucose-101* UreaN-26* Creat-0.5 Na-142
K-3.9 Cl-108 HCO3-25 AnGap-13
IMAGING:
CXR IMPRESSION:
Persistent small to moderate left pleural effusion and
atelectasis.
Underlying consolidation/infection is not excluded in the
correct clinical
setting. Findings are similar to that of ___.
MICRO: NONE
Brief Hospital Course:
___ w dementia, HFpEF, HTN, hypothyroidism p/w melena, likely
UGIB. Patient made CMO during hospitalization.
# melena: could be upper or lower, BUN elevated which could
suggest upper. Received 2U PRBCs in ED with effect of increasing
hct from 16 to 24. Hemodynamically stable throughout, though
continued to hold her home BP meds (except for metoprolol) with
BPs ranging 105-160 systolic. Initially started on PPI gtt.
Given goals of care (see below), ___ not pursued, and PPI
gtt stopped. Initially there was some concern she might have had
C diff since she recently used abx, but she had a soft abdomen,
no abdominal pain, and never stooled in house, so this was
deemed unlikely.
# goals of care: patient and healthcare proxy were moving
towards transitioning to hospice prior to this admission and
actually had an appointment 2d after this discharge with PCP to
make such changes. Given the above, discussed goals of care with
patient and niece (HCP) who both agreed that comfort-oriented
care was best. Though patient has some degree of dementia, her
attention is intact and she agrees that her time is coming and
she is most interested in being home rather than any
interventions or hospitalizations. She says calmly, "I have
lived a long life" and "I'm going to a place with very nice
people some day" about her future. Patient was set up with
hospice services. A MOLST was signed which included a
do-not-hospitalize order. PCP was aware and agreed with such an
approach.
# HFpEF, HTN, AI, MR: ___ to slightly dry on admit. As
above, held home amlodipine and lisinopril, continuing her home
metop fractionated, which she tolerated well. Given goals of
care, would consider continuing to monitor BP since CHF would be
uncomfortable and resuming BP meds if/when necessary to prevent
flash pulmonary edema. ASA was stopped given goals of care.
# hypothyroid: continued home LT4 for comfort.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Ibuprofen 400 mg PO DAILY:PRN Pain - Mild
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Lisinopril 5 mg PO IF SBP >120 IN AM, GIVE 5MG (1 TAB) IN AM;
IF SBP >150 IN THE AFTERNOON; GIVE 2.5MG ___ TAB) IN THE
AFTERNOON.
5. Metoprolol Succinate XL 50 mg PO DAILY
6. mupirocin calcium 2 % topical DAILY
7. Potassium Chloride Dose is Unknown PO DAILY
8. Aspirin 81 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ibuprofen 400 mg PO DAILY:PRN Pain - Mild
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until instructed by your doctor.
5. HELD- Lisinopril 5 mg PO IF SBP >120 IN AM, GIVE 5MG (1 TAB)
IN AM; IF SBP >150 IN THE AFTERNOON; GIVE 2.5MG ___ TAB) IN
THE AFTERNOON. This medication was held. Do not restart
Lisinopril until instructed by your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ was an absolute pleasure caring for you during your
admission. You were admitted because you had a lot of blood loss
from your stools. You received a unit of blood and improved.
Given your goals, we did not pursue an endoscopy or colonoscopy
and stopped checking blood levels or giving you blood and
instead focused on making you comfortable. We have set you up
with a home hospice agency. If you have recurrence of your
bleeding, shortness of breath, or any other troubling symptom,
the hospice nurses ___ help keep you comfortable. We stopped a
couple of your blood pressure medications, as you had been
holding them at home anyway, but you should follow up with your
primary care provider and visiting nurses if you need to resume
them (in order to prevent uncomfortable shortness of breath from
high blood pressure causing heart failure).
We wish you all the best.
Followup Instructions:
___
|
19621223-DS-3
| 19,621,223 | 26,241,006 |
DS
| 3 |
2182-09-27 00:00:00
|
2182-09-27 17:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with no medical history
presenting after a
25 foot fall from a tree while working. He was on a tether which
broke/was cut and he fell onto his back onto the dirt. Reported
___ minute loss of consciousness on scene. When midflight
arrived, patient was AAO x3, reporting chest and back pain.
Patient was immobilized. Initially patient was hypotensive
to the ___ systolic x2, pressures responded to SBP 130 with
small 200 cc fluid. Patient received 1g TXA en route. On
arrival, patient is anxious, reporting pain in his chest, right
wrist, back. He denies any shortness of breath or
trouble breathing and does not have a headache.
Past Medical History:
No Past Medical History
Social History:
___
Family History:
non- contribuatory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.1 HR 100 , BP 120/ palp RR 20 PO2 97% RA GCS 15
Constitutional: anxious, uncomfortable, in C collar on backboard
HEENT: Normocephalic, atraumatic, PEERLA , no c spine
tenderness, no facial deformity, no skull fractures, no
hemotympanium
Resp: Clear to auscultation, normal work of breathing, sternum
TTP
CV: Regular rate and rhythm, normal S1/S2, 2+ distal pulses.
Pulses palpable in all extremities
Abd: guarding, non tender, nondistended, normal rectal tone
GU: Pelvis stable, no blood at the meatus
MSK: TTP T8, TTP right wrist w/o deformity, full ROM of
extremities
Skin: No rash, Warm and dry, spine non tender
Neuro: Cranial nerves II Through XII intact, 5+ strength in all
extremities
DISCHARGE PHYSICAL EXAM
Vitals: T 98.5, HR 78 BP 112/69 RR 18 PO2 95% RA
General: Note in acute distress, comfortable
HEENT: within normal limits
Rest: CTAB, no respiratory distress,
Chest: TTP over right anterior chest
HR: RRR, normal S1/S2
Abd: soft, non-tender, non distended
Extremities: full range of motion, no pain or tenderness
Pertinent Results:
___ 11:17AM GLUCOSE-99 UREA N-16 CREAT-1.5* SODIUM-143
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-19* ANION GAP-18
___ 11:32AM HGB-14.6 calcHCT-44 O2 SAT-92 CARBOXYHB-7*
MET HGB-0
MB: 7 Trop-T: <0.01
___- CK 3840
___- CK: 2977
___- CK: 1756
___- CT HEAD W/O CONTRAST
No acute intracranial process.
___- CT C-SPINE W/O CONTRAST
No fracture or misalignment.
___- CT CHEST/ ABD/ PELVIS W/CONTRAST
1. Pneumomediastinum with oblong air density likely arising
within the
paramediastinal right lower lobe with mild adjacent ground-glass
opacification
and air tracking into the right hilum suggestive of traumatic
pneumatocele/pulmonary laceration.
2. Displaced fracture of the right seventh rib costal cartilage.
3. No other acute fractures. No other evidence of intrathoracic
or
intra-abdominal injury.
___- RT WRIST FOREARM & WRIST
Normal right hand, wrist, and forearm radiographs. No fracture
___- TTE
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function.
Brief Hospital Course:
Mr. ___ presented to ___ after he sustained a trauma
when falling 25 feet from a tree, where he was found to have a
small right pneumatocele, pneumediastinum, and a displaced
fracture of the right seventh rib costal cartilage. He was
admitted to the Acute Care Surgery Service for hemodynamic and
respiratory monitoring, pain control, and management.
Patient was found to have rhabdomyolysis from the injuries he
sustained with an elevated CPK, to 3840. He was started on
generous IV fluid hydration and made NPO. His chest and back
pain was being controlled with IV pain medication.
On HD 1, his CPK was down trending, from 3480 to 2970, and he
was started on a regular diet. He was continued on IV fluids for
his rhabdomyolysis. He was ambulating, voiding, and was switched
to oral pain medications
On HD 2, patient was endorsing pressure like right sided chest
pain and a rapid heart rate. An EKG was performed which showed
new onset atrial fibrillation with rapid ventricular rate, which
spontaneously converted. He was seen by inpatient cardiology,
who recommended a transthoracic echo, which was normal. Patient
does not have a history of atrial fibrillation. No outpatient
cardiology follow up needed at this time, and he was recommended
to see to a cardiologist in the future, and if he becomes
symptomatic.
During his hospitalization, he was seen by and worked with
physical therapy, who felt he was stable and able to ambulate
independently, and recommended discharge home.
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.
Medications on Admission:
No Medication
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Take lowest affective dose, wean as tolerated. ___ request
partial fill
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*36 Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QPM back pain
Place on skin over affected area
5. Senna 8.6 mg PO BID
Please hold for loose stools
Discharge Disposition:
Home
Discharge Diagnosis:
[] Traumatic pneumatocele
[] Pulmonary laceration
[] Displaced fracture of the right seventh rib costal cartilage
[] Rhabdomyolysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after falling from a tree. Your
injuries included pulmonary trauma and damage to the cartilage
on your 7th rib. You also developed rhabdomyolysis, a condition
in which damaged skeletal muscle tissue breaks down and releases
a byproduct that is harmful to your kidneys. You received
aggressive IV fluids to flush out your system, and your lab
values are improving. You have worked with ___ and OT, your pain
is well controlled on oral pain medicine, and you are tolerating
a regular diet. You are medically cleared for discharge home to
continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
* Your injury caused the right 7th rib cartilage to fracture
which can cause severe pain and subsequently cause you to take
shallow breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
You may call and follow up at the Cognitive Neurology clinic if
you have post concussive symptoms (headaches, forgetfulness,
trouble concentrating, light sensitivity, ect) in the next ___
weeks
Please follow up with your Primary Care Physican and your Acute
Care Surgeon at the appointments provided. Please have labs
drawn prior to your surgery appointment.
If any questions or concerns arise, the Acute Care Surgery
Clinic can be reached at ___
Warm Regards
Your ___ Acute Care Surgery Team
Followup Instructions:
___
|
19621248-DS-21
| 19,621,248 | 22,714,973 |
DS
| 21 |
2194-11-28 00:00:00
|
2194-11-28 20:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
___ w/ hypothyroid, HTN, breast ca s/p chemo/radiation ___, who
presented to ___ ___ early on ___ w/ complaints of sudden
onset ___ abdominal pain on ___. Pain reportedly
worse in RUQ with radiation to back bilaterally. Pt denies prior
episodes of similar pain, which has gradually gotten better
since initial onset. Pt was seen in ___ soon after initial
attack, w/ CT and RUQ demonstrating equivocal evidence of
cholecystitis and was subsequently discharged home. On further
review of imaging, however, it was felt that findings were most
compatible w/ early acute cholecystitis. Since initial
presentation, pt endorses several episodes of of NBNB emesis
with subjective fevers and chills.
Pt endorses intermittent "twinges" in epigastrium in days
immediately preceeding presentation, but denies actual abdominal
pain, diarrhea, acolic stools, dark urine, jaundice, pruritis,
changes in weight.
Past Medical History:
Past Medical History: hypothyroidism, HTN, breast CA (s/p chemo
and radiation ___, recurrent UTIs
Past Surgical History: repair of bladder prolapse ___ at ___, R
subtotal thyroidectomy "many years ago" (Dr. ___, R
lumpectomy (___)
Social History:
___
Family History:
Family History: no h/o biliary disease, liver disease
Physical Exam:
arrival:
Vitals: 97.8 80 144/53 16 97% RA
GEN: A&Ox3, 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, no rebound or guarding,
normoactive bowel sounds, no palpable masses, tender to deep
palpation in RUQ, ttp suprapubic region as well, nonpalpable
gallbladder
DRE: deferred
Ext: No ___ edema, ___ warm and well perfused
discharge:
GEN: A&Ox3, 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, no rebound or guarding,
normoactive bowel sounds, no palpable masses, mildly TTP in RUQ
Ext: No ___ edema, ___ warm and well perfused
wound: laparoscopic incision sites ___ with no
erythema or drainage, minimally TTP over incisions
Pertinent Results:
___ 02:10AM BLOOD ___
___ Plt ___
___ 07:40AM BLOOD ___
___ Plt ___
___ 07:40AM BLOOD ___
___
___ 02:10AM BLOOD ___
___
___ 02:10AM BLOOD ___
___ 07:40AM BLOOD ___
___ 07:40AM BLOOD ___
___ 04:00AM URINE ___ Sp ___
___ 04:00AM URINE ___
___
___ 04:00AM URINE ___
___
___ 72 ___
Radiology ReportCT ABD & PELVIS WITH CONTRASTStudy Date of
___ 3:11 AM
___ ___ 3:___BD & PELVIS WITH CONTRAST Clip # ___
Reason: eval for AAA, intraabdominal process, pancreatitis
Field of view: 40 Contrast: OMNIPAQUE Amt: 130
UNDERLYING MEDICAL CONDITION:
History: ___ with sudden onset mid abdominal pain and back
pain
REASON FOR THIS EXAMINATION:
eval for AAA, intraabdominal process, pancreatitis
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: EHAd SAT ___ 4:17 AM
1. Distended gallbladder with very minimal pericholecystic fluid
but no wall
edema or adjacent fat stranding.
2. Normal aorta and pancreas
Final Report
HISTORY: ___ female with sudden onset of mid abdominal
and back pain.
Evaluate for abdominal aortic aneurysm or pancreatitis.
TECHNIQUE: MDCT images were obtained from the lung bases to
pubic symphysis
after administration of 130 cc of IV Omnipaque contrast. Axial
images were
interpreted in conjunction with coronal and sagittal reformats.
COMPARISON: None.
FINDINGS:
The visualized portion of the heart is unremarkable. The lung
bases are
clear. No pericardial or pleural effusion is visualized.
ABDOMEN:
The liver, intra and extrahepatic bile ducts, pancreas, spleen,
and adrenal
glands are normal. The gallbladder is distended and there is a
trace amount
of pericholecystic fluid. One or two gallstones are present
within. The
kidneys enhance symmetrically and excrete contrast promptly.
The ureters are
normal in course and caliber.
The stomach is unremarkable. A duodenum diverticulum is
incidentally noted.
The small and large bowel have a normal course and caliber.
Colonic
diverticulosis is present without evidence for diverticulitis.
The appendix
is normal.
The portal and ___ systemic vasculature are normal.
No
retroperitoneal or mesenteric lymphadenopathy. No free
abdominal fluid,
pneumoperitoneum, or abdominal wall hernia. Abdominal aorta is
normal in
caliber with atherosclerotic calcifications.
PELVIS: The bladder and terminal ureters are normal. The
uterus is fibroid.
No free pelvic fluid or inguinal hernia. No pelvic sidewall or
inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for
malignancy.
IMPRESSION:
1. Distended gallbladder with trace pericholecystic fluid/wall
edema and a
few gallstones. Please correlate with clinical symptoms as
findings are
potentially concerning for cholecystitis.
2. No evidence of aortic aneurysm or pancreatitis as
questioned.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
Approved: SAT ___ 11:56 AM
Imaging Lab
Report History
SAT ___ 11:53 AM
by ___ Close
___ 72 ___
Radiology ReportLIVER OR GALLBLADDER US (SINGLE ORGAN)Study
Date of ___ 4:22 AM
___ ___ 4:22 AM
LIVER OR GALLBLADDER US (SINGL Clip # ___
Reason: evaluate for cholecystitis
UNDERLYING MEDICAL CONDITION:
History: ___ with RUQ abdominal pain
REASON FOR THIS EXAMINATION:
evaluate for cholecystitis
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: EHAd SAT ___ 5:01 AM
Distended gallbladder containing a few gallstones. No wall edema
or
pericholecystic fluid to suggest cholecystitis. No reported
sonographic
___ sign.
Final Report
HISTORY: ___ female with right upper quadrant abdominal
pain.
Evaluate for cholecystitis.
COMPARISON: CT abdomen pelvis of the same day.
FINDINGS: The liver is normal without focal or textural
abnormality. The
main portal vein is patent with hepatopetal flow. The
gallbladder is
distended and contains sludge and a few gallstones. There is
minimal wall
edema seen on a few images. No reported sonographic ___
sign. The common
duct measures 4 mm and there is no intra or extrahepatic bile
duct dilatation.
The visualized portion of the pancreas is unremarkable. The
pancreatic tail
is obscured by overlying bowel gas. The right kidney measures
9.1 cm. The
aorta is of normal caliber throughout. The visualized portion
of the IVC is
unremarkable.
IMPRESSION: Distended gallbladder with gallstones and mild wall
edema.
Findings may represent acute cholecystitis. If clinically
indicated, HIDA
could be obtained for confirmation.
Findings were communicated via phone call by ___ to Dr.
___
attending, on ___ at 9:37am.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
Approved: SAT ___ 11:56 AM
Imaging Lab
There is no report history available for viewing.
Brief Hospital Course:
___ p/w colicky RUQ pain x 1 day, had CT a/p and RUQ ultrasound
showing cholecystitis s/p lap cholecystectomy.
Cholecystitis: pt taken for laparoscopic cholecystectomy on
___, patient tolerated surgery well no complications. She
has been recovering appropriately tolerating regular diet and
pain well controlled on oral pain medications. LFTs wnl
___. WBC normal.
- f/u surgery in ___ weeks
- PO dilaudid and tylenol for pain control
UTI: pt noted to have UTI on ___ arrival, pt gets frequent UTI's,
she was started on cipro and will continue for 3 day course.
- f/u PCP
- cipro ___ 3 days
- phenazopyridine for sx relief PRN
Medications on Admission:
atenolol 25', betamethasone dipropionate 0.05 % prn, fluticasone
50 mcg'', gabapentin 300''', HCTZ 25', hydroquinone 4 % Topical
Cream prn, levoxyl 112' (5x/week), Macrobid ___, temazepam 15
qPM prn, tretinoin 0.025 %prn, ASA 81', ___ D daily,
cranberry extract, flaxseed oil, claritine 10', MVI, omega 3
fatty acid daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*6 Tablet Refills:*0
3. Atenolol 25 mg PO DAILY
hold for sbp < 110, hr < 50
4. Gabapentin 300 mg PO TID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine [___] 95 mg 1 tablet(s) by mouth three
times a day Disp #*12 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis s/p laparoscopic cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ for acute cholecystitits
(inflammation of your gallbladder) and had surgery to remove
your gallbladder. ___ did well after surgery and are recovering
appropriately. ___ were also noted to have a UTI on admission
for which ___ will take antibiotics (Cipro) for 3 more days.
DISCHARGE INSTRUCTIONS
___ were admitted to the acute care surgery service for
cholecystitis.
Please call your doctor or go to the emergency department if:
___ experience new chest pain, pressure, squeezing or
tightness.
___ develop new or worsening cough, shortness of breath, or
wheeze.
___ are vomiting and cannot keep down fluids or your
medications.
___ 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.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
___ develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. ___
may not drive or heavy machinery while taking narcotic analgesic
medications. ___ may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until ___ with your surgeon, who will instruct
___ further regarding activity restrictions. Please also
___ with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
___ have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
___ may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If ___ have staples, they will be removed at your ___
appointment.
*If ___ have ___, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19621518-DS-13
| 19,621,518 | 24,294,523 |
DS
| 13 |
2162-02-19 00:00:00
|
2162-02-19 13:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / iron / Effexor
Attending: ___.
Chief Complaint:
Difficulty breathing yesterday
Major Surgical or Invasive Procedure:
Rigid and flexible bronchoscopy (___)
Old metallic ultraflex was removed (___)
18x40 mm uncovered ultraflex was placed (___)
History of Present Illness:
Ms. ___ is a ___ year old female with stage IIb
(T2bN0M0) metastatic non small cell adenocarcinoma of the lung
s/p chemotherapy and RUL lobectomy with mediastinal lymph node
dissection in ___ at OSH, s/p stent (28x18x8 Cook covered
stent) placed on ___ for respiratory difficulty secondary
to metastatic mediastinal/anterior neck mass s/p removal on
___ due to stent migration and placement of 18x40mm
uncovered metal stent on ___. She had received
palliative chemoradiation since then complicated by
thrombocytopenia, pneumonia and dysphagia leading to PEG tube
placement on ___.
She reports feeling fatigued, worsening productive cough and
poor appetite for the past week. She was noted by her husband
to have difficulty breathing and what was described as
stridorous nosie yesterday which prompted them to present to the
OSH ED. CT Chest/neck showed extrinsic compression from
hypoattenuating mass in superior anterior medisastinum at the
cephalad aspect of the stent narrowing the lumen approximately 5
mm AP by 7 mm traverse. She was given Zosyn 3.375 gm IV x 1 for
possible postobstructive pneumonia and decadron 10 mg po x 1 and
transferred to ___ for further evaluation and management.
At ___ ED, initial vitlas were: 98.4 137/79 99 20 94%RA. She
appeared comfortable without respiratory distress. IP evaluated
her in the ED and would like to admit her to medicine for
monitoring and plan to take her to OR tomorrow. Labs notable
for CBC at baseline and normal Chem7. She was given IV levaquin
and admitted to medicine service.
On the floor, she reports no other complaints.
Past Medical History:
Stage IIb (T2bN0M0) metastatic non small cell adenocarcinoma of
the lung s/p chemotherapy and RUL lobectomy with mediastinal
lymph node dissection in ___ at OSH, s/p stent (28x18x8 Cook
covered stent) placed on ___ for respiratory difficulty
secondary to metastatic mediastinal/anterior neck mass s/p
removal on ___ due to stent migration and placement of
18x40mm uncovered metal stent on ___ now on palliative
chemoradiation
Graves disease s/p 2 radioactive iodine tx ___ and ___
with known thyroid nodules active on PET
Hypothyroidism
Anemia/eosinophilia
HTN
GERD
R upper lobectomy with mediastinal LN dissection
tubal ligation ___
tonsillectomy ___
Social History:
___
Family History:
Dad died at age ___ of stroke. Mother died at age ___ of heart
failure
Physical Exam:
Admission Exam
VS - 98.1 141/68 104 20 97%RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple. No JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB. No inspiratory wheezing or stridor noted.
ABDOMEN - Soft, NT and ND. J-tube with mild erythema and pus
around the insertion site .
EXTREMITIES - No edema. No rash
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, cerebellar exam intact, steady gait
Discharge Exam
98.4 125/72 82 20 98%RA
GENERAL - NAD. Comfortable. Mildly sedated
HEENT - Sclerae anicteric, OP clear
NECK - supple. No JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB. No inspiratory wheezing or stridor noted.
ABDOMEN - Soft, NT and ND. J-tube with mild erythema and pus
around the insertion site .
EXTREMITIES - No edema. No rash
NEURO - Mildly sedated. A&Ox3, CNs II-XII grossly intact
Pertinent Results:
___ 10:00AM BLOOD WBC-10.1 RBC-3.26* Hgb-9.8* Hct-30.5*
MCV-94# MCH-30.1# MCHC-32.1 RDW-19.8* Plt ___
___ 04:58AM BLOOD WBC-10.0 RBC-3.01* Hgb-9.2* Hct-28.7*
MCV-95 MCH-30.5 MCHC-32.0 RDW-20.2* Plt ___
___ 10:00AM BLOOD Glucose-138* UreaN-17 Creat-0.5 Na-133
K-4.3 Cl-95* HCO3-23 AnGap-19
___ 04:58AM BLOOD Glucose-103* UreaN-23* Creat-0.5 Na-135
K-3.9 Cl-98 HCO3-26 AnGap-15
___ 06:10AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.0
CXR (___)
The Port-A-Cath catheter tip is at the junction of
brachiocephalic vein and SVC. Heart size and mediastinum are
unchanged in appearance including
extensive post-surgical changes. No new consolidations have
been
demonstrated. The stent in the upper trachea and surrounding
mass are better appreciated on CT chest from ___
(obtained in outside facility).
Bronchoscopy (___)
A black rigid tracheoscope was used to intubate the airway
wihtout difficulty. The old metalloc stent was in good position
keeping the trachea open. There was granulation tissue over the
proximal end of the stent. Carina was sharp. The left side
airways were normal. The RUL showed evidence of lobectomy. There
was a smooth ridge on the distal BI which appeared benign, and
was benign appearing on NBI. There was yellow thick secretion in
the RLL and the RML which were aspirated. The RML was closed
with a slit like opening. Fogart balloon 5 was used to attempt
to open the RML wihtout success. The Metallic stent was removed
wtih rigid forceps. The granulation tissue was removed with
forceps and cryo. The trachea was patent even as the rigid
tracheoscope was backed out. The blood oozing was controlled
with ___ epinephrine. A LMA was placed, however ventilation
was poor. A flex bronch showed significant collapse of the upper
trachea ( >80%). ___ rigid tracheoscope was
reintroduced and a 18x40 mm uncovered ultraflex stent was placed
in proper position. The ridig scope was removed and patient had
a LMA placed.
Impression: Black Rigid bronchoscopy
Flexible bronchoscopy
Therapeutic aspiration of secretion
Attempt to open the RML
Old metallic ultraflex was removed.
As the upper trachea collapsed, a new 18x40 mm uncovered
ultraflex was placed.
Brief Hospital Course:
___ year old female with stage IIb (T2bN0M0) metastatic non small
cell adenocarcinoma of the lung s/p tracheal stent and on
palliative chemoradiation presents with one day of respiratory
difficulty with CT neck showing narrowing at the cephalad aspect
of her tracheal stent and possible aspiration pneumonia. She
was treated with levaquin for possible aspiration pneumonia and
interventional pulmonology took her to the OR for rigid
bronchoscopy with replacement of her tracheal stent. She
tolerated the procedure well and was discharged with follow up
with interventional pulmonology in one month and her oncologist
next week. She was continued on albuterol/ipratropium nebs and
started on sodium chloride nebulizers along with
guaifenasin/codeine prn for cough. She was also given oxycodone
as needed for throat pain due to prolong cough
Chronic problems
1. HTN: She was continued atenolol 50 mg daily
2. Anxiety: Continued sertraline 100 mg daily and ativan 0.5 mg
qhs and prn
3. Hypothyroidism: Continued levothyroxine 100 mg daily
4. Med reconcillation: Held reglan 5 mL QID and iron 4.5 mL BID
as we do not have liquid formulation.
Transitional issues
--> She had bronchial cultures which initially was reported as
positive for gram negative rods, but corrected to no growth.
She was continued on levaquin 500 mg per J-tube until
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Albuterol-Ipratropium 1 PUFF IH Q 8H
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lorazepam 0.5 mg PO HS
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE Liquid 5 mg PO Q6H:PRN pain
8. Sertraline 100 mg PO DAILY
9. IronUp *NF* (polysaccharide iron complex) 4.5 Oral BID
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
11. Metoclopramide 5 mg PO QIDACHS
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin [Guaiatussin AC] 100 mg-10 mg/5 mL 5 mL
by mouth every six hours Disp ___ Milliliter Refills:*0
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lorazepam 0.5 mg PO HS
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE Liquid 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg/5 mL 5 mg by mouth every six hours Disp #*50
Milliliter Refills:*0
8. Sertraline 100 mg PO DAILY
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID
RX *sodium chloride 3 % 1 nebulizer twice a day Disp #*30
Inhaler Refills:*0
10. Albuterol-Ipratropium 1 PUFF IH Q 8H
11. IronUp *NF* (polysaccharide iron complex) 4.5 Oral BID
12. Metoclopramide 5 mg PO QIDACHS
Discharge Disposition:
Home
Discharge Diagnosis:
1. Shortness of breath
2. Metastatic adenocarcinoma of the lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was pleasure taking care of you during your hospital stay.
You were admitted because of difficulty breathing prior to
admission. Interventional pulmonology replaced your tracheal
stent and you were given antibiotics for aspiration pneumonia.
You tolerated the procedure well and were discharged with follow
up with interventional pulmonology in one month which they will
schedule and your oncologist in few days.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICAL REGIMEN
START LEVAQUIN 500 mg by PEG TUBE for 4 more days (End date:
___
START normal saline 3% nebulizers twice a day
Followup Instructions:
___
|
19621761-DS-11
| 19,621,761 | 29,010,954 |
DS
| 11 |
2151-01-18 00:00:00
|
2151-01-18 15:55:00
|
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 lower extremity pain/ulceration
Major Surgical or Invasive Procedure:
R lateral ankle I&D, distal fibulectomy, ___, ___ ___ pin,
Frame application, VAC application
History of Present Illness:
___ y/o male w/ history of diabetes mellitus, right ankle
fusion in ___ for arthritis presenting with two weeks of
progressive right lateral malleolus and calcaneus lower
extremity
ulceration. This began when patient began to wear a special
boot
to cushion his foot when he ambulated since he has trouble
landing his foot flat. Denies fever, chills, discharge,
numbness,
tingling or weakness in the lower extremity. Patient was
evaluated by wound clinic in ___ s/p wound debridement and
referred to the ED for evaluation.
In the ED:
- Initial vital signs were: 97.8 98 130/78 19 98% RA
- Exam notable for: Right ankle: lateral malleolus with deep
ulceration, bone exposed, tender appears infected; superficial
ulceration at ball of foot, Left foot: superficial ulceration at
ball of foot, chronic
- Labs were notable for: CRP 49.3, HgbA1c 7.4%, lactate 2.6
- Studies performed include: plain films of the R foot/ankle
showing severe degenerative changes at the tibiotalar joint with
severe joint space narrowing, severe flattening of the talus and
osseous sclerosis. No priors available for comparison. It is
difficult to exclude underlying infection radiographically.
Soft
tissue swelling. No acute fracture.
- Patient was given: 1L LR, vanc/zosyn
- Consults: orthopedics, plastic surgery - no acute intervention
as per orthopedics, plastic surgery recommended admission to
medicine for possible OM and broad spectrum abx coverage
- Vitals on transfer: 98.3 82 118/77 18 99% RA
Upon arrival to the floor, the patient feels well without
complaints.
Past Medical History:
- DM
- Right ankle fusion for arthritis in ___
Social History:
___
Family History:
Family hx of DM, lung cancer from smoking.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VITALS: 97.6 PO 119 / 77 80 16 98 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Moist mucous membranes, good dentition. Oropharynx is
clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Right foot DP and ___ pulses 2+ , Normal sensation
to light touch, right lateral malleolus lesion is stage four
probes to bone, surrounding erythema, yellow exudate with
necrotic tissue. Approximate Width if 5 cm and height is 5 cm
right heal lesion is stage one 3 cm x 2 cm. Left foot lesion is
2 cm x 2 cm, clean borders, well healed
SKIN: Warm. Cap refill <2s. No rash.
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
General: Well-appearing, breathing comfortably
MSK: drain w/ sanguinous output, moves toes to command, no new
swelling
Drain discontinued and dressing applied
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 12:20PM BLOOD WBC-10.0 RBC-4.40* Hgb-14.6 Hct-40.8
MCV-93 MCH-33.2* MCHC-35.8 RDW-12.8 RDWSD-42.8 Plt ___
___ 12:20PM BLOOD Neuts-74.2* Lymphs-16.7* Monos-6.0
Eos-2.1 Baso-0.4 Im ___ AbsNeut-7.44* AbsLymp-1.67
AbsMono-0.60 AbsEos-0.21 AbsBaso-0.04
___ 12:20PM BLOOD ___ PTT-28.8 ___
___ 12:20PM BLOOD Glucose-236* UreaN-25* Creat-0.9 Na-138
K-5.1 Cl-95* HCO3-30 AnGap-13
___ 12:20PM BLOOD ALT-22 AST-18 AlkPhos-109 TotBili-0.6
___ 12:20PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.1 Mg-1.7
___ 12:20PM BLOOD %HbA1c-7.4* eAG-166*
___ 12:20PM BLOOD CRP-49.3*
___ 12:31PM BLOOD Lactate-2.6*
======
MICRO:
======
___ Blood cultures pending
================
IMAGING/STUDIES:
================
___ FOOT/ANKLE XRAY
Severe degenerative changes at the tibiotalar joint with severe
joint space narrowing, severe flattening of the talus and
osseous sclerosis. No priors available for comparison. It is
difficult to exclude underlying infection radiographically. Soft
tissue swelling. No acute fracture.
No perihardware loosening seen.
===============
PERTINENT LABS:
===============
===============
DISCHARGE LABS:
===============
Brief Hospital Course:
___ with a background history of type II DM, gout, HTN and right
ankle fusion (___), presenting with two weeks of progressive
right lateral malleolus and calcaneus lower extremity
ulceration,
concerning for osteomyelitis.
====================
ACUTE/ACTIVE ISSUES:
====================
# RLE ulceration
# Possible osteomyelitis
Patient presented with two week history of worsening RLE
ulceration, likely in setting of possible vascular insufficiency
and peripheral diabetic neuropathy from uncontrolled DM.
Clinical exam concerning for OM and plain films unable to rule
out
infection. Received IV vanc/zosyn in ED, but had superficial
cultures and wound debridement performed at wound clinic in
___ prior to this.
- appreciate plastics/ortho recs
- holding Abx until deep wound cultures obtained given VSS
- obtain deep wound cultures
- follow-up pending blood cultures
- follow-up tissue cultures performed in ___ wound clinic
- MRI for further evaluation if ortho want same
- hold off ID consult at present
# Type 2 DM
Last known HbA1c 7.4%. Held metformin and glipizide while
inpatient. Transitioned to Humalog insulin sliding scale while
admitted.
======================
CHRONIC/STABLE ISSUES:
======================
# Gout
- continue home allopurinol
====================
TRANSITIONAL ISSUES:
====================
============================================
# CODE STATUS: Full
# CONTACT: ___, mother, ___
From orthopedic standpoint:
The patient was taken to the operating room on ___ for
right lateral ankle I&D, distal fibulectomy, ___, TTC ___
pin, Frame application, with VAC application, 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
nonweightbearing in right lower extremity, and will be
discharged on lovenox for DVT prophylaxis.
The patient will return to the hospital on ___ for another
procedure with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. GlipiZIDE Dose is Unknown PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Gabapentin 300-600 mg PO BID
6. Bumetanide 1 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. levocetirizine 5 mg oral DAILY
9. Naproxen 220 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 325 mg 2 tablet(s) by mouth q8hr Disp #*60
Tablet Refills:*0
2. Ampicillin-Sulbactam 3 g IV Q6H
RX *ampicillin-sulbactam 3 gram 3 gram intravenous q6hr Disp
#*84 Vial Refills:*0
3. Bisacodyl 10 mg PO DAILY:PRN Constipation
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
4. Enoxaparin Sodium 40 mg SC Q24H
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous at bedtime Disp
#*28 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*30 Tablet
Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
7. GlipiZIDE 5 mg PO DAILY
RX *glipizide 5 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
8. Allopurinol ___ mg PO DAILY
9. Bumetanide 1 mg PO DAILY
10. Gabapentin 300-600 mg PO BID
11. levocetirizine 5 mg oral DAILY
12. Losartan Potassium 50 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right ankle osteoarthritis
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:
- nonweightbearing to right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- VAC changes 3x/week until surgery
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:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Non weight bearing
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
VAC changes to right lower extremity wound: 3 times per week
Approximate wound size 4cm W x 3cm D
Antibiotics:
Unasyn 3g q6hr IV
Followup Instructions:
___
|
19621990-DS-15
| 19,621,990 | 25,821,878 |
DS
| 15 |
2126-02-28 00:00:00
|
2126-03-06 09:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, Chest pain
Major Surgical or Invasive Procedure:
___ minimally invasive L3-L5 posterior lateral fusion and
stabilization.
___ Open reduction and internal fixation of bilateral
calcaneal fractures.
History of Present Illness:
___ PPD smoker x ___ years
Past Medical History:
PMHx: Disorder of thyroid gland, hypercholesterolemia,
alcoholism, alcohol abuse, tobacco dependenc, depressive
disorder, glaucoma, asthma, COPD, ?sarcoidosis, history of
pulmonary embolism, GERD,
PSHx: Right Tibial plateau fracture s/p ORIC Dr. ___ ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Discharge Physical Exam:
V T97.8 BP 162/89 HR 79 RR 16 O2 sat 97% on 2L
General: Pleasant, in NAD, lying in bed
HEENT: No NC in place, bruising under right eye and abrasion to
right cheek, EOMI
CV: Skin warm and well perfused, no ___ edema
Pulm: Breathing comfortably on RA without noted SOB, some
unproductive coughing
Abd: NT, ND
Psych: Engaged and appropriate
Skin: abrasion to face as above, tattoo on dorsum of left
forearm
Extremities: b/l short leg casts over heels
MSK: ___ to EF, EE, WE, FF, Fabd, HF, KE b/l. PF/DF not
performed given b/l casts. Able to flex/extend toes.
Neuro: Sensation intact to light touch in L2, L3, S2 dermatomes.
No abnormal movements noted. Sensation intact to first webspace
b/l. Able to repeat 5 numbers forward but unable to repeat 3
numbers backward. Able to name two similarities between objects
x2. Unable to copy a cube. Unable to decipher a parable (x2).
Discharge Physical Exam:
VS: T: 98.8 PO BP: 118/74 L Lying HR: 68 RR: 18 O2: 94% Ra
GEN: A+Ox3, NAD
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender
BACK: Surgical incisions x3 with running suture and staples,
wounds well-approximated, no s/s infection.
EXT: b/l ___ in splints, capillary refill <2 seconds b/l, moves
all digits.
Pertinent Results:
___ 10:30AM BLOOD WBC-8.1 RBC-2.63* Hgb-8.8* Hct-25.1*
MCV-95 MCH-33.5* MCHC-35.1 RDW-12.6 RDWSD-43.1 Plt ___
___ 06:20AM BLOOD WBC-6.0 RBC-2.88* Hgb-9.7* Hct-27.5*
MCV-96 MCH-33.7* MCHC-35.3 RDW-12.9 RDWSD-44.6 Plt ___
___ 06:26AM BLOOD WBC-7.9 RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.2* MCHC-34.3 RDW-12.9 RDWSD-45.4 Plt ___
___ 06:35AM BLOOD WBC-7.3 RBC-2.65* Hgb-9.1* Hct-25.4*
MCV-96 MCH-34.3* MCHC-35.8 RDW-13.2 RDWSD-45.7 Plt ___
___ 07:00AM BLOOD WBC-6.6 RBC-3.05* Hgb-10.3* Hct-29.4*
MCV-96 MCH-33.8* MCHC-35.0 RDW-13.4 RDWSD-46.6* Plt ___
___ 05:24AM BLOOD WBC-6.1 RBC-3.20* Hgb-11.0* Hct-30.2*
MCV-94 MCH-34.4* MCHC-36.4 RDW-13.2 RDWSD-44.8 Plt ___
___ 06:05AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.9* Hct-28.4*
MCV-95 MCH-33.2* MCHC-34.9 RDW-12.9 RDWSD-44.5 Plt ___
___ 06:30AM BLOOD WBC-5.0 RBC-2.85* Hgb-9.6* Hct-26.9*
MCV-94 MCH-33.7* MCHC-35.7 RDW-12.6 RDWSD-43.4 Plt ___
___ 06:35AM BLOOD WBC-4.6 RBC-2.64* Hgb-8.9* Hct-25.1*
MCV-95 MCH-33.7* MCHC-35.5 RDW-12.7 RDWSD-43.8 Plt ___
___ 07:01AM BLOOD WBC-4.9 RBC-2.87* Hgb-10.0* Hct-27.5*
MCV-96 MCH-34.8* MCHC-36.4 RDW-12.7 RDWSD-44.1 Plt ___
___ 07:14AM BLOOD WBC-5.7 RBC-2.93* Hgb-9.9* Hct-27.9*
MCV-95 MCH-33.8* MCHC-35.5 RDW-12.5 RDWSD-43.5 Plt ___
___ 01:30PM BLOOD WBC-6.6 RBC-3.38* Hgb-11.5* Hct-32.5*
MCV-96 MCH-34.0* MCHC-35.4 RDW-12.7 RDWSD-44.5 Plt ___
___ 05:55AM BLOOD WBC-6.1 RBC-3.46* Hgb-11.8* Hct-33.9*
MCV-98 MCH-34.1* MCHC-34.8 RDW-12.9 RDWSD-46.1 Plt ___
___ 06:20AM BLOOD ___ PTT-26.0 ___
___ 06:26AM BLOOD ___ PTT-26.4 ___
___ 07:00AM BLOOD ___ PTT-24.7* ___
___ 05:24AM BLOOD ___ PTT-26.4 ___
___ 06:30AM BLOOD ___ PTT-25.5 ___
___ 05:55AM BLOOD ___ PTT-25.4 ___
___ 03:10PM BLOOD ___ PTT-24.1* ___
___ 10:30AM BLOOD Glucose-142* UreaN-7 Creat-0.6 Na-137
K-3.7 Cl-97 HCO3-28 AnGap-12
___ 06:20AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-94* HCO3-31 AnGap-12
___ 06:26AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-139
K-3.8 Cl-96 HCO3-27 AnGap-16
___ 06:35AM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-138
K-3.4* Cl-101 HCO3-23 AnGap-14
___ 07:00AM BLOOD Glucose-118* UreaN-7 Creat-0.5 Na-137
K-3.7 Cl-99 HCO3-23 AnGap-15
___ 05:24AM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-138
K-3.9 Cl-98 HCO3-28 AnGap-12
___ 06:05AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-140
K-4.0 Cl-99 HCO3-25 AnGap-16
___ 06:30AM BLOOD Glucose-90 UreaN-9 Creat-0.6 Na-141 K-3.8
Cl-99 HCO3-24 AnGap-18
___ 06:35AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-138 K-3.7
Cl-101 HCO3-28 AnGap-9*
___ 07:01AM BLOOD Glucose-84 UreaN-6 Creat-0.6 Na-140
K-3.4* Cl-98 HCO3-25 AnGap-17
___ 07:14AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-138
K-3.6 Cl-98 HCO3-25 AnGap-15
___ 05:55AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-141
K-4.2 Cl-103 HCO3-24 AnGap-14
___ 05:55AM BLOOD ALT-30 AST-90* AlkPhos-55 TotBili-1.2
___ 10:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6
___ 06:20AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.9
___ 06:26AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9
___ 06:35AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2
___ 07:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.5*
___ 05:24AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.7
___ 06:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
___ 06:30AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0
___ 06:35AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
___ 07:01AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
___ 07:14AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.4*
___ 05:55AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.4*
___ 03:10PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:10PM BLOOD Glucose-96 Lactate-5.6* Na-138 K-3.3
Cl-102
___ 03:10PM BLOOD Hgb-15.8 calcHCT-47 O2 Sat-89 COHgb-3
MetHgb-0
___ 03:10PM BLOOD freeCa-1.05*
Radiology:
___ Lspine Xray: Posterior spinal fusion of L3, L4 and L5
without evidence of hardware complication.
___ CXR: Lungs are low volume with minimal bibasilar
atelectasis. Cardiomediastinal silhouette is stable. There is
stable biapical pleuroparenchymal scarring. There is no pleural
effusion. No pneumothorax is seen
___. Comminuted fracture of the calcaneus as described above with
fracture at the base of the sustentacular tali.
2. The nondisplaced fracture of the superior cuboid.
___omminuted fracture of the calcaneus
___ CT Cspine:
1. No acute cervical spine fractures or traumatic subluxation.
2. Bilateral apical bullae and scarring, incompletely imaged.
3. Right zygomaticomaxillary complex fracture as well as a
displaced inferior right orbital wall fracture
___. Small left parietal scalp subgaleal hematoma. No acute
fracture.
2. No acute intracranial hemorrhage or mass effect.
3. Fractures of the right orbit, zygomatic arch, maxillary
sinus,
and nasal bone with surrounding soft tissue swelling and
subcutaneous emphysema. Associated right maxillary hemosinus.
___ bil ankle Xray:
1. Comminuted, mildly impacted left calcaneal fracture with
intra-articular extension.
2. Mildly impacted right calcaneal fracture with intra-articular
extension and mild stranding in the ___ fat pad.
3. Probable left cuboid fracture.
___ MRI L Spine:
1. Examination is moderately degraded by motion.
2. L4 burst fracture with approximately 40% loss of height and
10
mm of retropulsion of the posterior cortex with severe vertebral
canal narrowing.
3. L2 superior endplate fracture with approximately 10% loss of
height.
4. T12 superior endplate fracture with minimal loss of height.
5. Question discontinuity of posterior longitudinal ligament at
L4.
6. Question partial to complete tear of the interspinous
ligament
at L3-L4.
7. Multilevel multifactorial degenerative disc disease of the
lumbar spine as described above, most pronounced at L3-4 where
there is severe vertebral canal and moderate bilateral neural
foramina narrowing.
8. L4-5 moderate vertebral canal and moderate bilateral neural
foraminal narrowing.
Brief Hospital Course:
Mr. ___ is ___ yo M who presented to the emergency
department via EMS from the scene after a reported 15 foot fall.
He sustained right orbital fracture, bilateral calcaneus
fractures, L4 burst fracture with retropulsion, L2 and T12
fractures, left 6th rib fracture and a sternal fracture. He
remained hemodynamically stable in the trauma bay. Initially
hematocrit was 43.9 and on repeat dropped to 33.9. He had no
obvious source of blood loss. Hematocrit then stabilized at 25
and did not require transfusions. Neurosurgery was consulted for
the spine fractures and ultimately the patient was maintained on
bedrest with logroll precautions until ___ when he was
taken to the operating room and underwent minimally invasive
L3-L5 posterior lateral fusion and stabilization. Post
operatively he remained stable and a TLSO brace was fitted for
mobility >30 degrees in bed. Orthopedic surgery was conulsted
for the bilateral calcaneus fractures and bilateral splints were
placed. The patient was maintained non-weight bearing. After
further review of imaging, it was decided that his bilateral
calcaneus fractures required operative intervention and
therefore on ___ the patient was taken to the operating
room and underwent ORIF Bilateral Calcaneus Fractures. Please
see operative report for details. The patient was evaluated by
plastic surgery who recommended non-operative management
inpatient, sinus precautions, and outpatient follow up.
The remainder of his hospital course was uneventful. The patient
remained alert and oriented. Given history of alcohol misuse a
CIWA scale was ordered. He was evaluated by occupational therapy
for positive loss of consciousness and diagnosed with a
traumatic brain injury. Pain was well controlled with oral
agents and he had no evidence of cardiac injury on continuous
telemetry. He tolerated a regular diet without difficulty. He
made adequate urine and intake and output were closely
monitored. The patient's fever curves were closely monitored for
sings of infection of which there was none. The patient was
given subcutaneous heparin for DVT prophylaxis. He can restart
Xarelto on ___ per Neurosurgery. On ___, the patient's
left back surgical incision had a running stitch that had
broken, so Neurosurgery removed the running stitch and placed
staples which will be removed at the patient's outpatient
Neurosurgery follow-up appointment.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, out of bed with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
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. Atorvastatin 40 mg PO QPM
2. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
3. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
5. Omeprazole 20 mg PO BID
6. Vitamin D ___ UNIT PO DAILY
7. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Third Line
3. Calcium Carbonate 500 mg PO QID:PRN acid reflux
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
Discontinue this medication when you resume your home
Rivaroxaban on ___.
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Atorvastatin 40 mg PO QPM
11. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
12. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
14. Omeprazole 20 mg PO BID
15. Vitamin D ___ UNIT PO DAILY
16. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until 10 days after lumbar fusion.
___ resume on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left scalp subgaleal hematoma
Right orbit, maxillary sinus, nasal bone, ZMC fracture
Left calcaneal fracture
Right calcaneal fracture
Burst fracture L4 w retropulsion
Compression fracture L2
L3 and L4 rt TP fracture
Left anterior 6th rib fx
Sternal fracture
History of DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care surgery Service on ___
after a fall sustaining multiple injuries including: bilateral
calcaneus (heel) fractures, rib fractures, facial factures, and
spine fractures. You were taken to the operating room with the
neurosurgery for a spinal fusion to protect your spinal cord.
Please continue to wear your TLSO (hard brace) at all times when
head of bed is elevated greater than 30 degreed.
You were taken to the operating room with the orthopedic
surgeons for repair of your heel fractures and had casts placed
on both feet. Please continue to be non-weight bearing on both
feet. It is okay to kneel on your knees.
You were evaluated by the plastic surgery team for your facial
fractures and should continue sinus precautions (no straws, no
nose blowing, sneeze with your mouth open, no bending or heavy
lifting).
* Your injury caused rib and sternum fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19622090-DS-11
| 19,622,090 | 25,562,189 |
DS
| 11 |
2192-03-09 00:00:00
|
2192-03-09 15:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Chief complaint:Jerking movements
The pt is a ___ year-old woman with PMHx of DM2, CHF, HTN, HL, MS
and cirrhosis with portal hypertension who presents with a R
fibula fracture, found on later exams to have a jerking movement
of all 4 extremities.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old woman with PMHx of DM2, CHF, HTN, HL, MS
and cirrhosis with portal hypertension who presents with a R
fibula fracture, found on later exams to have a jerking movement
of all 4 extremities. The patient reports that she was in her
USOH on the morning of ___, but then she decided to walk to her
car without a walker or cane as she was in a rush. She tripped
and fell down and most of the force of the fall was stopped when
her face hit the ground. She had to come to the ED when she
realized she may have broken her R leg/ankle. In the ED, she
had
an x-ray of her R ankle that showed a R fibula fx. She also had
a CT head that showed no ICH and a ___ that showed no acute
injury. She was seen by orthopedics who felt the patient could
be weight bearing as tolerated, but that she needed a walking
boot from ortho tech. The patient remained in the ED overnight
waiting for this boot, and once it was placed, she was able to
more easily transfer herself from the bed to the commode.
However, around 5am on ___, she began to notice jerking of her
arms of legs when she tried to move them or get up to the
bathroom. She felt that this was like a prior MS flare that had
occurred ___ years ago.
In the ED, her primary neurologist was called who felt that
given
the timing of the symptoms she was experiencing this was not an
MS flare ___ quick an onset) and was more likely a medication
side effect, possibly from the percocets the patient was
receiving in the ED. She was admitted to neurology for further
workup and treatment.
On neuro ROS, the pt reports the jerking movements as above, but
denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt reports recent UTI treated
with Bactrim, but denies recent fever or chills. No night
sweats
or recent weight loss or gain. Denies cough, shortness of
breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
1. Relapsing remitting multiple sclerosis, diagnosed ___ after
she presented with transverse myelitis. Last exacerbation
___ as above.
2. Hypertension
3. DM type 2, last HbA1c 5.9 on ___.
4. Atypical chest pain, with prior admissions for rule out, echo
with impaired relaxation and early diastolic dysfunction, normal
P-MIBI ___.
5. Diastolic dysfunction as above.
6. Mild restrictive lung disease, last PFTs ___ with FVC
2.35 (81%), FEV1 2.02 (97%), FEV1/FVC 119%, reduced RV.
7. Obstructive sleep apnea on CPAP 7.
8. Tarsal tunnel syndrome status post surgical repair ___
9. Status post CCY
10. Status post TAH-BSO
11.H/O Squamous cell ca of skin (several face) and actinic
dermatosis
12.Chronic thrombocytopenia: etiology unclear but probable
chronic ITP
13. Mild anemia
14. Arthritis
15. OSA
Social History:
___
Family History:
Mother died from bladder ca at age ___
Father died from DM2 and CHF at age ___
Physical Exam:
On admission:
Vitals: T: 97.8 P: 72 R: 18 BP: 130/60 SaO2: 96% on RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, MMM, no lesions noted in
oropharynx, large hematoma over R eye
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to wiggling fingers.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally, but when pt is tested she begins to have flapping
jerking movements of her arms and hands. With hands
outstretched
she has asterixis, but she also has similar jerky movements
performing any movement. The jerking dissipates after about
___ seconds.
.
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 - - - -*
* unable to test distal RLE due to walking boot in place and
recent fx
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 -
Plantar response was flexor on the L and untestable on the R
because of the walking boot.
-Coordination: Some rapid alternating movements slowed
bilaterally and some slowness on FNF bilaterally.
-Gait: patient got up to edge of bed and went to stand then had
bilateral jerking of her legs and refused to walk.
On discharge:
Vitals: T: 97.9 P: 61 R: 20 BP: 99/48 SaO2: 98% on RA Glucose:
184
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, large hematoma over R eye
Extremities: No C/C/E bilaterally, Orthopedic boot on left foot.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
VII: No facial droop, facial musculature symmetric.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. With hands outstretched she has asterixis.
.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 5- - 5 5 5 5 5 5 5
R 5 5 5- ___ - 5 5 5 - - - -*
* unable to test distal RLE due to walking boot in place and
recent fx
-Gait: patient has been mobilizing with walker and feels ready
to go to rehabilitation.
Pertinent Results:
___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 05:35 3.5* 3.12* 10.0* 29.0* 93 32.1* 34.5 14.8
71*
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 05:35 71*
LAB USE ONLY
___ 05:35
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:35 171*1 26* 1.3* 139 3.7 ___
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 15:25 Using this1
Using this patient's age, gender, and serum creatinine value of
1.6,
Estimated GFR = 32 if non ___ (mL/min/1.73 m2)
Estimated GFR = 39 if ___ (mL/min/1.73 m2)
For comparison, mean GFR for age group ___ is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 15:25 20 27 183 561 80 0.7
NEW REFERENCE INTERVAL AS OF ___ LIMIT ___ %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
CPK ISOENZYMES CK-MB
___ 15:25 2
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 05:35 8.4 2.8 2.2
OTHER CHEMISTRY Ammonia Osmolal
___ 05:30 299
PITUITARY TSH
___ 15:25 2.4
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
___ 15:25 NEG NEG1 NEG NEG NEG NEG2
NEG
80 (THESE UNITS) = 0.08 (% BY WEIGHT)
POSITIVE TRICYCLIC RESULTS REPRESENT POTENTIALLY TOXIC
LEVELS;THERAPEUTIC TRICYCLIC LEVELS WILL TYPICALLY HAVE NEGATIVE
RESULTS
Urine Hematology
GENERAL URINE INFORMATION Type Color ___
___ ___ Yellow Clear 1.017
Source: ___
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
___ 17:02 NEG NEG NEG NEG NEG NEG NEG 5.5 TR
Source: ___
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 17:02 1 3 NONE NONE 1 <1
Source: ___
URINE CASTS CastHy
___ 17:02 1*
Source: ___
MISCELLANEOUS URINE Eos
___ 17:02 NEGATIVE 1
Source: ___
Radiology:
1.ANKLE (AP, MORTISE & LAT) RIGH Clip # ___
Reason: head - eval for bleedmax/face - eval for fxc-spine -
eval fo
UNDERLYING MEDICAL CONDITION:
History: ___ with trip and fall. +head strike. c/o ankle pain
as well.
REASON FOR THIS EXAMINATION:
head - eval for bleedmax/face - eval for ___-spine - eval for
fxankle - eval
for ___ - eval for rib fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
RIGHT ANKLE, THREE VIEWS: ___
HISTORY: ___ female with trip and fall with ankle pain.
FINDINGS: AP, lateral, and oblique views of the right ankle.
No prior.
There is an acute horizontally-oriented fracture through the tip
of the distal fibula. It extends to the ankle mortise. There
is no significant
displacement. No other fractures identified. Based on these
non-stress
views, the mortise appears congruent. Plantar calcaneal spur is
again
identified. Soft tissue swelling is seen adjacent to the
lateral malleolus.
IMPRESSION: Non-displaced horizontally-oriented fracture
through the distal right fibula as above.
2.CHEST (PA & LAT) Clip # ___
Reason: head - eval for bleedmax/face - eval for fxc-spine -
eval fo
UNDERLYING MEDICAL CONDITION:
History: ___ with trip and fall. +head strike. c/o ankle pain
as well.
REASON FOR THIS EXAMINATION:
head - eval for bleedmax/face - eval for ___-spine - eval for
fxankle - eval
for fxcxr - eval for rib fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with trip and fall.
FINDINGS: Frontal and lateral views of the chest are compared
to previous
exam from ___. The lungs are clear. There is no
effusion or
pneumothorax. The cardiomediastinal silhouette is normal.
Osseous and soft tissue structures are unremarkable noting no
displaced rib fracture.
IMPRESSION: No acute cardiopulmonary process.
3.CT HEAD W/O CONTRAST Clip # ___
Reason: head - eval for bleedmax/face - eval for fxc-spine -
eval fo
UNDERLYING MEDICAL CONDITION:
History: ___ with trip and fall. +head strike. c/o ankle pain
as well.
REASON FOR THIS EXAMINATION:
head - eval for bleedmax/face - eval for ___-spine - eval for
fxankle - eval
for fxcxr - eval for rib fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ___ ___ 1:28 ___
No ICH or calvarial frx. Scattered white matter hypodensities,
likely related to known MS. ___ foci of air within superior
sagittal sinus, may be related to IV placement. Right
supraorbital hematoma without globe deformity or retroorbital
involvement.
Wet Read Audit # 1
Final Report
INDICATION: ___ female with trip and fall and head
strike. Evaluate for fracture or intracranial hemorrhage.
TECHNIQUE: Contiguous axial MDCT sections were obtained through
the brain without administration of IV contrast. Axial images
were interpreted in conjunction with coronal, sagittal, and thin
bone slice reformats.
COMPARISONS: Multiple prior head MRs, most recently head MR
with and without contrast of ___.
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or large territorial infarction. The ventricles and
sulci are mildly prominent, compatible with age-related volume
loss. Scattered white matter hypodensities, including a
well-defined lesion in the right centrum semiovale, are
compatible with patient's known history of multiple sclerosis.
The basal cisterns appear patent, and there is preservation of
gray-white matter differentiation. A right supraorbital
hematoma is present without evidence of underlying globe
deformity or retroorbital involvement. The globes are normal in
appearance. No underlying fracture is identified. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION:
1. No intracranial hemorrhage or calvarial fracture.
2. Right periorbital hematoma without globe deformity or
retroorbital
involvement.
3. Scattered white matter hypodensities, likely related to
known MS.
4.CT ___ W/O CONTRAST Clip # ___
Reason: head - eval for bleedmax/face - eval for ___-spine -
eval fo
UNDERLYING MEDICAL CONDITION:
History: ___ with trip and fall. +head strike. c/o ankle pain
as well.
REASON FOR THIS EXAMINATION:
head - eval for bleedmax/face - eval for ___-spine - eval for
fxankle - eval
for fxcxr - eval for rib fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ___ ___ 1:38 ___
Mild anterolisthesis of C7 on T1, which may be related to facet
arthrosis at this level; please correlate with acute symptoms at
this site. C4-5 posterior disc bulge and C5-6 posterior disc
osteophyte complex indent the thecal sac without severe spinal
canal narrowing. No fracture or prevertebral soft tissue
abnormality.
Wet Read Audit # 1
Final Report
INDICATION: ___ female with trip and fall and head
strike.
Complaining of head pain. Evaluate for cervical spine fracture.
COMPARISON: None.
TECHNIQUE: Helical axial 2.5 mm sections were obtained through
the cervical spine from the skull base to the superior aspect of
T2. Axial images were interpreted in conjunction with coronal
and sagittal reformats.
FINDINGS: There is no evidence of fracture. Vertebral body
heights are
maintained. Multilevel degenerative changes are present, with
loss of
intervertebral disc space height at C5-C6 with a posterior disc
osteophyte complex at this level indenting the thecal sac
without significant spinal canal narrowing. Mild
anterolisthesis of C7 on T1 is likely degenerative and related
to facet arthrosis at this level. No prevertebral soft tissue
abnormality is present. The thyroid is unremarkable. No
cervical lymphadenopathy. The visualized lung apices are clear.
IMPRESSION:
1. No fracture or prevertebral soft tissue abnormality.
2. Mild anterolisthesis of C7 on T1, which may be related to
degenerative changes at this level; please correlate with acute
symptoms at this site.
5.CT SINUS/MANDIBLE/MAXILLOFACIA Clip # ___
Reason: head - eval for bleedmax/face - eval for ___-spine -
eval fo
UNDERLYING MEDICAL CONDITION:
History: ___ with trip and fall. +head strike. c/o ankle pain
as well.
REASON FOR THIS EXAMINATION:
head - eval for bleedmax/face - eval for ___-spine - eval for
fxankle - eval
for ___ - eval for rib fx
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ___ ___ 1:34 ___
Well-corticated osseous fragment adjacent to right mandibular
condyle within glenoid fossa, likely related to TMJ arthritis,
but please correlate with acute symptoms at this site.
Otherwise, no evidence of acute facial bone fracture.
Wet Read Audit # 1
Final Report
INDICATION: ___ female with trip and fall and head
strike. Evaluate for fracture.
COMPARISONS: None.
TECHNIQUE: Helical axial images were obtained through the
facial bones.
Axial images were interpreted in conjunction with coronal and
sagittal
reformats.
FINDINGS:
A well corticated osseous fragment adjacent to the right
mandibular condyle within the glenoid fossa is likely chronic
and may be related to TMJ degenerative changes. Otherwise,
there is no evidence of facial bone
fracture. The paranasal sinuses are normally aerated without
mucosal
thickening or air-fluid level. The ostiomeatal units are
intact. Cribriform plates are intact. Mastoid air cells and
middle ear cavities are clear.
Right periorbital hematoma is present without underlying
fracture, globe
deformity, or retroorbital involvement. The nasal bone and
orbital walls are intact.
IMPRESSION: Right periorbital hematoma. No evidence of acute
facial bone fracture.
6.MR HEAD W/O CONTRAST Clip # ___
Reason: ? PML, ? MS flare
UNDERLYING MEDICAL CONDITION:
___ year old woman with MS and new action myoclonus
REASON FOR THIS EXAMINATION:
? PML, ? MS flare
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with multiple sclerosis with new
symptoms,
question PML versus new lesions.
TECHNIQUE: FLAIR and fast inversion recovery axial and sagittal
FLAIR images
of the brain were acquired. Diffusion axial images of the brain
were
obtained. Comparison was made with the previous MRI of
___.
FINDINGS: Again multiple periventricular and subcortical
hyperintensities are identified. Compared to the prior study
there has been no significant interval change and no definite
new lesions are identified. There is mild prominence of
ventricles seen as before. There is no acute infarct.
IMPRESSION: Overall no significant change in appearance of the
brain, with signal abnormalities in the subcortical and
periventricular white matter compared with the previous MRI of
___. No definite new T2 lesions are identified. No
ill-defined abnormalities seen in the subcortical white matter.
7.MR ___ W/O CONTRAST Clip # ___
Reason: any MS plaques? anything to explain myclonus?
Contrast: PROHANCE Amt: 15
UNDERLYING MEDICAL CONDITION:
___ year old woman with MS and new action myoclonus
REASON FOR THIS EXAMINATION:
any MS plaques? anything to explain myclonus?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAM: MRI cervical spine.
CLINICAL INFORMATION: Patient with multiple sclerosis with new
action
myoclonus.
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of
cervical spine obtained before gadolinium. T1 sagittal and
axial images were obtained following gadolinium. Comparison was
made with the outside MRI of ___.
FINDINGS: Focal signal abnormality in the posterior portion of
the spinal cord is seen at C3-C4 level, unchanged from prior
study. No abnormal enhancement seen in this region. No other
discrete foci of signal abnormality identified. Subtle signal
abnormalities at C5 and C6 within the spinal cord on sagittal
inversion recovery images and appear artifactual as no
corresponding abnormalities are seen on axial images, nor there
is evidence of enhancement. Mild multilevel degenerative
changes with disc bulging noted from C3-4 to C6-7 as before.
IMPRESSION: Overall, no significant change in appearance of
cervical spinal cord compared with the previous outside MRI
examination of ___. Focal signal abnormality in the
posterior portion of the spinal cord are again noted at C3-4
level. Degenerative changes are again seen. No enhancing
lesions are identified.
8.RENAL U.S. Clip # ___
Reason: ELEVATED CREAT. QUERY PARENCHYMAL CHANGES,
HYDRONEPHROSIS
UNDERLYING MEDICAL CONDITION:
___ year old woman with ms, cirrhosis, DM, rising creatinine
REASON FOR THIS EXAMINATION:
Query parenchymal changes, hydronephrosis
Final Report
TYPE OF THE EXAM: RENAL ULTRASOUND.
REASON FOR THE EXAM: ___ woman with cirrhosis, diabetes
mellitus, and rising creatinine, query parenchymal changes and
hydronephrosis.
COMPARISON STUDIES: Ultrasound of the abdomen, dated ___ and renal ultrasound dated ___.
FINDINGS: The right kidney measures 9.8 cm and demonstrates no
evidence of hydronephrosis, nephrolithiasis or suspicious renal
masses. There is no significant parenchymal thinking. Left
kidney measures 9.9 cm without evidence of hydronephrosis,
nephrolithiasis or suspicious renal masses.
IMPRESSION:
1. No evidence of hydronephrosis, nephrolithiasis or suspicious
renal masses.
2. Stable renal size compared to the prior studies without
significant
parenchymal thinning.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with PMHx of DM2, CHF, HTN,
HL, MS and cirrhosis with portal hypertension who presented for
evaluation of right ankle injury and head trauma status post
fall. On initial admission, she was evaluated regarding her fall
and the extent of damage incurred, thus the following were
performed: CT SINUS/MANDIBLE/MAXILLARY, CT ___ W/O
CONTRAST,CT HEAD W/O CONTRAST, CHEST (PA & LAT),ANKLE (AP,
MORTISE & LA). All imaging was normal, apart from ankle XR that
determined she had a R distal fibula fracture and CT sinus that
showed a Right periorbital hematoma.
She was evaluated by orthopedics who felt the patient could be
weight bearing as tolerated and requested that an orthopedic
boot was fitted.
On subsequent exam, it was determined that she had jerking
movement of all 4 extremities when she tried to move them or get
up to the bathroom. In the ED, her primary neurologist was
called who felt that given the timing of the symptoms she was
experiencing this was not an MS flare ___ quick an onset) and
was more likely a medication side effect, possibly from the
Percocets the patient was receiving in the ED. She was admitted
to neurology for further workup and treatment. MRI ___ (w/
and w/out contrast) and head (w/contrast) were performed to
rule-out an MS ___- there were overall no significant changes
in spine/brain indicative of a flare.
___ was consulted during this admission, with the following
recommendations: She will benefit from skilled ___ in the rehab
setting to maximize her functional independence and return her
to her baseline level of function. Good rehab prognosis d/thigh
level of motivation, prior level of function, supportive
family but she is negatively impacted by her multiple
comorbidities.
She is being discharged to an Extended Care Facility: ___
Rehab for the purpose of rehabilitation following her injuries
sustained prior to admission (primarily her broken fibula)
before returning to her home in ___. She will be followed up
by her PCP.
Ms. ___ have her regular ___ infusion on ___
___.
Medications on Admission:
- clonazepam 0.25mg Q4H PRN leg pain
- janumet 50/500mg QD
- MVI
- neurontin 1200mg Qdinner and QHS
- oxcarbazepine 150-300mg QAM
- provigil 100mg BID
- tysabril 300mg IV Qmonthly
- atenolol 50mg QD
- folic acid 1mg QD
- lasix 40mg QD
- metformin 500mg QD
- omeprazole 20mg QD
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
2. Clonazepam 0.25 mg PO Q4H:PRN leg pain
3. Multivitamins 1 TAB PO DAILY
4. Gabapentin 1200 mg PO BID
At dinner and at bedtime.
5. Provigil *NF* (modafinil) 100 mg Oral BID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
6. Atenolol 50 mg PO DAILY
Hold for SBP <110
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 40 mg PO DAILY
Hold for SBP <110
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
13. Oxcarbazepine 300 mg PO DAILY
14. Pravastatin 20 mg PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
16. Spironolactone 25 mg PO DAILY
Hold for SBP <110
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN to the
itchy spots on skin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fibular 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:
You were admitted to the hospital after a fall. You were found
to have a fibular fracture. You had a CT head, which did not
show a bleed in your head, and a CT of your neck that showed no
acute fracture or injury. The orthopedic surgeons recommended an
ortho boot for your foot.
You then developed some jerking motions (myoclonus). This is
likely secondary to the pain killers or metabolic abnormalities,
which improved with hydration and after switching your
antibiotics. Your outpatient neurologist, Dr. ___, was
called, and we agreed that these events were not consistent with
a multiple sclerosis flare. We also performed MRI of the head
and cervical spine, which did not show any new lesions.
Your kidney lab tests (creatinine) was slightly elevated during
this admission. This was likely a combination of the Bactrim you
were taking for a UTI, and some dehydration. It improved after
we switched
you from Bactrim to Augmentin.
Followup Instructions:
___
|
19622090-DS-20
| 19,622,090 | 25,845,376 |
DS
| 20 |
2196-06-12 00:00:00
|
2196-06-22 17:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / bee sting / bandaid / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Bactrim
Attending: ___.
Chief Complaint:
dysuria
Major Surgical or Invasive Procedure:
___ guided PICC insertion on ___
History of Present Illness:
Ms. ___ is a ___ with hx relapsing-remitting MS with
associated neurogenic bladder requiring CIC, NASH cirrhosis, DM
type II, MDS, HFpEF, and recurrent ESBL klebsiella pneumoniae
UTIs who is presenting with one day of dysuria, cloudy urine and
suprapubic tenderness. She had recent treatment with 21 days
Ertapenem for Klebsiella UTI, midline catheter removed one week
ago. Recent fall on ___ due to increasing MS symptoms. UA on
___ showed clear urine, but culture grew enterococcus,
decision was made not to treat at that time due to no urinary
symptoms. She self catheterizes twice daily for residual, no
indwelling cath. She endorses a slight increase in lower
extremity and abdominal bloating from baseline. Otherwise denies
worsening of MS symptoms, CP, blood in the urine or stool, N/V/D
or decreased PO intake.
She was most recently admitted from ___ with a
similar presentation of dysuria during which she was empirically
placed on meropenem for a UTI, though urine cultures were
negative. Per previous notes, the ___ had recently initiated
fosfomycin suppressive therapy prior to that admission.
In the ED, initial vitals: 97.3F, HR 66, BP 119/40, RR 16, 98%
RA
Labs were significant for:
BUN 31, Cr 1.4, WBC 3.4, Hg 9.3, Hct 26.2, Platelets 42
UA with large leukocytes, 15 RBCs, >182 WBCs, few bacteria
In the ED, she received Zosyn 4.5 g IV x 1, Vancomycin 1g x 1
Vitals prior to transfer: 98.6F, HR 60, BP 110/51, RR 16, 98%
RA
Upon arrival, ___ denies fevers, chills, back pain, or
significant abdominal pain. She is still having dysuria and foul
smelling urine.
Past Medical History:
-DM type II
-CKD
-NASH Cirrhosis
-Multiple sclerosis (relapsing/remitting)
--On Tysabri
--neurogenic bladder requiring CIC BID
-Recurrent UTIs
-MDS
-___ on CPAP
-___
-Diastolic CHF
-R breast cancer s/p lumpectomy and XRT
-GERD
-h/o R ankle fracture
-s/p cholecystectomy
-s/p hysterectomy
-s/p bladder suspension surgery
Social History:
___
Family History:
No family hx of MS; mother had bladder CA
Physical Exam:
ADMISSION:
VS: T97.9 159/62 HR65 RR18 96% RA
GEN: Alert, lying in bed, no acute distress
HEENT: healing ecchymosis on side of face; Moist MM, anicteric
sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, mild suprapubic tenderness, non-distended
EXTREM: Warm, well-perfused, 2+ edema bilaterally
NEURO: CN II-XII grossly intact, ___ strength in LLE.
DISCHARGE:
VS: 98.3 100-122/54-60 ___ 18 93RA
GEN: Alert, lying in bed, no acute distress.
HEENT: healing ecchymosis on side of face; Moist MM, anicteric
sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, mild suprapubic tenderness, non-distended
EXTREM: Warm, well-perfused, 2+ edema bilaterally
NEURO: CN II-XII grossly intact, ___ strength in LLE, improving
from yesterday's exam.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
=======================
___ 01:35PM BLOOD WBC-3.4* RBC-2.87* Hgb-9.3* Hct-26.2*
MCV-91 MCH-32.4* MCHC-35.5 RDW-13.6 RDWSD-45.1 Plt Ct-42*
___ 01:35PM BLOOD Neuts-62.3 ___ Monos-5.6 Eos-2.4
Baso-0.3 NRBC-0.9* Im ___ AbsNeut-2.12 AbsLymp-0.97*
AbsMono-0.19* AbsEos-0.08 AbsBaso-0.01
___ 01:35PM BLOOD Plt Ct-42*
___ 01:35PM BLOOD Glucose-298* UreaN-31* Creat-1.4* Na-136
K-4.0 Cl-98 HCO3-28 AnGap-14
MICRO:
=====
___ 11:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
=======
none
LABS AT DISCHARGE:
================
___ 06:55AM BLOOD WBC-2.5* RBC-2.58* Hgb-7.8* Hct-24.0*
MCV-93 MCH-30.2 MCHC-32.5 RDW-13.6 RDWSD-46.2 Plt Ct-38*
___ 06:55AM BLOOD Glucose-125* UreaN-27* Creat-1.3* Na-139
K-4.0 Cl-103 HCO3-30 AnGap-10
Brief Hospital Course:
Ms. ___ is a ___ with hx relapsing-remitting MS with
associated neurogenic bladder requiring CIC, NASH cirrhosis, DM
type II, MDS, HFpEF, and recurrent ESBL klebsiella pneumoniae
UTIs who presented with one day of dysuria, cloudy urine and
suprapubic tenderness with UA c/f recurrent UTI.
#Recurrent MDR UTI.
Recently completely a 21d course of ertapenem for MDR klebsiella
UTI (completed on ___. She has not taken fosfomycin ppx since
that time given prior failure of this method to prevent
recurrence. Prior to admission, UA on ___ notable for
enterococcus sensitive to vancomycin. No treatment at that time
given lack of symptoms. On day of admission, Ms. ___
developed dysuria and cloudy foul-smelling urine consistent with
past UTIs. UA in the ED notable for > 182 WBCs. She was admitted
and started on empiric vancomycin and meropenem. Unfortunately,
repeat culture ultimately resulted in no growth. ID was
consulted who recommended discontinuing vancomycin given likely
culprit was recurrent klebsiella. ___ continued on meropenem
and PICC line was placed prior to transitioning to 7 days of
ertapenem as per ID recommendations. Further management of
recurrent UTIs, including ppx, will be coordinated with
outpatient ID specialist, Dr. ___.
# Acute on Chronic Kidney Injury - ___ with elevated Cr at
1.5 on admission, improved to baseline 1.2-1.3 on discharge.
# Multiple Sclerosis.
Continued home modafinil, tamsulosin, gabapentin, oxcarbazepine,
and tramadol.
___ endorsed worsening lower extremity weakness that
gradually improved with treatment of infection.
# T2DM
- Held home metformin and liraglutide and resumed on discharge.
No significant high or low glucose levels.
# hx of Breast Ca
Continued home anastrozole.
# HLD
Continued home pravastatin.
# MDS
___ with pancytopenia with WBC 3.4, Hg 9.3, Hct 26.2,
Platelets 42 on admission. Stable per OMR.
TRANSITIONAL ISSUES:
=================
- Will require treatment with ertapenem for 7 days total (day 1
= ___
- Will require removal of PICC line following abx therapy.
- close f/u with outpatient ID specialist and PCP regarding
further management of MDR UTIs.
- Rec continued ongoing multi-disciplinary approach to
management of relapsing/remitting MS with immunomodulation and
symptom management.
- Rec repeat CBC at PCP visit to assess for worsening
pancytopenia while on antibiotics.
# CODE STATUS: full, confirmed.
# CONTACT: ___ ___ ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anastrozole 1 mg PO DAILY
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 500 mg PO
TID
3. Carvedilol 12.5 mg PO BID
4. ClonazePAM 0.25 mg PO QHS:PRN anxiety/insomnia
5. estradiol 10 mcg vaginal 2X/WEEK
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Gabapentin 1200 mg PO BID
11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
12. MetFORMIN (Glucophage) 500 mg PO DAILY
13. Modafinil 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. natalizumab 300 mg/15 mL injection Other
16. Omeprazole 20 mg PO DAILY
17. OXcarbazepine 150 mg PO BID
18. Pravastatin 20 mg PO QPM
19. Spironolactone 100 mg PO DAILY
20. TraMADol 25 mg PO QAM
21. TraMADol 25 mg PO QPM
22. TraMADol 50 mg PO QHS
23. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 g daily Disp #*6 Vial Refills:*0
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Natalizumab 300 mg injection QMONTHLY
4. Anastrozole 1 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 500 mg PO
TID
6. Carvedilol 12.5 mg PO BID
7. ClonazePAM 0.25 mg PO QHS:PRN anxiety/insomnia
8. Estradiol 10 mcg vaginal 2X/WEEK (MO,FR)
9. Ferrous GLUCONATE 324 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 1200 mg PO BID
13. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
14. MetFORMIN (Glucophage) 500 mg PO DAILY
15. Modafinil 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. OXcarbazepine 150 mg PO BID
19. Pravastatin 20 mg PO QPM
20. Spironolactone 100 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. TraMADol 25 mg PO QAM
23. TraMADol 25 mg PO QPM
24. TraMADol 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- urinary tract infection (unknown organism)
- ___ on CKD
- Multiple sclerosis c/b neurogenic bladder
Secondary diagnosis:
- T2DM
- ___ cirrhosis
- MDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with a recurrent urinary tract
infection. Ultimately your urine culture did not grow a
causative organism. Given your history of frequent multidrug
resistant UTIs, we consulted our infectious disease team, who
decided to treat empirically with an additional seven days of
ertapenem, which you can receive at home via ___ line.
Please continue to take all other medications as prescribed and
follow up with your PCP and outpatient ID doctor. If you
develop any of the danger signs listed below, please call your
doctor or return to the emergency room immediately.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19622090-DS-21
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DS
| 21 |
2196-07-22 00:00:00
|
2196-07-22 17:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / bee sting / bandaid / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Bactrim
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with hx relapsing-remitting MS on ___
with associated neurogenic bladder requiring CIC, ___
cirrhosis, DM type II, MDS, HFpEF, CKD and recurrent ESBL
klebsiella pneumoniae UTIs who presents today after a fall with
headstrike. The patient was taking out her trash and reportedly
fell down ___ steps. She is amnestic to the event but remembers
icy handrails. She was found prone with a bleeding head
laceration and was awake and alert. It is unclear if she lost
consciousness.
Past Medical History:
-DM type II
-CKD
-___ Cirrhosis
-Multiple sclerosis (relapsing/remitting)
--On ___
--neurogenic bladder requiring CIC BID
-Recurrent UTIs
-MDS
-___ on CPAP
-___
-Diastolic CHF
-R breast cancer s/p lumpectomy and XRT
-GERD
-h/o R ankle fracture
-s/p cholecystectomy
-s/p hysterectomy
-s/p bladder suspension surgery
Social History:
___
Family History:
No family hx of MS; mother had bladder CA
Physical Exam:
On admission:
Gen: Elderly female with head bandage lying on stretcher in NAD.
HEENT: Pupils: PERRL EOMs Fyll
Neck: Supple.
Lungs: No respiratory distress
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. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2.5mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength R delt ___ (pain limited), R IP ___, otherwise
full power ___ throughout. No pronator drift
Sensation: Intact to light touch
DISCHARGE:
====================================
Vitals: 98.3 114/63 72 18 97RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear; posterior head
lac, c/d/I with sutures in place (placed ___ dried blood
in hair
Neck: supple, bruising over right neck
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no fluid
wave
GU: no foley, no CVAT b/l
Ext: warm, well perfused, 2+ pulses, trace edema in b/l ___
Neuro: A&Ox3, appropriately interactive; MAE, non-focal.
Decreased sensation in ___.
Skin: multiple bruises and abrasions over b/l knees, thighs, and
arms
ACCESS: LUE PICC
Pertinent Results:
ADMISSION LABS:
===========================
___ 01:33PM BLOOD WBC-5.4 RBC-2.88* Hgb-9.3* Hct-26.6*
MCV-92 MCH-32.3* MCHC-35.0 RDW-14.6 RDWSD-48.9* Plt Ct-42*
___ 01:33PM BLOOD Neuts-73.0* ___ Monos-4.1*
Eos-1.1 Baso-0.4 NRBC-0.7* Im ___ AbsNeut-3.97
AbsLymp-1.13* AbsMono-0.22 AbsEos-0.06 AbsBaso-0.02
___ 12:59PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-2+
Schisto-OCCASIONAL Stipple-1+ Tear Dr-1+
___ 01:33PM BLOOD ___ PTT-29.9 ___
___ 04:40PM BLOOD ___ 12:59PM BLOOD Ret Aut-3.6* Abs Ret-0.08
___ 01:33PM BLOOD Glucose-320* UreaN-28* Creat-1.4* Na-140
K-4.3 Cl-103 HCO3-28 AnGap-13
___ 03:12AM BLOOD ALT-12 AST-18 LD(LDH)-172 AlkPhos-70
TotBili-0.3
___ 03:12AM BLOOD Albumin-3.1* Calcium-8.0* Phos-2.9 Mg-2.0
Iron-68
___ 03:12AM BLOOD calTIBC-246* ___ Ferritn-33 TRF-189*
MICROBIOLOGY:
===========================
+ ___ Urine Culture: Klebsiella Pneumoniae (MDR), sensitive
to ciprofloxacin, gentamycin, and meropenem
IMAGING/OTHER STUDIES:
===========================
+ CXR ___:
BORDERLINE CARDIOMEGALY IS STABLE. LUNGS FULLY EXPANDED AND
CLEAR. NO PLEURAL EFFUSION. LEFT PIC LINE ENDS IN THE REGION OF
THE SUPERIOR CAVOATRIAL JUNCTION. Although no acute fracture or
other chest wall lesion is seen, conventional chest radiographs
are not sufficient for detection or characterization of most
such abnormalities. If the demonstration of trauma to the chest
wall is clinically warranted, the location of any referable
focal findings should be clearly marked and imaged with either
bone detail radiographs or Chest CT scanning.
+ CT HEAD ___:
1. Unchanged acute left frontal subdural hematoma measuring up
to 6mm. Small focus of subdural hemorrhage along the left
anterior falx is also unchanged.
2. Hyperdense focus within a right parietal lobe sulcus is
compatible with an additional focus of subarachnoid hemorrhage,
which was not definitively seen on the prior examination.
3. Right parietal scalp laceration and hematoma without evidence
of underlying fracture.
+ CT ABD/PELVIS ___:
1. No acute traumatic injury within the abdomen or pelvis.
2. Cirrhotic appearing liver with sequela of portal hypertension
including splenomegaly and ascites.
3. Fat containing ventral hernia.
+ CT HEAD ___:
1. Left frontal subdural hematoma measuring up to 5 mm, not
significantly changed compared to the prior study.
2. No evidence of midline shift.
3. Small left anterior falx subdural hemorrhage and punctate
right parietal subarachnoid hemorrhage, unchanged.
4. Right parietal scalp hematoma with laceration and
subcutaneous emphysema without underlying fracture.
+ ENDOSCOPY (___):
4 cords of small/medium varices were seen in the esophagus.
There was some inflammatory-appearing nodularity of the antrum.
There is friable pyloric channel polyp which is prolapsing in
and out of the proximal duodenum. No bleeding was seen on
initial evaluation, but the polyp started oozing substantially
after biopsy. Cold forceps biopsies were performed for histology
at the antrum and pyloric polyp. Normal duodenum. Impression:
Esophageal varices
There was some inflammatory-appearing nodularity of the antrum.
There is friable pyloric channel polyp which is prolapsing in
and out of the proximal duodenum. No bleeding was seen on
initial evaluation, but the polyp started oozing substantially
after biopsy. (biopsy)
Recommendations: Will follow up biopsy report and inform patient
Polypectomy will be very high risk for bleeding given
coagulopathy and thrombocytopenia, so will discuss risk/benefit
with hepatology team. Continue PPI
+ COLONOSCOPY (___): No large lesions or bleeding was seen,
although prep was suboptimal for identification of small polyps
DISCHARGE PHYSICAL EXAM:
===============================
___ 05:18AM BLOOD WBC-2.2* RBC-2.49* Hgb-7.7* Hct-22.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.2 RDWSD-46.7* Plt Ct-37*
___ 04:16AM BLOOD ___ PTT-27.5 ___
___ 05:18AM BLOOD Glucose-183* UreaN-19 Creat-1.1 Na-135
K-3.8 Cl-99 HCO3-27 AnGap-13
___ 04:52AM BLOOD ALT-11 AST-19 LD(LDH)-163 AlkPhos-73
TotBili-0.6
___ 05:18AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a PMH notable for NASH
cirrhosis c/b pancytopenia, relapsing remitting MS on ___
c/b recurrent falls, dCHF, OSA, T2DM, and recurrent MDR UTI's
who was admitted for fall c/b small L SDH and head lac I/s/o
recurrent MDR Klebsiella UTI. Hospital course complicated by
waxing and waning headache, photophobia, vertigo and diplopia
attributed to new ___, which showed interval improvement on
serial cross-sectional imaging and acute on chronic anemia
attributed to scalp laceration and upper gastrointestinal
bleeding.
# Upper Gastrointestinal Bleed:
# Acute anemia:
Patient with history of pancytopenia of likely multifactorial
etiology ___ underlying liver disease, kidney disease and
probable bone marrow disease. Her baseline WBC is ~3, Hgb ~9,
and Plts ~50. The patient however, since admission has had an
acute drop in Hgb from ~9 to 6.5 from ___ to ___ with loose
BM that was guaiac positive, raising suspicion for anemia due to
GIB vs. blood loss from fall and head injuries. Given her
history of cirrhosis and known varices per last EGD in ___,
there is concern albeit limited given hemodynamic stability that
this could be variceal bleed and so endoscopy with surveillance
colonoscopy pursued. ___ completed ___ without evidence of
active bleed but friable mucosa. Recommended to continue high
dose PPI and followup with hepatology. Continued home iron and
folate supplementation.
[ ] f/u biopsy results from endoscopy
# Thrombocytopenia
# Asterixis
# NASH Cirrhosis: Patient with h/o NASH cirrhosis without note
of prior SBP or ascites. She appeared mildly decompensated with
asterixis on presentation but without signs of synthetic liver
dysfunction. Rifaximin chosen over lactulose given patient's
unsteady gait, recurrent MDR UTIs with concern that lactulose
could precipitate more UTIs. She was continued on home
diuretics. Continue rifaxmin. Followup with cardiology.
[ ] continue rifaximin
# UTI with MDR Klebsiella Pneumoniae: Patient has extensive h/o
UTI with MDR resistant organisms. Given this history and
intermittent sensitivity to cipro, using carbapenem. Patient
completed 7 day course with ___.
PICC line kept in place given history of recurrent UTIs.
[ ] She will need ID followup.
# SDH: Patient with small, traumatic L SDH, which was stable on
serial imaging. Current symptoms are minor psychomotor slowing,
headache, and waxing and waning diplopia. Changing symptoms
prompted repeat head CT on ___ which showed improvement in SDH
size. She completed 1 week of Keppra while inpatient.
[ ] She will need Repeat head CT and appointment with ___
Neurosurgery in 4 weeks Dr ___
# Scalp laceration:
# Fall: Patient appeared to fall without any preceding symptoms
or LOC concerning for pre/syncopal sx. Tele also without any
concerning findings, EKG without appreciable abnormalities.
Injuries sustained include SDH (detailed below) as well as
multiple lacs, notably to head. She was given Tylenol/tramadol
for pain
[ ] suture removal in ___ days (placed ___
CHRONIC ISSUES:
=================================
# Chronic, compensated diastolic CHF: last TTE in ___ with
EF55% and normal RV/LV function without elevated PASP or
significant valvular disease. Continued home meds
# Neurogenic bladder:
# MS: Patient with h/o MS on monthly ___: continued home
modafinil, calcium and vit D supplementation, vitamin C, MVI.
Continued home CIC and tamsulosin
# OSA: on CPAP, but unable to tolerate due to bad headache from
SDH and associated pain from head lac.
# H/o R breast CA s/p Mastectomy: on anastrazole as maintenance
therapy. Continued
#Neuropathy: Patient with chronic neuropathy of extremities,
unclear if due to diabetes (unlikely given recent, well
controlled A1c) or MS. ___ continue home gabapentin and
anastrazole
#T2DM: Patient on victoza and metformin as outpatient. ISS while
inpatient
#CKD: patient with mildly elevated Cr of 1.4 on admission, but
now with baseline Cr of 1.2.
#Insomnia: continued home clonazepam 0.5mg PO qHS
TRANSITIONAL ISSUES:
==============================
#Communication: ___ (Nephew/___ - ___
___ (___)
[ ] suture removal in ___ days (placed ___
[ ] She will need Repeat head CT and appointment with ___
Neurosurgery in 4 weeks Dr ___
[ ] She will need ID followup.
[ ] f/u biopsy results from endoscopy
[ ] continue rifaximin
Medications on Admission:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 g daily Disp #*6 Vial Refills:*0
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Natalizumab 300 mg injection QMONTHLY
4. Anastrozole 1 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 500 mg PO
TID
6. Carvedilol 12.5 mg PO BID
7. ClonazePAM 0.25 mg PO QHS:PRN anxiety/insomnia
8. Estradiol 10 mcg vaginal 2X/WEEK (MO,FR)
9. Ferrous GLUCONATE 324 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 1200 mg PO BID
13. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
14. MetFORMIN (Glucophage) 500 mg PO DAILY
15. Modafinil 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. OXcarbazepine 150 mg PO BID
19. Pravastatin 20 mg PO QPM
20. Spironolactone 100 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. TraMADol 25 mg PO QAM
23. TraMADol 25 mg PO QPM
24. TraMADol 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
======================
# Subdural hematoma
# Upper Gastrointestinal Bleed:
# Acute anemia:
# Complicated UTI
SECONDARY:
==================
# ___ cirrhosis
# Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted to ___ after a fall at home. You had a UTI that
likely lead to the fall. You were found to have a cut on your
head and small bleed inside your head. You were seen by surgery
who repaired your cut and felt that you did not need
neurosurgery. While in the hospital your blood counts dropped
and we were concerned that you had a GI bleed. We gave you
medications to prevent bleeding and did an endoscopy and
colonoscopy which showed no active bleeding. You are now safe to
go to an acute rehab to regain your strength prior to returning
home to your dogs.
You have followup appointments below.
We wish you the best,
Your ___
PS: These are the discharge instruction from the neurosurgery
service below.
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.
-___ 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:
___
|
19622090-DS-22
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2196-12-02 00:00:00
|
2196-12-02 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / bee sting / bandaid / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Bactrim
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o relapsing-remitting MS on ___, neurogenic bladder
requiring intermittent catheterization & recurrent ESBL
klebsiella pneumoniae UTIs who presents after a fall. She just
returned from a vacation in ___ and fell with neck strike
against a table. Initially, her voice was hoarse with associated
hemoptysis. The hoarseness stabilized, and she presented to the
ED for evaluation.
Past Medical History:
-DM type II
-CKD
-___ Cirrhosis
-Multiple sclerosis (relapsing/remitting)
--On ___
--neurogenic bladder requiring CIC BID
-Recurrent UTIs
-MDS
-___ on CPAP
-___
-Diastolic CHF
-R breast cancer s/p lumpectomy and XRT
-GERD
-h/o R ankle fracture
-s/p cholecystectomy
-s/p hysterectomy
-s/p bladder suspension surgery
Social History:
___
Family History:
No family hx of MS; mother had bladder CA
Physical Exam:
Admission Physical Exam:
Vitals: 97.9 87 130/66 18 98% RA
GEN: A&O, NAD; hoarse voice
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R, no stridor
ABD: Soft, nondistended, nontender, no rebound or guarding,
palpable hernia, nonreducible, no TTP
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: 98.5 ___
GEN: A&O, NAD; hoarse voice improved
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no murmurs
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
2-3 cm palpable hernia on LLQ, non-reducible, no TTP.
Ext: No ___ edema, ___ warm and well perfused
GU: no foley in place
Neuro: AOx3
Pertinent Results:
___ 05:34AM BLOOD WBC-2.8* RBC-3.02* Hgb-9.2* Hct-27.1*
MCV-90 MCH-30.5 MCHC-33.9 RDW-14.8 RDWSD-48.7* Plt Ct-36*
___ 06:23AM BLOOD WBC-3.0* RBC-3.11* Hgb-9.4* Hct-28.1*
MCV-90 MCH-30.2 MCHC-33.5 RDW-15.4 RDWSD-51.1* Plt Ct-36*
___ 09:19PM BLOOD WBC-4.0# RBC-3.21*# Hgb-9.8*# Hct-28.8*#
MCV-90 MCH-30.5 MCHC-34.0 RDW-15.2 RDWSD-50.0* Plt Ct-34*
___ 05:31AM BLOOD WBC-2.5* RBC-2.36* Hgb-7.4* Hct-21.9*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.7 RDWSD-46.5* Plt Ct-38*
___ 03:24PM BLOOD WBC-3.5* RBC-2.62* Hgb-8.1* Hct-24.2*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.5 RDWSD-45.6 Plt Ct-40*
___ 06:02AM BLOOD WBC-2.6* RBC-2.58* Hgb-7.9* Hct-23.4*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.5 RDWSD-44.1 Plt Ct-41*
___ 10:40PM BLOOD WBC-4.2# RBC-3.19* Hgb-9.6* Hct-29.0*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.2 RDWSD-43.6 Plt Ct-46*
___ 05:34AM BLOOD Glucose-277* UreaN-34* Creat-1.6* Na-135
K-4.0 Cl-101 HCO3-25 AnGap-13
___ 06:23AM BLOOD Glucose-221* UreaN-40* Creat-1.6* Na-136
K-4.4 Cl-103 HCO3-24 AnGap-13
___ 05:31AM BLOOD Glucose-169* UreaN-37* Creat-1.5* Na-137
K-3.5 Cl-102 HCO3-25 AnGap-14
___ 03:24PM BLOOD Glucose-383* UreaN-40* Creat-1.7* Na-137
K-3.4 Cl-99 HCO3-25 AnGap-16
___ 06:02AM BLOOD Glucose-361* UreaN-38* Creat-1.6* Na-134
K-3.4 Cl-97 HCO3-28 AnGap-12
___ 10:40PM BLOOD Glucose-150* UreaN-22* Creat-1.2* Na-139
K-3.8 Cl-99 HCO3-30 AnGap-14
___ 05:34AM BLOOD CK(CPK)-27*
___ 05:34AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.2
___ 06:23AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.4
___ 05:31AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.4
___ 03:24PM BLOOD Calcium-8.4 Phos-2.9 Mg-2.5
___ 06:02AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.9*
___ 09:19PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:19PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 11:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:30PM URINE RBC-0 WBC-30* Bacteri-NONE Yeast-NONE
Epi-0
___ 11:30PM URINE CastHy-9*
___ 10:48PM URINE Hours-RANDOM UreaN-789 Creat-99 Na-21
Cl-20
___ 10:48PM URINE Osmolal-435
___ 10:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:30 pm URINE
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 CFU/mL.
Daptomycin Sensitivity testing per ___ ___ (___)
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ 9:19 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
___ CT chest
1. No acute rib fracture, pneumothorax, pulmonary hemorrhage or
findings to explain hemoptysis.
2. Cirrhotic liver morphology with evidence of portal
hypertension including small volume ascites and splenomegaly.
3. Small enhancing right breast lesion compatible with known
breast cancer
recurrence.
___ CT Head:
1. No evidence of an acute intracranial hemorrhage or fracture.
2. Grossly stable white matter hypodensities compatible with
patient's known history of multiple sclerosis.
___ CT/CTA neck:
1. No evidence of hematoma or major neck vessel injury. Patency
of the
cervical vessels without stenosis or dissection.
2. No evidence of a discrete fracture, accounting for
heterogeneous appearance of the cartilaginous structure from
osteopenia. If clinically warranted, MRI is a more sensitive
means for further evaluation, especially for underlying
ligamentous injury.
3. No subcutaneous emphysema to suggest tracheal fracture.
4. Minimal anterolisthesis of C7 on T1, unchanged.
5. Multilevel cervical spondylosis with mild spinal canal
narrowing at C4-C5 and C5-C6.
___ Chest Portable:
Shallow inspiration accentuates heart size, pulmonary
vascularity. No edema no sizable pleural effusion. Minimal
basilar opacities, likely atelectasis, similar to prior. Left
PICC line tip at cavoatrial junction. No pneumothorax.
IMPRESSION:
PICC line.
___ Pelvis Xray:
1. No displaced pelvic or proximal femoral fracture.
2. Degenerative changes as described.
Brief Hospital Course:
Ms. ___ is a ___ yo F with DM II, CKD, NASH Cirrhosis,
neurogenic bladder, recurrent urinary tract infections,
obstructive sleep apnea, anemia, diastolic heart failure,
history of breast cancer, and non incarcerated abdominal hernia
who presented to the emergency department after a mechanical
fall striking her neck on a coffee table. Acute Care trauma
surgery and ENT were consulted for further evaluation. CT neck
was done and showed no evidence of hematoma or major neck vessel
injury and no acute fracture. CT head, neck, chest, abdomen
negative for acute traumatic injury. The patient was admitted to
the Acute Care Surgery service on ___ for airway monitoring
and pain management.
On HD1 the patient was given 10 mg decadron x 3 doses for
swelling. She was given humidified oxygen. Patient passed
bedside speech and swallow text and was given a diabetic diet
with good tolerability. She remained stable from a
cardiopulmonary standpoint. Baseline twice daily urinary
catheterization schedule was maintained.
On HD2 the patient underwent fiber optic endoscopy with the ear,
nose, and throat surgery team which showed ecchymotic changes to
the bilateral arytenoids, L>R with mild edema that does not
obstruct the airway, edema appears to be improved from prior
exam. There is also ecchymosis of the bilateral false cords. The
airway is widely patent. She remained neurologically intact and
hemodynamically stable on home medications. Lasix was held in
setting of acute on chronic kidney injury with creatinine of
1.6. She was given 1 liter IV fluids. ___ diabetes
was consulted to manage her elevated glucose in setting of type
II diabetes, on metformin and victoza, and steroid dosing. She
was started on Lantus and insulin sliding scale with good
control. Once discharged to home plan to resume regular
medication and monitor blood glucose.
On HD3 hematocrit drifted from 23.4 on admission to 21.9 with no
obvious source of bleeding. She was given 2 units of packed red
blood cells and repeat hematocrit appropriately increased to
28.8. Patient had scheduled appointment for chemotherapy and did
not go due to inpatient status; oncology team notified and okay
with missing dose. Urine culture sent due to cloudy appearance
and history of frequent urinary tract infections. Culture showed
enterococcus that was MDR (sensitive to vancomycin). Infectious
disease consulted and the patient was started on vancomycin with
renal dosing for a total of 3 doses every 48 hours.
She was seen and evaluated by physical therapy who recommended
discharge to rehab.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance, voiding adequate urine, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged to
rehab with follow up appointments scheduled. Repeat chemistry to
evaluate creatinine recommended 1 week post discharge.
Transitional Issues
-------------------
[] needs Chem10 check in one week. RE: monitor creatinine. Last
checked ___ Cr 1.6
[] One more doses of vancomycin required: ___ at 12 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 3000 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Gabapentin 1200 mg PO AT DINNER, QHS
4. ___ (natalizumab) 300 mg/15 mL injection every month
5. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
6. Rifaximin 550 mg PO BID
7. Anastrozole 1 mg PO DAILY
8. Ascorbic Acid ___ mg PO BID
9. Baclofen 2.5 mg PO PRN Muscle Spasms
10. ClonazePAM 0.25 mg PO QHS
11. Docusate Sodium 200 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
15. Modafinil 100 mg PO BID
16. Omeprazole 20 mg PO BID
17. OXcarbazepine 150 mg PO BID
18. Pravastatin 20 mg PO QPM
19. Spironolactone 100 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
21. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
22. Ferrous Sulfate 325 mg PO DAILY
23. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
24. lactobacillus combo ___ billion cell oral daily
25. EPINEPHrine (EpiPEN) 0.3 mg IM PRN Allergy
26. ___ (cranberry extract) 1000 mg oral TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
3. Ferrous GLUCONATE 324 mg PO DAILY
4. Glargine 20 Units Bedtime
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Vancomycin 1000 mg IV Q48H Duration: 3 Doses
6. Anastrozole 1 mg PO DAILY
7. Ascorbic Acid ___ mg PO BID
8. Baclofen 2.5 mg PO PRN Muscle Spasms
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
10. ClonazePAM 0.25 mg PO QHS
11. ___ (cranberry extract) 1000 mg oral TID
12. Docusate Sodium 200 mg PO BID
13. EPINEPHrine (EpiPEN) 0.3 mg IM PRN Allergy
14. Ferrous Sulfate 325 mg PO DAILY
15. Fish Oil (Omega 3) 3000 mg PO DAILY
16. FoLIC Acid 1 mg PO DAILY
17. Furosemide 40 mg PO DAILY
18. Gabapentin 1200 mg PO AT DINNER, QHS
19. lactobacillus combo ___ billion cell oral daily
20. Modafinil 100 mg PO BID
21. Multivitamins 1 TAB PO DAILY
22. Natalizumab (natalizumab) 300 mg/15 mL injection EVERY
MONTH
23. Omeprazole 20 mg PO BID
24. OXcarbazepine 150 mg PO BID
25. Pravastatin 20 mg PO QPM
26. Rifaximin 550 mg PO BID
27. Spironolactone 100 mg PO DAILY
28. Tamsulosin 0.4 mg PO QHS
29. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
30. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until you go home.
31. HELD- Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY This medication was held. Do not restart
Victoza 2-Pak until you go home.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mechanical fall from standing sustaining bilateral arytenoid
ecchymosis and edema, L>R; ecchymosis of the bilateral false
cords. B/l cords mobile. pooling of old blood in post-cricoid
region.
Acute on Chronic Kidney Injury
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall sustaining an injury to throat. You were seen and
evaluated by the ear, nose, and throat specialists and found to
have swelling in your neck and vocal cords. You were given a
course of steroid to help the swelling and humidified air. Your
voice is slowly improving, your air way remained patent and
stable. You had a urine specimen sent for cultures which showed
enterococcus. Infectious disease was consulted due to your
history of frequent, resistant urinary tract infections. They
recommended vancomycin IV while in the hospital and transition
to IV vancomycin (every 48 hours) once discharged for a total
course of 7 days.
Your creatinine, a measure of kidney function was elevated. You
were given red blood cells and fluid and your function improved.
You were seen and evaluated by physical therapy who recommend
discharge to rehab to regain your strength.
You are now ready to be discharged from the hospital to continue
your recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you,
--Your ___ Care Team
Followup Instructions:
___
|
19622138-DS-5
| 19,622,138 | 28,046,776 |
DS
| 5 |
2153-02-04 00:00:00
|
2153-02-04 21:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH notable for alcohol abuse (last drink at 5am
___, chronic nausea, and IDDM who was BIBA for intoxication
and nausea. He was in his usual state of health until 1 week ago
when he was admitted to ___ for similar
presentation thought to be related to alcohol withdrawal. He
reports several months of chronic nausea that is mostly related
to cessation of drinking. He drinks 750mLs of vodka/day with
most recent drink being 5am ___. He reports a history of
seizures from withdrawals but denies DTs with most recent detox
in ___, after which he relapsed immedaitely. He denies
current cigarette use and current/past illicits.
His nausea resolved after discharge from ___ until 1 day
prior to admission, after which is has been constant. Nothing
makes it better including his home reglan except drinking. He
reports continuous dry heaving with no vomiting. Because of
this, he has no appetite, however, when he does eat he tolerates
it with no nausea, regurgitation, dysphagia, or vomiting. His
BMs have been normal for him with no change in frequency,
caliber, or color (non-bloody). Along with this nausea, he
reports abdominal pain that is chronic in his LUQ. It is a dull
ache that occurs when he is dry heaving, unrelated to eating,
and worse with laying down. This pain is on top of his chronic
pain from shingles in his LUQ (denies open wounds). He denies
ever having a colonoscopy, however, he reports having an
endoscopy that was normal (unclear when).
Although he reports chronic SOB, he is experiencing increasing
SOB over the past few weeks. He is able to walk 1 block before
getting SOB (changed from baseline of several blocks) and
requires 3 pillows (prior 2). For the past ___ days, he reports
a non-productive cough and denies fevers and chills.
In the ED, initial vitals: 98.3 101 187/82 18 98%
- Exam notable for: TTP in LUQ, otherwise normal
- Labs notable for:
WBC 10 w/ 80% PMNs, H/H 13.2/38.4
AST 41/ALT 61, otherwise normal LFTs, Lipase
20
Chem 10 notable for K 5.2,
HCO3 of 12 with Anion Gap of 32 (corrected to
HCO3
of 24 and AGAP 19 after fluids)
Cr 1.1, Gllucose 131
Lactate 9.6 (dropped to 3.8)
Trop< 0.01
UA notable for protein, glucose 300, ketones
of 40
- Imaging: RUQ normal and CXR normal
- Consultants: None
- Patient was given: fluids, ativan/diazepam on CIWA, maalox,
lido, donnatol, folate, MVI
- Vitals prior to transfer: 98.6 96 150/75 18 98%
On arrival to the floor, pt reports resolving nausea, mild
abdominal pain, and no appetite. His last BM was 2pm and was
normal. He denies mental status changes, chest palpitations,
diaphoresis, and tremors.
Of note, he is compaining of eye pain and discharge that started
2 days ago. Otherwise, he has no complaints.
ROS: Please refer to HPI for pertinent positives and negatives.
10 point ROS is otherwise negative.
Past Medical History:
- Alcohol Abuse
- Chronic Back Pain
- Hypertension
- Anxiety / Depression
- Post herpetic neuralgia
- DIABETES TYPE II
- CEREBELLAR DEGENERATION felt 2o to EtOH
Social History:
___
Family History:
Mother died at ___ years brain cancer; father died of bladder
cancer at ___ years
Physical Exam:
On Admission:
============
PHYSICAL EXAM:
Vitals: Tm/Tc 98.4 BP 179/78 HR 95 RR 18 100% RA
General: AAOx3, comfortable appearing, mildly diaphoretic, in
NAD
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear.
R eye with crusted exudate and draining purulent fluid.
Erythematous. Blind in L eye.
Neck: supple, no LAD, no JVP elevation
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, mild TTP in LUQ with no
rebound or gaurding. No HSM.
GU: no foley
Ext: Mild tremor bilaterally in upper extremities. WWP. 2+
peripheral pulses. No edema.
Neuro: CNs II-XII intact except II in L eye not working
(baseline blindness). Grossly normal strength and sensation.
On Discharge:
=============
Vitals: Tm/Tc 98.8/97.8 BP 176/84 (to SBP 160s after AM dose
labetalol) HR 72 RR 19 97% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
R eye interval decrease in exudate and erythema. L eye clear.
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP in LUQ/LLQ, otherwise non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function and sensation grossly
normal.
Pertinent Results:
Admission Labs:
==============
___ 08:25AM WBC-10.0# RBC-4.07* HGB-13.2* HCT-38.4*#
MCV-94 MCH-32.4* MCHC-34.4 RDW-13.2 RDWSD-45.3
___ 08:25AM NEUTS-80.7* LYMPHS-12.7* MONOS-5.6 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-8.10* AbsLymp-1.28 AbsMono-0.56
AbsEos-0.01* AbsBaso-0.04
___ 08:25AM PLT COUNT-313#
___ 08:25AM ETHANOL-39*
___ 08:25AM ALBUMIN-4.3 CALCIUM-10.3 PHOSPHATE-5.0*
MAGNESIUM-2.2
___ 08:25AM cTropnT-<0.01
___ 08:25AM LIPASE-20
___ 08:25AM ALT(SGPT)-61* AST(SGOT)-41* ALK PHOS-54 TOT
BILI-0.5
___ 08:25AM GLUCOSE-131* UREA N-30* CREAT-1.1 SODIUM-137
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-12* ANION GAP-32*
___ 08:46AM LACTATE-9.6*
___ 09:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:30PM GLUCOSE-304* UREA N-29* CREAT-1.1 SODIUM-134
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
___ 12:47PM LACTATE-3.8*
___ 05:40PM GLUCOSE-192* UREA N-27* CREAT-1.1 SODIUM-135
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-24 ANION GAP-19
___ 05:49PM O2 SAT-51
___ 05:49PM LACTATE-3.1*
___ 05:49PM ___ PO2-31* PCO2-42 PH-7.38 TOTAL CO2-26
BASE XS--1
Discharge labs:
===============
___ 06:45AM BLOOD WBC-8.5 RBC-3.65* Hgb-11.7* Hct-35.9*
MCV-98 MCH-32.1* MCHC-32.6 RDW-13.0 RDWSD-47.1* Plt ___
___ 06:45AM BLOOD Glucose-158* UreaN-16 Creat-1.2 Na-135
K-4.3 Cl-99 HCO3-24 AnGap-16
___ 06:45AM BLOOD Calcium-10.0 Phos-4.4 Mg-1.9
Imaging:
========
RUQ ultrasound ___:
- No ascites of evidence of hepatobiliary process
CXR ___:
- No acute cardiopulmonary process.
Brief Hospital Course:
___ with PMH notable for alcohol abuse (last drink at 5am
___, chronic nausea, and IDDM who was BIBA for intoxication
and nausea found to have a lactic acidosis that responded with
IV fluids.
Active issues:
==============
# Nausea and abdominal pain: Initially felt this was most likely
due to alcholism as it partially resolved with drinking.
Symptoms were well-controlled with ondansetron. However after
completing withdrawal from alcohol he continued to have nausea
with occasional dry heaving. He was therefore treated with BID
PPI, sucralfate, metoclopramide and ondansetron. Considering
other causes of nausea: unlikley hepatobiliary given history
(location, character), exam (- ___, no RUQ tenderness),
labs (only mild elevation AST/ALT, no alkP elevation), and
normal RUQ ultrasound. Pancreatitis is unlikely given character
of pain and labs (lipase normal). GERD vs. PUD may play a role
given the pain is positional, however, it is unrelated to meals
and he is on omeprazole at home. Of note, patient reports recent
negative endoscopy (not confirmed). Although unlikley, it is
important to consider intestinal angina given chronicity and
persistence with no clear cause. The onset was not acute so a
superior mesenteric embolus is unlikley. Further, given his
history of DM and alcoholism, gastroparesis is possible,
however, the nausea is unrelated to eating and he denies
vomiting.
On the day of discharge his nausea had improved and he was
tolerating PO without difficulty.
#Anion Gap Metabolic Acidosis : On admission HCO3 was 12 and
AGAP was 32 with a lactate of 9.8, which downtrended to a HCO3
of 24 and normal anion gap with lactate of 3.1. Most likely due
to a combination of Lactic acidosis and ketoacidosis in the
setting of his alcoholism and hypovolemia due to poor PO intake,
especially given their response to fluids and food. This
hypovolemia may be due to poor glucose control given UA (gluc
300, ketones 40) vs. poor PO from persistent nausea (see above)
and alcoholism. Liver disease is unlikley given history, exam,
and labs (mild transaminitis though).
# Alcohol withdrawal: He was initially scoring >10 on CIWA scale
mostly for tremors, hypertension, tachycardia, and anxiety and
recieved diazepam 10mg multiple times. Prior to discharge, he
was no longer receiving diazepam and was taken off of CIWA.
Social work worked with him to establish post-discharge
treatment for his alcoholism.
# Conjunctivitis of R eye: Most likely was bacterial given the
significant purulent drainage and pain. He was given
erythromycin 5 mg/gram ophthalmic ointment in both eyes for 5
days, after which it resolved.
Chronic issues:
==============
# Diabetes Mellitus Type II
- Continued lantus and placed on ISS
- Held glipizide
# Chronic sinusitis
- Continued fluticasone nasal spray
# Post perpetic neuralgia
- Continuned home dose of neurontin
# Depression
- Held mirtazipine. Amitryptilline discontinued on discharge.
# Chronic back pain
- Treated with lidocaine patches and tramadol.
# Chronic nausea
- see above
# HTN
- Continued lisonpril, HCTZ, and labetalol
Transitional issues:
===================
-Patient has chronic alcoholic gastritis w/nausea and abdominal
pain, please confirm that he has had a recent (clean) EGD
-Patient followed by case manager from ___
___, who will discuss with patient enrolling in crisis
stabilization program for alcohol abuse. Patient refused
transfer to such a program on discharge.
-Blood pressure at discharge in 160s, consider additional
antihypertensive medication as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Senna 8.6 mg PO BID
8. Thiamine 100 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Glargine 44 Units Dinner
11. Mirtazapine 7.5 mg PO QHS
12. Hydrochlorothiazide 25 mg PO DAILY
13. Amitriptyline 50 mg PO QHS
14. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
15. GlipiZIDE 5 mg PO BID
16. Ibuprofen 600 mg PO Q8H:PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Glargine 44 Units Dinner
4. Labetalol 300 mg PO BID
RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO Q12H
RX *omeprazole 40 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*60 Capsule Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
11. Metoclopramide 10 mg PO Q8H
RX *metoclopramide HCl 10 mg 1 tab by mouth Q8H:PRN Disp #*15
Tablet Refills:*0
12. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
13. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
14. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. Ibuprofen 600 mg PO Q8H:PRN pain
16. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
RX *lidocaine 5 % (700 mg/patch) apply one patch to affected
area QAM Disp #*30 Patch Refills:*0
17. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Alcohol withdrawal
R eye bacterial conjunctivitis
Gastritis
Secondary diagnoses:
IDDM
Post perpetic neuralgia
Depression
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure to care for you during your admission at
___.
You were admitted for nausea and abdominal pain, which were
related to your heavy alcohol use. Your labs showed that you
were very dehydrated probably from heavy drinking and not eating
well. These labs got better after we gave you IV fluids. We took
an x-ray of your chest and belly, both of which looked normal.
Your nausea improved with zofran (ondansetron), fluids,
increased eating, and withdrawal from alcohol. Therefore, we
think it is related to your drinking and will be prevented by
staying sober.
Given how much alcohol you were drinking, we had to give you
valium (diazepam) to prevent you from having serious withdrawal
complications. We had social work see you to workout options for
staying sober after you leave the hospital. This is the number
one priority for you-- staying off of alcohol.
Your eye was infected with bacteria, so we gave you antibiotics
(erythromycin cream) for BOTH of your eyes.
- Your ___ care team
Followup Instructions:
___
|
19622209-DS-11
| 19,622,209 | 28,420,575 |
DS
| 11 |
2188-09-02 00:00:00
|
2188-09-02 11:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / lidocaine
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of HTN, hypothyroidism, seizure d/o, retinoblastoma s/p
R
enucleation, depression/anxiety who presented with weakness and
fatigue. Patient notes day prior to admission, she was visiting
___. She did a lot of walking that day and felt tired
by the end of the visit. Today, while at her ALF, she noted
feeling more fatigued and tired than normal. Patient felt her
"head was sleepy" during music group and she repeatedly dropped
her instrument as a result. When she got up to leave the group,
her knees buckled slightly and she was helped to a chair by the
staff. Also notes hands were more shakey today as well. She
denies CP or SOB, though notes it is "hard for her to breath
with
the demons around my neck and mouth. I feel the pain of aborted
fetuses and unborn children, I'm a very spiritual person." Has
chronic cough that is occasionally productive of white sputum.
Reports urinary frequency but no dysuria, abdominal or flank
pain. Denies leg swelling but "I'm not in touch with my body."
She states someone told her that her R leg is more swollen than
the L but not sure how long it has been this way.
In ED, patient's vitals were as follows: T 97.7 HR 79 RR 18 BP
93/68 SpO2 90 on RA --> 95% on 2L NC. CBC with leukocytosis to
19.8, CMP with elevated bicarb. Initial UA with moderate ___, 18
WBCs, few bacteria, 6 Epis. Lactate 2.1. CTH non con without
acute process. CTA head and neck without occlusions, apical lung
fields with GGOs. Patient was seen by neurology and no new neuro
deficits noted. She was given 1L NS and 1g CTX. She was admitted
to medicine for further work up and management.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
Hyporthyroidism
Seizure d/o
Eye cancer s/p enucleation (? retinoblastoma)
Depression
Anxiety
Social History:
___
Family History:
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
GENERAL: Alert and in no apparent distress
EYES: s/p R enucleation, L eye EOMI, pupil reactive
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD. Trace ___
edema b/l
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, R calf > L calf
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, tangential, strong belief that she is afflicted
by demons, but AAOx3.
Pertinent Results:
CXR ___
FINDINGS:
Cardiomediastinal hilar silhouettes are unchanged. Again seen
left lower lung
basal subsegmental atelectasis. Similar appearance of the
interstitial
thickening bilaterally without focal opacities to suspect
pneumonia. There is
no pleural effusion or pneumothorax.
Surgical clips seen along the right side of the neck.
IMPRESSION:
No focal opacities to suggest pneumonia. Again seen
subsegmental
atelectasis
in the left base.
CTA Head and Neck ___
Head CT: No intracranial hemorrhage. Bilateral parietal temporal
calcifications. No evidence of acute territorial infarction.
CTA head: Patent circle of ___ and major tributaries.
Mild-to-moderate
narrowing of the right A1 segment (601:40).
CTA neck:
1. Unremarkable neck vessels.
2. Post right parotidectomy with postsurgical changes and
surgical clips which
surround the right common carotid artery just inferior to the
mandible.
3. 1.8 cm calcified and 2.0 cm solid masses in the left parotid
gland may
represent Warthin's tumors and could be further assessed with
MRI
clinically
indicated (3:163, 03:149).
4. Nodular and ground-glass opacities in both lung apices may be
infectious or
inflammatory which appear new from prior chest CT ___.
5. 7 left apical pulmonary nodule appears new since ___
(03:30). See
recommendations.
___ 11:14AM BLOOD WBC-12.2* RBC-3.98 Hgb-11.1* Hct-35.8
MCV-90 MCH-27.9 MCHC-31.0* RDW-15.6* RDWSD-51.2* Plt ___
___ 01:20PM BLOOD WBC-19.8* RBC-4.02 Hgb-11.2 Hct-35.8
MCV-89 MCH-27.9 MCHC-31.3* RDW-15.3 RDWSD-50.0* Plt ___
___ 01:20PM BLOOD ALT-12 AST-16 AlkPhos-94 TotBili-0.3
___ 01:20PM BLOOD TSH-0.33
___ 01:20PM BLOOD T4-5.1 Free T4-1.3
Brief Hospital Course:
Ms. ___ is a ___ female with the past medical
history of HTN, hypothyroidism, seizure d/o, retinoblastoma s/p
R enucleation, depression/anxiety who presented with weakness
and fatigue, found to have PNA and UTI.
ACUTE/ACTIVE PROBLEMS:
#Deconditioning - secondary to acute illnesses. Mild anemia was
present but appears to be better than baseline. ___ evaluated and
recommended rehab. Neurology evaluated the patient. She has a
history of radiation to the right side of her neck. Concern for
TIA less likely as CTA of head/neck are clear and unlikely to
cause bilateral leg buckling.
[ ] Would consider non urgent MRI of C spine to evaluate for
cervical myelopathy - either structural from spondylosis or
radiation induced.
[ ] Also consider non urgent MRI of L spine given diminished
lower extremity reflexes.
#Acute hypoxic respiratory failure
#Community acquired PNA - noted to be 90% on RA on arrival,
improved with NC. Imaging with opacities and pt with SOB.
initially treated with ctx/azith and converted to PO levoflox to
finish course on ___.
#UTI - Ecoli. Levoflox will cover for both.
#constipation-bowel regimen
CHRONIC/STABLE PROBLEMS:
#Seizure d/o - does not appear to be on AEDs aside from
gabapentin
#Hypothyroidism - continue synthroid
#Anxiety
#Depression - continue home medications, monitor QTC on
Seroquel/levoflox was WNL
#HTN - restarted home meds
#Lung nodule: For incidentally detected multiple solid pulmonary
nodules
measuring 6 to 8mm, a CT follow-up in 3 to 6 months is
recommended in a
low-risk patient, with an optional CT follow-up in 18 to 24
months. In a
high-risk patient, both a CT follow-up in 3 to 6 months and in
18 to 24 months
is recommended.
Transitional issues:
[ ] Levofloxacin for one more dose on ___
[ ] Would consider non urgent MRI of C spine to evaluate for
cervical myelopathy - either structural from spondylosis or
radiation induced.
[ ] Also consider non urgent MRI of L spine given diminished
lower extremity reflexes.
[ ] For incidentally detected multiple solid pulmonary nodules
measuring 6 to 8mm, a CT follow-up in 3 to 6 months is
recommended in a
low-risk patient, with an optional CT follow-up in 18 to 24
months. In a
high-risk patient, both a CT follow-up in 3 to 6 months and in
18 to 24 months
is recommended.
Ms. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Fluvoxamine Maleate 100 mg PO DAILY
4. ARIPiprazole 30 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Calcium Carbonate ___ mg PO BID
7. Levothyroxine Sodium 125 mcg PO QHS
8. Ibuprofen 400 mg PO BID
9. Calcitriol 0.25 mcg PO BID
10. Metoprolol Tartrate 50 mg PO BID
11. QUEtiapine Fumarate 100 mg PO BID
12. QUEtiapine Fumarate 200 mg PO QHS
13. Gabapentin 600 mg PO QHS
14. TraZODone 300 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Levofloxacin 500 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Calcium Carbonate 1000 mg PO BID
6. amLODIPine 2.5 mg PO DAILY
7. ARIPiprazole 30 mg PO DAILY
8. Calcitriol 0.25 mcg PO BID
9. Fluvoxamine Maleate 100 mg PO DAILY
10. Gabapentin 600 mg PO QHS
11. Ibuprofen 400 mg PO BID
12. Levothyroxine Sodium 125 mcg PO QHS
13. Metoprolol Tartrate 50 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. QUEtiapine Fumarate 100 mg PO BID
16. QUEtiapine Fumarate 200 mg PO QHS
17. TraZODone 300 mg PO QHS
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Deconditioning
PNA
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of weakness and found to have
pneumonia and a urinary tract infection. You improved with
antibiotics. The physical therapist recommended rehab.
Followup Instructions:
___
|
19622209-DS-12
| 19,622,209 | 25,262,295 |
DS
| 12 |
2188-11-21 00:00:00
|
2188-11-21 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / lidocaine
Attending: ___
Chief Complaint:
s/p fall, weakness
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ female, long-term ___ resident,
with schizoaffective disorder, retinoblastoma s/p right
enucleation, restrictive lung disease, mild hypoxemia (thought
d/t shunt? see Dr. ___ dated ___, who presents to
the ED s/p fall. She states that she was in her USOH until
yesterday when she was walking to see the ___ nurse because she
felt "warm," and her knees became "shaky" causing her to fall
with a head strike. She denies LOC, but said after falling, she
was unable to get up on own. She suffered a small posterior head
laceration with bleeding that stopped spontaneously, and then
was
BIBA to the ED.
CT head, CT spine were normal. CXR showed small left pleural
effusion, slightly increased from the prior exam, with mild
pulmonary vascular congestion. Patchy bibasilar opacities,
likely atelectasis. Labs were notable for WBC of 18 w/ 91%
neutrophils, HC03 33 (chronic).
Per ED nursing notes, "patient placed on monitor upon arrival to
room 6, and noted to have SPO2 of 35-60% on room air with good
pleth, attempted on fingers, ears, and nose. Pt placed on 4L NC,
and MDs aware of low o2 sat. Patient denies any SOB, pt with
noted pursed breathing with exhalation, ___. Pt's o2 sat
improves gradually to 91% on 4L NC. Serial VBG were obtained
which, per notes, improved after the soft-collar was removed.
ROS: Reports that she is always "shaky," has "stress in her
head,", reports chronic difficulty swallowing, chronic
constipation, chronic nausea, denies CP, SOB, abdominal pain,
fevers, chills, change in bowel or bladder habits. Pertinent
positives and negatives as noted in the HPI; review of systems
otherwise negative.
Past Medical History:
- Hypertension
- Hypothyroidism
- Seizure d/o (? related to lidocaine)
- Schizoaffective disorder
- Restrictive lung disease, mild PAH and hypoxemia
- Retinoblastoma s/p right eye enucleation as a child
- Esophageal/hypopharyngeal stricture s/p dilation/botox ___
- OA status post bilateral TKR (___)
- S/P thyroidectomy
- S/P tracheostomy
Social History:
___
Family History:
Significant cancer, heart disease, lung disease,
and joint disease/ arthritis
Physical Exam:
Afebrile and vital signs stable (see eFlowsheet)
GENERAL: No apparent distress.
EYES: Anicteric and without injection.
ENT: Right eye enucleated with extensive radiation changes in
surrounding skin, healed tracheostomy scar
CV: Regular, S1 and S2, ___ SEM RUSB
RESP: Lungs with crackles/rhonchi at bilateral bases, but L>>R
wheezes.
GI: Abdomen soft, distended, non-tender to palpation.
MSK: BLE warm, well healed bilateral TKR scars.
SKIN: Warm and well perfused, no excoriations, lesions, rashes,
or ulcerations noted.
NEURO: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Speech is
fluent, verbal comprehension is intact. Gross motor function
intact and symmetric in all four extremities
Pertinent Results:
___ 10:30AM BLOOD WBC-20.5* RBC-4.10 Hgb-11.2 Hct-36.0
MCV-88 MCH-27.3 MCHC-31.1* RDW-15.6* RDWSD-49.8* Plt ___
___ 09:45AM BLOOD WBC-19.2* RBC-4.09 Hgb-11.1* Hct-35.8
MCV-88 MCH-27.1 MCHC-31.0* RDW-15.7* RDWSD-49.7* Plt ___
___ 05:45AM BLOOD Hct-UNABLE TO
___ 09:25AM BLOOD WBC-18.4* RBC-4.23 Hgb-11.7 Hct-36.6
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.7* RDWSD-50.0* Plt ___
___ 09:45AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-139
K-4.4 Cl-92* HCO3-34* AnGap-13
___ 05:45AM BLOOD Glucose-78 UreaN-11 Creat-0.7 Na-140
K-4.8 Cl-93* HCO3-33* AnGap-14
___ 09:25AM BLOOD Glucose-86 UreaN-16 Creat-0.8 Na-135
K-4.8 Cl-89* HCO3-33* AnGap-13
___ 03:33PM BLOOD Lactate-1.5
___ 09:41AM
CT SPINE
1. No acute fracture or traumatic subluxation.
2. Nodular and patchy opacities at the bilateral lung apices are
new from prior. Please refer to patient's chest radiograph
obtained earlier in the day.
3. Redemonstration of two parotid soft tissue masses measuring
up
to 1.8 cm. Recommend correlation with ultrasound or histology if
available.
4. Postsurgical changes at the right neck and face are stable.
CT HEAD
1. No acute intracranial infarction or hemorrhage. No acute
fractures.
2. Similar appearance of postsurgical and post radiation changes
to the right orbit.
CXR PORTABLE
Small left pleural effusion, slightly increased from the prior
exam, with mild pulmonary vascular congestion. Patchy bibasilar
opacities, likely atelectasis. BLOOD Lactate-1.7
bcx pending
ucx pending
Brief Hospital Course:
___ female, long-term SNF resident,
with schizoaffective disorder, retinoblastoma s/p right
enucleation, restrictive lung disease, mild hypoxemia, who
presents to the ED s/p fall. Found to have acute on chronic
hypoxemia and hypercarbia, with elevated WBC and CXR c/w
pneumonia.
# CAP -
#acute hypoxic respiratory failure
#atelectasis
Patient lives in a SNF, + MRSA ___. She presented with
generalized weakness and a fall. Her CXR showed R>L streaky
opacities and mild pulmonary vascular congestion. She received
vanc/zosyn in the ED which was later changed to
ceftriaxone/doxycycline. Based on prior labs/notes, she has
chronic mixed hypoxic/hypercarbic respiratory failure, but exact
baseline unclear. Attempted ABG (unsuccessful). She required 3L
oxygen at rest and 5L with activity. She was encouraged to use
incentive spirometry. She was discharged on a short course of
antibitoics with Cefdinir and Doxycycline.
#mechanical ___ consulted and they recommended that pt will
benefit from ___ rehab faciltiy. Head and neck CT were
normal.
# Hypothyroidism - continue synthroid
# Schizoaffective disorder - on multiple psychiatric
medications,
including quetiapine, fluvoxamine, and aripiprazole. Admission
ECG with normal QTc.
# Hypertension - Continue amlodipine.
# Seizure d/o NOS - details unclear; is on HS gabapentin.
# Lung/Parotid nodules - both previously identified, and require
follow-up - Letter sent to PCP in ___ dated ___.
GENERAL/SUPPORTIVE CARE:
# Nutrition/Hydration - S+S evaluation performed.
# Functional status - OOB with assist/cane. ___ evaluation
# Bowel Function - Constipation
# Lines/Tubes/Drains - PIV
# Precautions - Dysphagia
# VTE prophylaxis - Hep SC
# Consulting Services - ___, S+S
# Contacts/HCP/Surrogate and Communication - ___
Phone number: ___ Date on form: ___
# Code Status/ACP: Full
# Disposition:
- Anticipate discharge to SNF
- Discharge barriers: Improved gas exchange and ability to
ambulate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. ARIPiprazole 30 mg PO DAILY
3. Fluvoxamine Maleate 100 mg PO DAILY
4. Levothyroxine Sodium 125 mcg PO QHS
5. Metoprolol Tartrate 50 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. QUEtiapine Fumarate 50 mg PO BID PRN agitation
8. TraZODone 300 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Gabapentin 600 mg PO QHS
14. Ibuprofen 400 mg PO BID:PRN Pain - Mild
15. Capsaicin 0.025% 1 Appl TP TID to affected areas
16. ammonium lactate 12 % topical BID:PRN
17. LOPERamide 4 mg PO Q8H:PRN Diarrhea
18. Ondansetron 4 mg PO Q6H:PRN Nausea
19. Loratadine 10 mg PO DAILY:PRN allergies
20. Biotene Dry Mouth Oral Rinse (saliva substitute combo no.9)
1 rinse and swish mucous membrane QID:PRN
21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
22. Robafen (guaiFENesin) 100 mg/5 mL oral Q6H:PRN
23. QUEtiapine Fumarate 200 mg PO QHS
24. QUEtiapine Fumarate 100 mg PO BID
25. Calcitriol 0.25 mcg PO DAILY
26. Calci-Chew (calcium carbonate) 500 mg calcium (1,250 mg)
oral BID
27. Ibuprofen 400 mg PO BID
Discharge Medications:
1. cefdinir 300 mg oral BID
RX *cefdinir 300 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
4. amLODIPine 2.5 mg PO DAILY
5. ammonium lactate 12 % topical BID:PRN
6. ARIPiprazole 30 mg PO DAILY
7. Biotene Dry Mouth Oral Rinse (saliva substitute combo no.9)
1 rinse and swish mucous membrane QID:PRN
8. Calci-Chew (calcium carbonate) 500 mg calcium (1,250 mg)
oral BID
9. Calcitriol 0.25 mcg PO DAILY
10. Capsaicin 0.025% 1 Appl TP TID to affected areas
11. Docusate Sodium 100 mg PO BID
12. Fluvoxamine Maleate 100 mg PO DAILY
13. Gabapentin 600 mg PO QHS
14. Ibuprofen 400 mg PO BID
15. Ibuprofen 400 mg PO BID:PRN Pain - Mild
16. Levothyroxine Sodium 125 mcg PO QHS
17. LOPERamide 4 mg PO Q8H:PRN Diarrhea
18. Loratadine 10 mg PO DAILY:PRN allergies
19. Metoprolol Tartrate 50 mg PO BID
Hold for SBPO<100 or HR <60
20. Omeprazole 20 mg PO DAILY
21. Ondansetron 4 mg PO Q6H:PRN Nausea
22. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
23. QUEtiapine Fumarate 50 mg PO BID PRN agitation
24. QUEtiapine Fumarate 200 mg PO QHS
25. QUEtiapine Fumarate 100 mg PO BID
26. Robafen (guaiFENesin) 100 mg/5 mL oral Q6H:PRN
27. Senna 8.6 mg PO BID:PRN Constipation - First Line
28. TraZODone 300 mg PO QHS
29. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Acute hypoxic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You presented after a fall and generalized weakness. Your oxygen
levels were found to be low in the hospital and you were found
to have a pneumonia which was treated with antibiotics. You are
prescribed antibiotics at discharge - be sure to take them as
instructed. Your oxygen levels continued to be low at the time
of discharge hence you required oxygen supplementation.
Followup Instructions:
___
|
19622436-DS-18
| 19,622,436 | 26,468,578 |
DS
| 18 |
2179-06-05 00:00:00
|
2179-07-02 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ year old M s/p fall from tree sustaining right 7th rib
fracture and retrosternal hematoma.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of S/P FALL.
Trauma Patient
presenting status post fall ___ feet from a tree trying to get a
cat out of the tree. There was head strike but no loss of
consciousness. The patient is not anticoagulated. EMS was called
and found the patient on the ground. He landed on his right
shoulder. He remained hemodynamically stable until he was
transported and required oxygen. He was placed on 6 L.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
Physical Examination
HR: 70 BP: 150/90 Resp: 18 O2 Sat: 91% Ra Low
Constitutional: UNCOMFORTABLE ; OBESE
ENT / Neck: ABRASIONS RIGHT UPPER ABD/CHEST
Cardiovascular: cHEST WALL TTP STERNAL AND RIGHT SIDED; NO FLAIL
CHEST
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation; GCS 15; no s/m deficits;
pulses ___ all 4 ext
Pertinent Results:
___ 01:09PM GLUCOSE-114* LACTATE-2.5* NA+-145 K+-3.9
CL--105 TCO2-22
___ 01:09PM HGB-15.9 calcHCT-48 O2 SAT-95 CARBOXYHB-2 MET
HGB-0
___ 01:09PM freeCa-1.06*
___ 12:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:58PM WBC-10.8* RBC-5.00 HGB-15.3 HCT-46.6 MCV-93
MCH-30.6 MCHC-32.8 RDW-13.3 RDWSD-45.1
___ 12:58PM PLT COUNT-195
___ 12:58PM ___ PTT-25.0 ___
___ 12:58PM ___
Brief Hospital Course:
Patient presenting to the ED for evaluation of trauma. Upon
arrival he did require oxygen. His workup in the ED included a
negative fast and imaging including
CT and plain films. His imaging was notable for a small
retrosternal hematoma but no sternal fracture. He does have
acute minimally displaced fracture of the right seventh rib. He
did require oxygen during his emergency department stay. On
___, he was stable for discharge with follow up appointment
on ___ in ___ clinic.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Stool Softener] 100 mg 1 tablet(s) by mouth
twice a day Disp #*15 Tablet Refills:*0
3. Ibuprofen 400-600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 200 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___ posterior rib fracture
retrosternal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19622786-DS-14
| 19,622,786 | 27,601,888 |
DS
| 14 |
2166-04-09 00:00:00
|
2166-04-09 18:08:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
Opioid withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o opioid addiction s/p rehab, anxiety, p/w n/v/d and abd
pain.
Pt was transitioned off suboxone the day prior to admission. He
was seen by PCP today, who gave him oral naltrexone in the
clinic. Since then, pt reports abd cramping, nausea/vomiting,
diarrhea, tremor, sweating, tearing, and yawning. no brbpr,
melena, or hemoptysis. He reports buying oxycodone on the
streets, and was using oxycodone while trying to taper off with
suboxone. He reports buying 20 mg tablets and using up to 25
tablets a day, but he admits that the amounts do vary.
In the ED initial vitals were: 99.1 66 130/63 16 99% RA
- Labs were significant for WBC 18.9 (N80.1), lipase 1332,
negative serum tox, urine tox.
- Patient was given 2L NS, lorazepam 1mg x ___ x1, ondansetron
x 2, ketorolac 30mg x 1
Vitals prior to transfer were: 98.0 63 123/65 17 98% RA
He denies abd pain with radiation to back. He reports that he
only drinks socially (eg. ___ glasses of wine once or twice a
week). He denies h/o gallstones or pancreatitis.
He reports that he has otherwise been feeling well up until this
morning after the PCP ___. he has not been having f/c,
no sick contact, no dysuria, no hematuria.
On the floor, pt was actively vomiting, but reports that his abd
pain has improved
Past Medical History:
Anxiety
MVA in ___ with head trauma, he was diagnosed with questionable
seizure disorder in ___ potentially related to the previous
head trauma but reportedly EEG was inconclusive
Hyperplastic polyp by colon ___ (done for eval of abd pain and
abn BMs--resolved).
Social History:
___
Family History:
Father is ___, healthy. Mother is ___ with
anxiety and depression. Sister is ___ with HTN. Maternal half
sister is ___ healthy. PGM had depression. Paternal aunt is
___ with epilepsy.
Physical Exam:
PHYSCIAL EXAM ON ADMISSION:
Vitals - 99.1 108/62 74 18 98RA
GENERAL: +lacrimation, actively vomiting, appears uncomfortable.
HEENT: pupil 7mm b/l, reactive to light. AT/NC, EOMI, anicteric
sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: 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: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
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
Vitals - T 99.6 HR 55-69 BP 122/67 (122-143/67-83) RR 18 ___
GENERAL: appears uncomfortable lying in bed
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION
___ 03:20PM BLOOD WBC-18.9*# RBC-5.04 Hgb-14.9 Hct-42.0
MCV-83# MCH-29.6 MCHC-35.6* RDW-12.6 Plt ___
___ 03:20PM BLOOD Neuts-80.1* Lymphs-13.5* Monos-4.3
Eos-1.8 Baso-0.4
___ 03:20PM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-139
K-3.7 Cl-101 HCO3-24 AnGap-18
___ 03:20PM BLOOD ALT-21 AST-23 AlkPhos-79 TotBili-0.3
___ 03:20PM BLOOD Lipase-1332*
___ 03:20PM BLOOD Albumin-5.0
___ 06:55AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
LABS ON DISCHARGE
IMAGING:
CT abdomen and pelvis without contrast:
No CT evidence of complications of acute pancreatitis. No
evidence of bowel
obstruction, perforation, or other acute abnormality in the
abdomen or pelvis
Brief Hospital Course:
___ hx of opiate addiction s/p rehab and s/p suboxone, p/w n/v,
diarrhea/abd pain in setting of receiving naltrexone. He
received naltrexone from his addictions physician. He had been
on a suboxone taper, but was simultaneously using large amounts
of oxycodone. He experienced a high degree with withdrawal
symptoms
# Opioid withdrawl - iatrogenic in the setting of receiving
naltrexone this morning. pt had symptoms of n/v, abd cramping
and diarrhea. As pt had received opioid antagonist, treatment w/
methadone for withdrawl was not an option. He was given
clonidine TID. Acetaminophen (Tylenol) ___ mg po q 6h or
ibuprofen (Motrin and others) 600 mg po q4h for pain. For muscle
pain/cramps: methocarbamol (Robaxin) 750 mg po q6h. For GI
cramps: dicyclomine (Bentyl) 20 mg po q4h. For nausea or
vomiting, zofran, lorazepam, or compazine. On day of discharge
he had mild nausea and continued diarrhea but able to tolerate
PO intake. He was discharge with a prescription for compazine,
bentyl, and loperamide. He will begin an intensive outpatient
substance abuse program. This was discussed with him and his
wife at length; he is motivated to start an outpatient program
at ___ as soon as possible and had been in touch with them.
# elevated lipase - unclear etiology but it was unlikely that
patient had pancreatitis as he did not have epigastric pain and
was nontender on exam. His withdrawal likely caused his acute
onset of nausea, vomiting, and diarrhea. CT scan was without
evidence of pancreatitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (2mg-0.5mg) 1 TAB SL DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. LOPERamide 4 mg PO 4MG AT ONSET OF DIARRHEA AND 2MG AFTER
EACH LOOSE STOOL diarrhea Duration: 5 Days
Maximum of 16mg per day
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 2 tablets by
mouth at onset of diarrhea followed by 2mg after each additional
episode of diarrhea Disp #*40 Tablet Refills:*0
3. Prochlorperazine ___ mg PO Q6H:PRN nausea Duration: 5 Days
Do not exceed 40mg per day
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
4. DiCYCLOmine 20 mg PO QID:PRN GI cramps
RX *dicyclomine 20 mg 1 tablet(s) by mouth Q6hours prn abdominal
cramping Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Opioid withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted with symptoms of opioid withdrawal after taking
naltrexone. You were treated with IV fluids and medication to
help with nausea, abdominal pain, and muscle cramps. You were
not given any opioid medications while inpatient. You met with
our social worker to hear about different options for
rehabilitation. Please follow up with your primary care provider
on discharge. Your plan on discharge was to begin an intensive
outpatient substance abuse program.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19622824-DS-13
| 19,622,824 | 25,916,150 |
DS
| 13 |
2195-02-04 00:00:00
|
2195-02-04 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Penicillins
Attending: ___.
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ man with history of ___ Disease,
HTN, Prostate Cancer, DM2, HLD, CKD III, CAD with recent STEMI
medically managed presenting after presyncopal event.
Per review of ED ___ as discussed with the patient's daughter,
he was seated today, getting toenails clipped by his daughter
when she noticed that he slumped over and eyes were closed.
Yawned several times. This lasted about 10 minutes before he
returned to his mental baseline. No complaints such as shortness
of breath, chest pain, abdominal pain, headache, vision changes,
fever. On arrival to the ED, the patient had no complaints.
Of note, hospitalized in ___ for presumed STEMI with STE
V2-V6, due to poor baseline functional status, decision was made
in conjunction with family to manage medically.
He was seen in follow-up by Dr. ___ on ___. No changes made
in management, plan per that note was to continue
apixaban/plavix for 3 months total, then switch to ASA/Plavix.
Per review of Atrius records, there has been some confusion
about the anti-HTN medication changes that were made when he was
in the hospital for his STEMI--labetalol and amlodipine had been
d/c-ed but were filled by outpatient pharmacy. It does appear
that the patient's daughter was aware of this and was not giving
him the labetalol or amlodipine.
In the ED, initial VS were:
97.8
51
148/73
16
96% RA
Exam notable for:
- Neuro: AAOx1
ECG: Sinus rhythm at 58 with PVC, NA/NI, biphasic T waves V3-V6,
unchanged from prior ___.
Labs showed: trop negative x 1, Cr 1.6 (at baseline), UA with
large leuks
CXR with no acute process.
Patient received: ASA 324mg x 1.
Transfer VS were:
97.8
62
169/64
15
100% RA
On arrival to the floor, patient has no complaints. He thinks he
is getting his nails cut.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- CAD s/p presumed STEMI ___, medically managed)
- poor medication adherence
- HTN
- DM
- HLD
- Hx colon cancer
- Hx prostate cancer
- CKD (baseline 1.5-1.6)
- ___ disease
- Dementia (undiagnosed - AOx1-2 at baseline)
- concern for cerebral amyloid angiopathy on prior MRI
Social History:
___
Family History:
Sister with CVA. Family history of hypertension and diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed in eflowsheets
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: AO x 1, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 517)
Temp: 98.3 (Tm 98.9), BP: 198/94 (138-198/69-94), HR: 67
(64-81), RR: 17 (___), O2 sat: 98% (98-99), Wt: 172.8 lb/78.38
kg
Fluid Balance (last updated ___ @ 514)
Last 8 hours Total cumulative -1100ml
IN: Total 0ml
OUT: Total 1100ml, Urine Amt 1100ml
Last 24 hours Total cumulative -520ml
IN: Total 980ml, PO Amt 980ml
OUT: Total 1500ml, Urine Amt 1500ml
GENERAL: NAD, A&Ox1, no distress
CV: regular rhythm, bradycardic, S1/S2, +S4, no murmurs,
gallops,
or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
EXTREMITIES: warm, no cyanosis, clubbing, or edema
NEURO: moving all 4 extremities with purpose, face symmetric,
speech fluent
Pertinent Results:
ADMISSION LABS
___ 07:10PM BLOOD WBC-4.4 RBC-3.90* Hgb-12.0* Hct-36.4*
MCV-93 MCH-30.8 MCHC-33.0 RDW-12.4 RDWSD-42.1 Plt ___
___ 07:10PM BLOOD Glucose-215* UreaN-26* Creat-1.6* Na-140
K-6.2* Cl-105 HCO3-24 AnGap-11
___ 07:10PM BLOOD cTropnT-<0.01
___ 01:48AM BLOOD cTropnT-<0.01
___ 07:10PM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
___ 09:47PM BLOOD K-4.3
DISCHARGE LABS
___ 06:50AM BLOOD WBC-5.4 RBC-4.02* Hgb-12.5* Hct-37.1*
MCV-92 MCH-31.1 MCHC-33.7 RDW-12.4 RDWSD-42.1 Plt ___
___ 06:30AM BLOOD Glucose-184* UreaN-22* Creat-1.6* Na-143
K-4.3 Cl-107 HCO3-23 AnGap-13
___ 06:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.7
Brief Hospital Course:
SUMMARY STATEMENT:
==================
___ man with history of ___ Disease, HTN,
prostate cancer, T2DM, HLD, CKD III, CAD with recent STEMI
(___) medically managed presenting after possible presyncopal
event/episode of decreased responsiveness. On admission, work up
showed negative cardiac enzymes, negative orthostatics, but
ongoing hypertensive urgency with SBPs >200. Patient's HTN
medications were titrated until SBPs were consistently in
140s-160s.
ACUTE ISSUES:
=============
#Pre-syncope/Altered Mental Status:
Patient initially presented with concern from his daughter about
an episode in which he suddenly became less responsive than
normal. He was getting his nails cut, slumped over and yawned
several times. This lasted 10 minutes. He did not endorse any
symptoms such as chest pain, shortness of breath, or
lightheadedness, but is a poor historian secondary to dementia.
Patient is on multiple anti-hypertensives and was bradycardic
with HR in the ___ on presentation, so differential included
hypotension vs. hypertensive urgency vs. symptomatic
bradycardia. Less likely hypoglycemia vs seizure given return to
baseline fairly quickly. Cardiac enzymes were negative and the
patient's EKG was unchanged from prior. Patient was monitored on
telemetry and BP regimen was titrated. No further episodes
occurred while admitted. His medication regimen is described
below.
#Hypertensive Urgency
Event of diminished responsiveness (described above) may have
been evidence of hypertensive emergency (daughter says patient
frequently refuses medications). Initially, the patient's BPs
were elevated to SBPs >200. He frequently refused medications
while delirious. As his mental status improved and he was able
to take his medications. He was continued on his home regimen of
hydralazine 50 TID (Held for SBPs <150), isordil 20 TID (Held
for SBPs <160), losartan 75 BID, and home metoprolol 50 QD was
downtitrated to 25mg in the setting of HRs to the ___. His
prior home medications of amlodipine 10mg and HCTZ 12.5mg QD
were started. Clonidine 0.1mg/24hr patch was started in hopes of
decreasing patient pill burden and increasing home compliance.
#?UTI:
On presentation, UA with leuks, few bacteria, no nitrites. Last
UA ___ had no leuks (although this was after antibiotics).
Patient denied any symptoms throughout admission though did have
episodes of incontinence. UCx was consistent with contamination.
#CAD s/p STEMI
#Apical ballooning:
Hx significant for recent admission ___ for presumed STEMI
with STE V2-V6 with apparent LOC, due to poor baseline
functional status, decision was made in conjunction with family
to manage medically. No concern for acute ischemia at this time.
Per outpatient cardiologist, apixaban 2.5mg BID was stopped and
patient was started on ASA 81mg and Plavix 75mg. He was
continued on his home atorvastatin, metoprolol succinate at
reduced dose.
CHRONIC ISSUES
==============
#CKD III: Cr was at baseline throughout admission.
___ disease
#Dementia: Continued home sinemet, memantine
#DM: Held home metformin, HISS while here
TRANSITIONAL ISSUES:
=====================
[] Home BP cuff in order to titrate hydralazine TID. Medication
burden is an issue for patient, so would be preferable to
minimize pills. Daughter was instructed to only give hydralazine
if SBP > 160.
[] Follow up BPs once clonidine patch reaches stead state
CODE: Full (per last admission)
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Memantine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. HydrALAZINE 50 mg PO Q8H
5. Losartan Potassium 50 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Apixaban 2.5 mg PO BID
8. Clopidogrel 75 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Isosorbide Dinitrate 20 mg PO TID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTUES
RX *clonidine [Catapres-TTS-1] 0.1 mg/24 hour 1x/week Disp #*4
Patch Refills:*0
3. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
5. Losartan Potassium 75 mg PO BID
RX *losartan 50 mg 1.5 tablet(s) by mouth TWICE DAILY Disp #*60
Tablet Refills:*0
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth ONCE DAILY
Disp #*30 Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Carbidopa-Levodopa (___) 1 TAB PO TID
10. Clopidogrel 75 mg PO DAILY
11. HydrALAZINE 50 mg PO Q8H
ONLY USE IF TOP BLOOD PRESSURE NUMBER IS >160
12. Memantine 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Spironolactone 25 mg PO DAILY
15.Outpatient Lab Work
I16.0 Hypertensive Urgency
BMP including lytes
Please fax results to Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Hypertensive Urgency
SECONDARY DIAGNOSIS
====================
Coronary Artery Disease
Type II Diabetes Mellitus
___ Disease
Dementia
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. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had an episode
where your family was concerned you weren't as responsive as are
normally.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
While you were in the hospital, we did tests to check if you had
a heart attack. You did not. We found that your blood pressures
run very high. We treated you with medications to try to get
your blood pressures under better control.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, swelling in your legs, abdominal
distention, or shortness of breath.
- Your daughter is going to help you with your blood pressure
medications by checking your blood pressure at home.
- Please adjust the medications at home by doing the following:
----Please take all of your medications regularly as prescribed
except for hydralazine
----Please check your blood pressure in the morning, at lunch
time and at bed time
----Please only take the hydralazine if the top blood pressure
number is greater than 160.
----If the top number is GREATER than 160, please take ONE
hydralazine pill. If your top blood pressure number is LESS than
160, please do NOT take the hydralazine pill.
- Please call your primary care doctor with any questions
- Please also call your primary care doctor if you see more than
two readings of a blood pressure greater than 200.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19622936-DS-21
| 19,622,936 | 24,900,163 |
DS
| 21 |
2162-08-01 00:00:00
|
2162-08-01 14:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
NG tube placed
History of Present Illness:
Mr. ___ is a pleasant ___ w/ pancreatic ca on Nap-B,
Gemcitabine and NPC-1C, last received ___.
He was noted by his ___ to have a SBP in the ___, p 93
and very fatigued and lightheaded. His appetite and po intake
has
been poor and has not had a BM for 7 days. He was referred to
the
___.
There he was afebrile at 98. BP 94/47 and 98% RA.
WBC 3.1, 75% neuts
Hg 8.5
Plt 279
Na 131
K 3.6
CL 98
Cr 0.56
AST 18
ALT 13
ALK 77
UA neg for ___
CXR revealed no acute process per the ___ report
He received 500 ml NS bolus with improvement of his BP. He was
referred to our ED for further management and admission to OMED.
Of note, patient was recently admitted for neutropenic fever and
hypotension.
In the ED, given an additional 500cc fluid bolus, along with
Morphine sulfate 4mg x2 for pain on ___, with persistently low
blood pressure sin the 90/60's.
On arrival to OMED, patient was actively nauseated. His wife
provided most of the history and she noted that his PO intake
has
been steadily declining for the past few months. His previous
weight was 185 now ___. He has worsened nausea over the past
week
with no bowel movements for the past 9 days. He was instructed
not to do enemas per his study team. Does admit to bloating and
dyspepsia for the past month. Today in ED he attempted eating
significantly more than usual and now vomiting. Bowel movements
prior to 9 days ago had been regular. No abdominal pain but does
feel sore at this time. He has not been taking his home
oxycontin
BID, but rather PRN basis ___ times per day at most, and not
w/in
the past few days.
Past Medical History:
ONCOLOGIC TREATMENT HISTORY:
___ - Patient presented with vague abdominal discomfort
radiating to his back. CT identified a mass in the pancreatic
body and tail. Also notable were several liver lesions of
unclear significance.
___ - FNA biopsy by Endoscopic ultrasound was positive for
adenocarcinoma. His ___ measured 525 U/mL.
___ - ___ Cycle 1 - Cycle 5 Received neoadjuvant
chemotherapy with FOLFIRINOX.
___ - ___ - Cycle 6 - Cycle 18 Transitioned to mFOLFIRI
due to neuropathy and poor tolerance of oxaliplatin.
___ - Received Cyberknife SBRT to the pancreatic mass
___ - CT identified two liver lesions consistent with
metastases.
___ - Liver biopsy was positive for malignant cells.
Currently on DF/HCC: ___
Protocol:
A Multicenter Randomized Phase II Study of NPC-1C in Combination
with Gemcitabine and nab-Paclitaxel versus Gemcitabine and
nab-Paclitaxel alone in Patients with Metastatic or Locally
Advanced Pancreatic Cancer Previously Treated with FOLFIRINOX.
___
PAST MEDICAL HISTORY:
1. Status post motorcycle accident with clavicle, scapula and
rib fractures. ___
2. History of adenomatous colon polyps. ___ and ___
3. Status post tonsillectomy. ___
4. Status post nasal polypectomy. ___
Social History:
___
Family History:
The patient's father died at ___ years with colon
cancer. His mother died at ___ years with dementia. His one
brother was treated for benign prostatic hypertrophy. His two
children are without health concerns
Physical Exam:
Discharge exam
T 97.9 BP 118/100 (had also been in lower 100s-110s today) HR 76
RR 18 98%RA
General: calm, sitting up eating cheet-os
muscle wasting diffusely, actively vomiting
HEENT: MM dry, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+ but hypoactive, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: ___ strength throughout
Pertinent Results:
___ 05:50AM BLOOD WBC-2.3*# RBC-3.07* Hgb-8.7* Hct-27.9*
MCV-91 MCH-28.3 MCHC-31.2* RDW-16.8* RDWSD-54.7* Plt ___
___ 05:40AM BLOOD WBC-3.6* RBC-2.71* Hgb-7.8* Hct-25.1*
MCV-93 MCH-28.8 MCHC-31.1* RDW-17.0* RDWSD-55.9* Plt ___
___ 05:50AM BLOOD Glucose-97 UreaN-6 Creat-0.4* Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
___ 05:40AM BLOOD Glucose-130* UreaN-3* Creat-0.4* Na-141
K-4.0 Cl-108 HCO3-28 AnGap-9
___ 04:12AM BLOOD ALT-12 AST-15 LD(LDH)-107 AlkPhos-83
TotBili-0.2
___ 04:12AM BLOOD Cortsol-6.5
___ 09:24AM BLOOD Cortsol-11.8
___ 09:55AM BLOOD Cortsol-22.8*
___ 10:25AM BLOOD Cortsol-27.6*
EKG unchanged from prior
CXR
IMPRESSION:
Compared to chest radiographs since ___, most
recently ___.
Successive frontal chest radiographs show advancement of the
esophageal
feeding tube with the wire stylet in place from the lower
esophagus to the
upper stomach.
Right central venous infusion port catheter ends in the low SVC
close to the
superior cavoatrial junction.
Lungs are clear. Normal cardiomediastinal and hilar silhouettes
and pleural
surfaces.
Brief Hospital Course:
Mr. ___ is a pleasant ___ w/ pancreatic ca on Nap-B,
Gemcitabine and NPC-1C, last received ___, who p/w
hypotension and failure to thrive.
# Hypotension
# Failure to thrive/severely decreased PO intake
# Dehydration
Hypotension was profound on admission (went to ___ but no
infectious source identified, felt ultimately ___ profound
dehydration from lack of PO intake as outpt likely ___
chemotherapy and malignancy. Blood coutns remained stable and no
e/o bleeding, trop reassuring, and EKG unchanged compared to
prior and no chest pain or hypoxia/shortness of breath. Symptoms
and BP improved with IVF. Pt did have borderline AM cortisol but
___ stim was reassuring. Decr po intake felt ___ pancreatic
cancer and maybe chemo induced nausea/vomiting also. NGT was
placed and tube feeds successfully initiated and pt tolerating
these well with discharge SBP ranging from low 100s to 118
systolic. Denied dizziness and felt well. Was eating high salt
diet also (Cheetos) to assist w/ elevating BPs. No further
nausea/vomiting. Had some diarrhea after tube feed initation but
this resolved spontaneously on discharge. Was sent home on bolus
Jevity tube feeds. There was also some consideration that his
study drug could be contributing to hypotension so his oncology
providers ___ address this at upcoming appointment. Continued
home dronabinol, mirtazapine.
# Pancreatic Ca - on Nap-B, Gemcitabine and NPC-1C, last
received ___, has apt ___ for next administration.
# Cancer-related pain - cont home oxycontin 20 mg BID with prn
po dilaudid
Greater than 30 minutes were spent in planning and execution of
this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole 1 TROC PO FIVE TIMES DAILY
2. Docusate Sodium 100 mg PO BID
3. Dronabinol 5 mg PO BID PRN nausea, anorexia
4. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN pain
5. Lactulose 15 mL PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. LORazepam 1 mg PO Q6H:PRN nasuea, anxiety
8. Mirtazapine 3.75 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
11. Prochlorperazine 10 mg PO Q6H:PRN nasuea, vomiting
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Vitamin D 7500 UNIT PO DAILY
Discharge Medications:
1. Jevity 1.5 Cal (lactose-reduced food with fibr) 0.06 gram-1.5
kcal/mL oral DAILY Duration: 30 Days
Please give 5 cans (240ml) daily, via boluses, with 150ml H20
flush Q4 hours
RX *lactose-reduced food with fibr [Jevity 1.5 Cal] 0.06
gram-1.5 kcal/mL 240 ml by mouth Five times daily Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Clotrimazole 1 TROC PO FIVE TIMES DAILY
4. Docusate Sodium 100 mg PO BID
5. Dronabinol 5 mg PO BID PRN nausea, anorexia
6. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN pain
7. Lactulose 15 mL PO BID:PRN constipation
hold if loose stool
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. LORazepam 0.25-1 mg PO Q6H:PRN nasuea, anxiety
10. Mirtazapine 7.5 mg PO QHS
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Vitamin D 7500 UNIT PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Prochlorperazine 10 mg PO Q6H:PRN nasuea, vomiting
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic pancreatic cancer
Hypotension
***if you are having diarrhea or had loose stools in the past 2
days don't take the lactulose!!!!
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please follow up with your primary oncologist as below.
You were admitted with low blood pressure. We think this was
from profound dehydration. We started nasogastric tube feeds to
get you supplemental nutrition but you were eating very well by
the time you left the hospital as well which is great. We didn't
find evidence of infection and your blood pressure was much
better by the time you left the hospital and you were feeling
well.
Please do the bolus tube feeds at home. You should drink ensure
supplements three times a day.
for the tube feeds:
Use Jevity 1.5. You want to get in about 5 cans per day
ultimately in boluses throughout the day, but it's ok if you can
only do a little less. Start out with just half a can at a time
in the first few days and if you tolerate that well (no
bloating, abdominal pain, nausea) you can do a full can at a
time. Also flush the tube with 150cc water every 4 hours for a
total of 1.8 liters of water in addition to the tube feeds.
Followup Instructions:
___
|
19623096-DS-18
| 19,623,096 | 23,767,315 |
DS
| 18 |
2170-01-13 00:00:00
|
2170-01-15 07:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Cipro
Attending: ___
Chief Complaint:
Fever, chills and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with recently diagnosed Crohn's disease in ___, on ___ who comes in with fevers chills and malaise.
Patient was in her usual state of health however the morning of
admission she was awoke with abdominal pain. She went back to
bed and pain got better as day resolved. She has had similar
experiences in the past since being diagnosed with Crohn's which
often leads her to reduce solid intake. On this particular day
however, she acutely developed chills and fevers by
mid-afternoon. She had one episode of emesis the afternoon of
her admission.
Of note patient has a significant h/o UTIs ___ years ago during
high school where she was treated with Macrobid and placed on
prophylatic macrobid for months. She had one recurrent episode
during high school but has not had a UTI since then. Treatment
with cipro during those times produced tendonitis.
On ROS: She states her abdominal has improved but admits to
having 2 episodes of diarrhea this morning. She also admits to
back pain, increased urinary frequency. Patient denies dysuria,
chest pain, shortness of breath, palpitations.
Past Medical History:
Recent diagnosis of Chron's in ___
h/o recurrent UTIs
Social History:
___
Family History:
Mother has ___ and father has history of recent colon cancer.
Paternal Grandfather has cardiac history of MI. Paternal
grandmother h/o diverticulitis
Physical Exam:
Physical exam on admission
Vitals: T: 100.3 BP: 126/62 P: 136 R: 18 18 O2:96% on RA
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,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, Presence of
CVA tenderness bilaterally L>R
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Physical exam on discharge
Vitals: Tmax: 99.2 Tc 98.9 BP: 121/68(121-136/66-87) P:
91(91-106) R: 20 O2:99% on RA
PPD MEASUREMENT after 48-72 hours: ~2mm
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,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, No CVA
Tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No focal lesions
Pertinent Results:
LAB RESUTLS ON ADMISSION
___ 03:50PM BLOOD WBC-3.3* RBC-5.12 Hgb-12.3 Hct-38.5
MCV-75* MCH-23.9* MCHC-31.8 RDW-13.4 Plt ___
___ 03:50PM BLOOD Neuts-88.0* Lymphs-10.6* Monos-0.6*
Eos-0.3 Baso-0.5
___ 03:50PM BLOOD ___ PTT-22.7* ___
___ 05:00PM BLOOD ___ 06:40AM BLOOD ESR-15
___ 03:50PM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-138
K-3.5 Cl-103 HCO3-21* AnGap-18
___ 03:50PM BLOOD ALT-9 AST-12 LD(LDH)-129 AlkPhos-85
TotBili-1.0
___ 06:40AM BLOOD Calcium-7.0* Phos-2.7 Mg-1.2*
___ 03:50PM BLOOD TSH-0.86
___ 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 06:40AM BLOOD CRP-143.0*
___ 07:59AM BLOOD Vanco-3.8*
___ 03:28PM BLOOD Lactate-1.7
LABS ON DISCHARGE
___ 10:31AM BLOOD WBC-4.4 RBC-4.18* Hgb-10.0* Hct-30.9*
MCV-74* MCH-23.8* MCHC-32.3 RDW-13.7 Plt ___
___ 10:31AM BLOOD Neuts-65.3 ___ Monos-5.8 Eos-1.5
Baso-0.3
___ 09:00AM BLOOD ESR-60*
___ 10:31AM BLOOD Glucose-87 UreaN-5* Creat-0.7 Na-141
K-3.6 Cl-103 HCO3-32 AnGap-10
___ 10:31AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8
___ 09:00AM BLOOD CRP-28.4*
___ 03:33PM BLOOD Vanco-15.8
IMAGES:
CT ABDOMEN: There is a segment of distal ileum with fibrofatty
proliferation,
reactive lymph nodes, and luminal dilatation spanning 20-30cm
(601B:20). The
remaining portions of the small bowel are within normal limits.
The lung bases are clear. The visualized portions of the
heart and
pericardium are normal. The liver enhances homogenously and
there is no focal liver lesion. The hepatic and portal veins
are patent. The gallbladder, pancreas, spleen, and adrenals are
normal. The kidneys enhance symmetrically and excrete contrast
without evidence of hydronephrosis or mass.
CT PELVIS: There is a fistula formed between the sigmoid colon
and the cecum (2:61). Also, there is a loss of fat planes
between the distal ileum and the urinary bladder with tiny air
locules (601B:21,23). Accompanying this finding is a small
amount of air within the urinary bladder. There is also a loss
of fat planes between the distal ileum and rectosigmoid without
a definite fistula (602B:35). The uterus and adnexa are normal.
There is no pelvic lymphadenopathy. There is a trace amount of
pelvic free fluid, which is nonspecific in a female patient of
this age. The appendix is normal (2:57).
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
suspicious for
malignancy.
IMPRESSION: Distal ileitis with evidence of enterovesicular
fistula. No
intra-abdominal abscess identified. Likely fistula between the
cecum and
rectosigmoid. Findings are consistent with known Crohn's
disease
MRE RESULTS
FINDINGS:
ENTEROGRAPHY: In the terminal ileum, there is a 7 cm segment
of narrowing, mural wall edema, and abnormal hyperenhancement.
Arising from this area is an ileosigmoid fistula (5, 62). There
is surrounding inflammation and fluid within the fistula tract.
Inflammation and wall edema is also present in the cecum
extending into the appendix. There is an appendiceal-sigmoid
fistula, with fluid within the fistula tract. There is
inflammation and wall thickening at the site of the fistula
within the sigmoid colon extending approximately 1 cm beyond the
fistula. There is tethering and enhancement extending from the
terminal ileum to the bladder wall. There is no definite fluid
within the sinus tract. The previously seen air within the
bladder has resolved. There is also tethering between the
terminal ileum and the broad ligament. Approximately 5 cm of
terminal ileum proximal to the narrowed region has persistent
wall enhancement and mural edema. Overall the edema as
mildly improved from the prior CT. There is no surrounding
phlegmon or abscess. There is a small amount of free fluid in
the right lower quadrant. Prominent lymph nodes are present in
the mesentery, but none are pathologically enlarged.
ABDOMEN: The liver is normal in shape and contour. There is no
evidence of fatty infiltration. There are no focal hepatic
lesions. The portal vein is patent. The gallbladder is normal.
There is no intra- or extra-hepatic biliary duct dilation. The
spleen is borderline enlarged. It measures 12.9 cm. The pancreas
is unremarkable without focal pancreatic lesions or duct
dilation. The adrenal glands and kidneys are normal. There is no
evidence of hydronephrosis or renal masses.
PELVIS: There is no pelvic or inguinal lymphadenopathy. The
uterus is unremarkable. There is no abnormal signal within the
osseous structures.
IMPRESSION:
1. Two fistulas, one ileo-sigmoid and one appendiceal-sigmoid,
with surrounding inflammation of the adjacent terminal ileum and
sigmoid colon.
2. Sinus tract between the terminal ileum and the bladder
without definite patency of the tract. The previously seen air
within the bladder has resolved.
3. Tethering of the terminal ileum to the broad ligament.
4. Improvement in terminal ileal wall edema; approximately 12 cm
of terminal ileum is present with wall edema and wall
enhancement.
5. No evidence of phlegmon or abscess
LABS PENDING FOR FOLLOW UP:
- TPMT
- Quantiferon Gold Test
Brief Hospital Course:
This is a ___ year old woman with recently diagnosed Crohn's
disease coming in with fevers chills and malaise
# Crohn's disease:
Patient's Crohn's disease was diagnosed in ___. She presented
with acute onset of fevers and chills and abdominal pain.
Abdominal pain resolved on day 1 of admission. At that time, she
also had CVA tenderness and increased frequency of urination
which resolved by day 3 of admission. UA showed significant
pyuria but cultures were negative. On first night of admission,
patient experienced fevers up to 102.9 with tachychardia to 150s
and leukopenia, concerning for sepsis. Her budesonide was
stopped and started on Vancomycin and Zosyn. Cxray and KUB
negative. CT on the next day was concerning for enterovesicular
fistula. IV antibiotics were continued for 6 days while fever
curve trended down. She was then switched to Augmentin and
remained afebrile and stable until discharge. During admission,
colorectal surgery was consulted and after many conversations
between GI and surgery, medical management was agreed on. MR
___ on day prior to discharge showed no evidence of
abscess or phlegmon and actually showed no evidence of patency
between the terminal ileum and the bladder. ___ recieved
Remicade 400 mg VI x 1 on day of discharge with planned
follow-up with ___ clinic in approximately 2 weeks. Her CRP on
day of admission was 143 and it trended down to 28.4 by
discharge.
A PPD test done to screen for TB prior to starting remicade was
negative (less than 2mm) and a quantiferon gold test was also
sent in on ___ (negative at time of D/C summary).
# SIRS/Sepsis: Patient's symptoms resolved with antibiotitic
therapy as above, discharged on Augmentin. All blood culture
negative.
# Vaginal candidiasis: Likely in the setting of antibiotic use.
Was treated with Fluconazole x 2 in 72 hours. One dose ordered
for ___ (72 hours after the previous dose). Discharged on
Monistat cream to use while on antibiotics.
# Headaches: Patient has history of headaches for which she
takes hydroxyzine for the past ___ years. She was stable while
inpatient and ativan, tylenol and hydroxyzine were helpful in
managing her headaches.
# Prophylaxis: She was on subcutaneous heparin considering she's
in a hypercoagulable state with her inflammatory disease. She
had a transient drop in platelets from 246 to 125 and back to
265 prior to discharge. Etiologies such as Heparin induced
thrombocytopenia were ruled out.
# Transitional items
- Follow up on TPMT results
- Follow up with GI regarding when to get next
infliximab/remicade infusion
Medications on Admission:
Budesonide 3 times a day
Hydroxyzine for headaches 50mg 1 pill at night
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg twice a day Disp
#*28 Tablet Refills:*0
2. HydrOXYzine 50 mg PO QHS
3. Infliximab 400 mg IV AS DIRECTED
4. Fluconazole 150 mg PO ONCE Duration: 1 Doses
Take one dose on ___
RX *fluconazole 150 mg Once on ___ Disp #*1 Tablet Refills:*0
5. Miconazole Nitrate Vag Cream 2% 1 Appl VG HS Duration: 7 Days
RX *miconazole nitrate 2 % once a day Disp #*1 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Crohn's disease with ileovesicular fistula
Sepsis with UTI
Secondary
vaginal candidiasis
chronic headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Miss ___,
You were admitted due to fever, chills and abdominal pain. While
inpatient your temperatures remained high for multiple days and
you were septic. You were treated with IV vancomycin and zosyn
as this was an infection caused by a fistula connecting your
ileum and bladder due to your recently diagnosed Crohn's
disease. Your symptoms resolved while you were in patient and
you were switched to oral augmentin. After multiple discussion
with you and your family, the GI team and the colorectal surgery
team, you decided to first try medical therapy with remicade
(infliximab) before resorting to surgery.
Due to the antibiotics you were placed on, you also developed
persisting yeast infection for which you were treated with
fluconazole.
You were afebrile for more than 72 hours before discharge. You
were also having good oral intake of food and started your first
dose of remicade prior to discharge.
Medications stopped
Budesonide TID
Medications started
Remicade 400mg IV - frequency of infusions followed by GI
doctors
___ 875mg Twice a day for 2 weeks
Fluconazole 150mg one more dose on ___
Miconazole Nitrate Vag Cream 2% 1 Appl VG at bedtime for 7 days
Followup Instructions:
___
|
19623132-DS-12
| 19,623,132 | 23,747,950 |
DS
| 12 |
2183-03-22 00:00:00
|
2183-03-23 08:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins
Attending: ___.
Chief Complaint:
Rash/Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of anxiety, depression and ADHD presenting
with 5 day history of bilateral leg rash. Patient first noted
rash after shaving genital region approximately 5 days prior to
arrival. Rash was originally on bilateral scrotum and groin and
progressed to erythematous pruritic rash with small amount of
drainage. Went to ___ 3 days prior to admission and was
prescribed keflex and clotrimazole. Over the course of the next
3 days felt that rash spread to bilateral inner thighs. This
morning, was on the computer and felt feverish so took 3 tablets
of ibuprofen. He then felt very anxious, became tachycardic and
short of breath and felt like he had a panic attack. Of note,
patient has had panic attacks in the past and is currently being
treated for anxiety and depression. Because of the spreading of
the rash and the panic attack, patient came to ED for further
evaluation.
.
In ED, vitals were 100.8 134 169/84 18 100%. A CXR was obtained
which showed no evidence of acute itnrathoracic process. Labs
were notable for WBC of 6.0, lactate of 1.2 and negative urine
and serum tox screen. Patient was started on 1g IV vancomycin
for presumed bilateral cellulitis and admitted to medicine for
further evaluation and treatment.
.
On arrival to the floor, patient's vitals were 98.3, 148/74, 84,
16, 97% on RA. Patient appeared anxious, but was comfortable
overall. Denies any penile discharge/pain. Denies n/v/d.
Denies CP. Denies any new sexual encounters and has been tested
for STDs in the past.
Past Medical History:
anxiety, depression, ADHD
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: 98.3, 148/74, 84, 17, 97% RA
GEN: awake, alert, anxious appearing, in NAD
CV: RRR, nl S1/S2
PULM: CTA bilaterally
ABD: soft NT/ND
Genitals: some waxy wart-like papules on dorsum of penile shaft.
Separately, on bilateral groin just by the scrotum there was a
dark erythematous maculopapular rash, slightly raised w/ rough
texture.
Skin: bilateral maculopapular erythematous rash on inner thighs,
not confluent with groin rash. Lighter red in color, also raised
and rough. Scabs on bilateral ankles which patient reports is
from shaving
Extremities: 2+ DP pulses bilaterally
Neuro: moving all extremities
Psych: alert and oriented to person, place, date, appropriate
Pertinent Results:
___ 01:11PM LACTATE-1.2
___ 11:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:10AM GLUCOSE-135* UREA N-21* CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 11:10AM WBC-6.0 RBC-4.95 HGB-14.4 HCT-43.3 MCV-88
MCH-29.2 MCHC-33.3 RDW-12.4
___ 11:10AM NEUTS-67.3 ___ MONOS-5.3 EOS-5.7*
BASOS-0.9
___ 11:10AM PLT COUNT-196
___ 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CXR - FINDINGS: The heart is normal in size. The mediastinal and
hilar contours appear within normal limits. A nipple shadow
projects over the left mid lung field. Otherwise, the lung
fields appear clear. There is no pleural effusion or
pneumothorax. The bony structures are unremarkable. IMPRESSION:
No evidence of acute disease.
Brief Hospital Course:
___ M with history of anxiety, depression and ADHD presenting
with expanding rash over the past five days and increased heart
rate/difficulty breathing today.
.
# Rash - Patient with bilateral rash in groin and inner thighs,
nonconfluent. Was treated with keflex and clotrimazole cream
without significant improvement. While this could be a
cellulitis caused by irritation from shaving, the bilateral
nature and nonconfluence of the groin and inner thigh rash are
unusual. This is more likely a contact irritation given the
inner thigh rash and bilateral nature and constant shaving. ED
had concern for IVDU given scabs on bilateral ankles. Patient
adamantly denies IVDU and both serum and urine tox screens were
negative. Patient was started on IV vancomycin for presumed
cellulitis in ED. Treated with hydrocortisone cream for
presumed dermatitis caused by shaving. Patient will be
discharged home continuing keflex course for 10 days total as
prescribed by ___, hydrocortisone cream for thigh rash and
desitin cream OTC for groin rash.
# Shortness of breath - Patient had transient episode of rapid
heart rate and shortness of breath prior to arrival to the ED.
Patient reports that this felt exactly like his other panic
attacks in the past. CXR in ED was negative for acute
intrathoracic process. Patient was afebrile while on floor and
SOB had fully resolved.
# Fever - pt had temp in ED to 100.8. Eosinophil count slightly
elevated to ~5%. We found no infectious etiology of the fever
and are comfortable discharging patient with continuation of his
PO keflex as above.
Medications on Admission:
- Trileptal 300 mg Tab Oral 1 Tablet(s) Once Daily
- clonidine 0.1 mg Tab Oral 1 Tablet(s) Once Daily
- Celexa 20 mg Tab Oral 1 Tablet(s) Once Daily
- dextroamphetamine 5 mg Tab Oral 3 Tablet(s) Once Daily
- fluvoxamine 50 mg Tab Oral 1 Tablet(s) Once Daily
Discharge Medications:
1. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. dextroamphetamine 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. fluvoxamine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. cortisone 1 % Cream Sig: One (1) Appl Topical twice a day.
Disp:*1 tube* Refills:*2*
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
You were admitted to the hospital with a rash on your legs that
was concerning for a soft tissue infection called cellulitis.
You were started on IV antibiotics and observed on the floor.
Your rash seemed less likely to be of an infectious etiology and
likely irritation caused by shaving. You have been prescribed a
steroid cream to apply to your thighs. Please do NOT use the
steroids on your groin. You should buy desitin cream for your
groin rash. You should continue to take the keflex for the
entire prescribed course.
We have made the following changes to your medications:
# ADD 1% hydrocortisone cream apply to affected area two times
per day
please continue all other medications
Followup Instructions:
___
|
19623213-DS-3
| 19,623,213 | 23,706,347 |
DS
| 3 |
2162-11-29 00:00:00
|
2162-11-29 22:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___ pericardial drain placement
History of Present Illness:
___ with h/o recent pericarditis, HTN, and CKD presenting with
DOE. Pt was recently hospitalized for pericarditis and felt
well on discharge. She has noted gradually increasing fatigue
since she went home and over the past ___ days she has also been
experiencing shortness of breath. First she noticed this when
walking up stairs but began to progress. She went to her PCP's
office today and became winded even while walking on flat
ground, prompting her referral to the ED.
In the ED, initial vitals were: 97.8 80 142/78 16 100%. Her
labs were significant for a hematocrit around her recent
baseline, hyponatremia, and Cr of 1.4 (elevated compared to her
recent hospitalization, but lower than earlier this week). Her
EKG was overall unchanged. Her CXR revealed an increase in the
size of her cardiac silhouette and a globular formation. She
was evaluted by cardiology in the ED. A bedside TTE was
performed which reportedly revealed a moderately sized
pericardial effusion and RA systolic collapse. She is being
admitted to the CCU for close monitoring overnight. She also
had an episode of hemodynamically stable atrial fibrillation.
She was given metoprolol 5 mg IV x1 and returned to ___. Vitals
prior to transfer were 98.7 81 117/103 18 100% RA.
Upon arrival to the unit, the patient reports feeling well and
has no complaints.
REVIEW OF SYSTEMS:
Negative unless noted above. No CP, no F/C, no N/V, no D/C, no
urinary complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
-acute pericarditis with pericardial effusion ___
-anxiety
-HTN
-GERD
-hypothryoidism
-renal insufficiency
-R knee replacement
-cholecystectomy
-tubal ligation
Social History:
___
Family History:
father died at ___ from heart attack. Mother had lung cancer.
Physical Exam:
========================
ADMISSION EXAM
========================
General: Well appearing, NAD, pleasant and interactive with the
conversation. Mood/affect wnl. Pulsus 16.
HEENT: EOMI, PERRL, scelera anicteric, MMM, OP clear
Neck: Supple, unable to fully assess neck veins
CV: RRR, nl s1s2, no m/r/g
Lungs: CTAB, no w/ra/rh
Abdomen: S/NT/ND, NABS, no HSM
GU: Foley draining clear yellow urine
Ext: WWP, no CCE, DP 2+
Neuro: AAOx3, moving all 4 extremities spontaneously
========================
DISCHARGE EXAM
========================
General: pleasant, NAD
HEENT: atraumatic, PERRL, OP clear
Neck: supple, no JVD
CV: RRR, no m/g/r
Lungs: ctab, no wheezes/crackles/rhonchi
Abdomen: soft, +BS, nontender, nondistended
Ext: 1+ edema on R leg (chronic), trace edema on L leg
Neuro: A&Ox3, no focal neuro deficits
PULSES: 2+ peripheral pulses
Pertinent Results:
===============
ADMISSION LABS
===============
___ 06:12PM WBC-10.8# RBC-3.39* HGB-9.9* HCT-29.2* MCV-86
MCH-29.1 MCHC-33.7 RDW-14.7
___ 06:12PM NEUTS-77.0* LYMPHS-14.7* MONOS-6.9 EOS-1.0
BASOS-0.4
___ 06:12PM GLUCOSE-111* UREA N-35* CREAT-1.4*
SODIUM-125* POTASSIUM-8.5* CHLORIDE-89* TOTAL CO2-24 ANION
GAP-21*
___ 06:25PM LACTATE-1.4 NA+-126* K+-5.5*
===================
PERICARDIOCENTESIS
===================
Using ultrasound localization, the xiphoid space was entered and
the position of the guidewire in the pericardial space was
confirmed with fluoroscopy. The intrapericardial pressure was 25
mmHg. Approximately 500 cc serosanguineous fluid was removed.
Removal of the pericardial effusion was confirmed with
ultrasound
and the intrapericardial pressure was ___ mmHg.
===============
DISCHARGE LABS
===============
___ 09:00AM BLOOD WBC-5.4 RBC-4.20 Hgb-11.4* Hct-36.0
MCV-86 MCH-27.2 MCHC-31.7 RDW-14.8 Plt ___
___ 09:00AM BLOOD Glucose-121* UreaN-29* Creat-1.1 Na-137
K-3.9 Cl-99 HCO3-27 AnGap-15
___ 06:50AM BLOOD ALT-42* AST-27 AlkPhos-149* TotBili-0.0
========
STUDIES
========
___ TTE:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is normal. Trace
aortic regurgitation is seen. Physiologic mitral regurgitation
is seen (within normal limits). There is a moderate sized
circumferential pericardial effusion with intermittent right
atrial diastolic collapse c/w increased pericardial pressurs.
IMPRESSION: Suboptimal image quality. Moderate circumferential
pericardial effusion with echocardiographic signs of early
tamponade physiology.
___ TTE:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with borderline normal free wall
function. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. There is a very
small pericardial effusion. The pericardium appears thickened.
There are no echocardiographic signs of tamponade.
IMPRESSION: Trivial/small pericardial effusion without signs of
tamponade.
___ TTE:
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
IMPRESSION: Very small pericardial effusion with no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the effusion seems to have decreased.
Brief Hospital Course:
___ with h/o recent admission for pericarditis here with
worsening dyspnea on exertion found to have a pericardial
effusion.
# Pericardial effusion- Patient presented with fatigue and DOE.
She had recent admission for idiopathic pericarditis with cath
showing non-obstructive CAD. His effusion was related to his
pericaditis. Her pulsus on admission was 16 but increased to 24
over her first night of admission. She was brought emergently
to the cath lab due to concern for tamponade. She had a
significantly elevated pericardial pressure of 25 and she had a
drain placed. Her drain was left in place for 24h with normal
repeat pulsuses and no residual effusion seen on serial
echocardiograms. She continued colchicine for her effusion at
BID instead of daily dosing. Indomethacin was stopped. TTE on
day of discharge showed no reaccumulation of her effusion.
# Atrial fibrillation: Patient was noted to be in atrial
fibrillation in the ED. While admitted she briefly would go
into atrial fibrillation and at other times would sinus
tachycardia with frequent PACs. Her metoprolol was initially
held in the setting of concern for tamponade but was
subsequently uptitrated following placement of her pericardial
drain. She has a CHADS score of 1 (CHADSVASC of 3) and her AFib
was likely provoked in the setting of myocardial irritability
from her pericarditis and effusion. Rivaroxaban was started for
anticoagulation. Amiodarone was started for rhythm control and
metoprolol was continued for rate control. She converted to NSR
after initiating amiodarone.
# Hyponatremia: Patient developed weight gain and leg swelling
following her recent discharge. These were most likely in the
setting of RV dysfunction from her pericardial effusion and
subsequent development of tamponade causing hypervolemic
hyponatremia. Her sodium improved following pericardial
drainage and on discharge it was 137. This was not present
during recent hospitalization.
# HTN: home antihypertensives were briefly held in the setting
of tamponade and restarted after pericardiocentesis
# HLD: continued atorvastatin
# Nonobstructive coronary artery disease: Recent cath with
?microvascular dysfunction. Continued ASA and statin. Cards f/u
scheduled in Mid ___
TRANSITIONAL ISSUES:
[]titrate metoprolol to patient symptoms for atrial fibrillation
[]2.5 cm nodule centered at the lateral limb of the right
adrenal gland is indeterminate. Further evaluation with CT
abdomen with adrenal mass protocol is recommended.
[]outpatient TTE in 1 week
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 600 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Colchicine 0.6 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
10. potassium citrate 10 mEq oral TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Indomethacin 50 mg PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Colchicine 0.6 mg PO BID
3. Calcium Carbonate 600 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Amiodarone 400 mg PO BID Duration: 1 Week
LAST DAY ___. Amiodarone 400 mg PO DAILY Duration: 2 Weeks
start this dose on ___. last day at this dose ___.
9. Amiodarone 200 mg PO DAILY
start on ___ and continue to take this medication
10. Centrum Silver
(
m
u
l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.4-300-250 mg-mcg-mcg oral daily
11. Ranitidine 150 mg PO BID
12. potassium citrate 10 mEq oral TID
13. Rivaroxaban 20 mg PO DINNER
Discharge Disposition:
Home
Discharge Diagnosis:
#Idiopathic pericarditis
#Pericardial effusion
#Cardiac tamponade
#Chronic kidney disease, stage 3
#Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were readmitted to ___ with ___
recurrent pericardial effusion causing cardiac tamponade. This
effusion was drained. The likely cause is ongoing inflammation
from the pericardititis you had last admission. We continued
colchicine, which prevents recurrent pericarditis, and stopped
indomethacin as you were not having chest discomfort associated
with your pericarditis. You will need to continue this
medication until after your follow up visit with your
cardiologist.
You also had a few brief episodes of a cardiac arrhythmia called
atrial flutter. this persisted until we started you on
AMiodarone at which point you converted to sinus on your own. It
was likely due to pericardial inflammation. However, people who
have one episode of atrial fibrillation are more likely to have
it again in the future. Atrial fibrillation is associated with a
small risk of stroke, and your risk of stroke is quite low (3%
per year). We recommend and have started you on anticoagulation
with Xarelto to decrease your risk for stroke.
We have started you on amiodarone to keep you in sinus rhythm.
You will need to have your liover enzymes followed as an
outpatient and you should avoid sun exposure as it causes
sensitivity.This drug is a taper, meaning you take it a
decreasing dosages. Please see your med list for details.
A complete list of all of your medications are available to you
with your paperwork.
Followup Instructions:
___
|
19623346-DS-9
| 19,623,346 | 27,759,741 |
DS
| 9 |
2132-10-11 00:00:00
|
2132-10-11 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fluoxetine
Attending: ___.
Chief Complaint:
PRIMARY
Generalized Tonic Clonic Seizures from Ethanol Withdrawal
SECONDARY
Ethanol Dependence
Pineal Gland Cyst (stable)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a history of alcohol use (recent detox ~3
weeks ago), pineal cystic mass, presenting after GTC. Episode
ocurred while patient was at work, when she slid off her chair
and had a 60 second GTC. Per co-worker, she started shaking, her
lips turned blue, and she started spitting up. No history of
seizure. She did have a recent increase in her effexor from
150mg to 225mg QD.
Notably she detoxed from alcohol about 3 weeks ago. Prior to
this, she reportedly had been drinking ___ bottle wine per night
for about 2 weeks. She reports her parents were concerned about
her drinking and she detoxed at a center over ___ days. She has
never had an alcohol withdrawal seizure. She denies alcohol use
since her detox.
In ___, she was having daily headaches for several months, and
was found to have a cystic pineal mass. Surgery was discussed
but she was lost to follow up.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals: Pain ___ T 98.6 HR 124 BP 119/77 RR 17 Sat
98% RA
- EKG: sinus tach with rate 120
In ED patient had another GTC sz which lasted about 20 seconds
where she became rigid and stared off and started convulsing.
She did not lose control of her bowels or bladder. Her lips
turned blue and she started spitting up.
Pertinent physical exam findings: tachycardic, diaphoretic,
dilated pupils and tremulous
Tox screen negative
NCHCT showed no acute intracranial process, unchanged pineal
cyst.
- She was given 2mg Ativan and placed on non-rebreather.
- She was started on CIWA protocol and given Valium 10 PO x 2
- Patient's tachycardia improved to 98
On arrival to the MICU,
Review of systems:
(+) headache
(-) Denies fever, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, nausea,
vomiting, diarrhea, constipation, abdominal pain. Denies
dysuria, frequency, or urgency.
Past Medical History:
- EtOH Dependence with EtOH withdrawal seizures
- Pineal Gland Cyst
- Anxiety
- Migraines
Social History:
___
Family History:
Father had a single seizure, unclear context. No other family
history of seizure or neurologic disorders
Physical Exam:
ADMISSION:
Vitals- T: BP: 114/79 P: 98 R: 24 O2: 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
NECK: supple, 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
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CN ___ intact, ___ strength all extremities, no
dysmetria/ dysdiadochokinesia.
DISCHARGE:
VITALS: 98.1, 74-75, 105-114/64-65, ___, 100% on RA, CIWA 6,
0, 0
GENERAL: NAD, A+Ox3, Pleasant and Cooperative
HEENT/Neck: Supple neck, MMM, EOMI/PERRL, no JVD/LAD
CV: RRR, no MRG
PULM: CTAB, no wheezes/crackles/rhonchi
ABD: Soft, ND/NT, +BS, no masses or organomegaly
EXT: 2+ ___ pulses, no peripheral pitting edema
NEURO: Motor and sensory grossly intact, no tremors
Pertinent Results:
ADMISSION LABS
___ 10:29AM BLOOD WBC-6.7 RBC-3.79* Hgb-11.2* Hct-34.1*
MCV-90 MCH-29.6 MCHC-32.9 RDW-13.1 Plt ___
___ 06:50PM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-139 K-3.7
Cl-102 HCO3-27 AnGap-14
___ 03:43AM BLOOD ALT-11 AST-18 AlkPhos-54 TotBili-0.3
___ 06:50PM BLOOD Calcium-9.5 Phos-1.5* Mg-2.5
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD W/O CONTRAST ___ 00:30 =
No acute intracranial abnormality is identified. Unchanged 0.9
cm pineal cyst with coarse rim calcifications.
___. ___
___. ___: FRI ___ 9:39 AM
NEUROLOGY CONSULT ___ =
Neurology Resident Consult Note
Reason for Consult: ___ seizure x 2
HPI:
The pt is a ___ year-old woman with history of pineal cyst and
alcohol misuse disorder brought in by ambulance after a
witnessed seizure at work. Per ED notes, she was at work when
she slid off her chair and had about 60 second episode during
which a co-worker noted that patient was shaking, started
spitting up and lips turned blue and then she was confused and
shaky afterward. Upon arrival to ED a trigger was called when
she had another episode in which she became rigid and stared off
and started convulsing lasting about 20 seconds. Per records,
her lips turned blue and she started spitting up. She was
tachycardic, diaphoretic, and tremulous with dilated pupils. She
did not lose control of her bowels or bladder during either
event and there was no evidence of oral trauma. Her labs at that
time were notable for a white count of 12.5 and a blood glucose
of 77. Urine and serum tox screens were negative and UA was
unremarkable. She received 2mg of ativan after her seizure.
Given that patient has a history of alcohol misuse and underwent
detox 3 weeks ago, she was started on CIWA protocol, recieved
Valium 10mg x 2 and admitted to the MICU for monitoring for
alcohol withdrawal.
Overnight patient repeatedly denied any alochol relapse since
her detox two weeks ago. She did not require PRNs as CIWA scores
<10, and her vitals were stable and exam was without tremors or
diaphoresis. Patient also reported an increase in venlafaxine
from 150 to 225 in the past 3 weeks and a had decreased ativan
from 1 to 0.5mg ___ times daily over the past two weeks. She
denies any previous history of seizures, including febrile
seizures.
On interview with neurology patient admits to drinking one beer
on ___ night, approx 72 hours ago.
Per collateral from patient's mother and other family members,
four bottles of beer and up to 8 nips were found in the
patient's bedroom on ___ morning. They also state she has
been abusing fioricet and had been abusing her ativan until
about one month ago when the patient's mother locked up the
ativan.
On neuro ROS, the pt denies headache, vision or speech changes,
no hearing difficulty, lightheadedness, vertigo. Denies
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No dysuria. Denies cough, shortness of breath. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain.
PMH:
Migraines
Pineal Cyst
Home medications:
-Ativan 0.5mg BID
-Effexor XR 225 mg daily
-Omeprazole 20mg BID
Current Meds:
Docusate Sodium (Liquid) 100 mg PO BID
Diazepam 10 mg PO/NG Q4H:PRN CIWA>10
Heparin 5000 UNIT SC TID
Phosphorus 500 mg PO ONCE Duration: 1 Dose
Potassium Chloride 60 mEq PO ONCE Duration: 1 Dose
Allergies:
fluoxetine - tremors
Social Hx:
___
Family Hx:
No family history of seizure disorders.
**********
Physical Exam:
Vitals: Tc: 98.1 Tm 98.4 P: ___ R: ___ BP: ___
SaO2: 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to conversation. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 4mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic ___ WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
-Sensory: No deficits to light touch throughout. Vibratory sense
intact bilateral lower extremities.
-DTRs:
___ Pat Ach
L ___ 3 2
R ___ 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: not tested
**********
Laboratory Data:
11.2
6.7>----<224
34.1
138 | 107 | 5
--------------<71 AG: 11
3.3 | 23 | 0.5 Albumin 3.8 Calcium 8.2 Phos 2.4 Mg 2.2 ALT 11
AST 18 AlkPhos 54 TotBili 0.3
Radiologic Data:
___ Non-Contrast CT of Head:
No acute intracranial abnormality is identified. Unchanged 0.9
cm pineal cyst with coarse rim calcifications.
ASSESSMENT:
___ woman with history of pineal cyst and recent alcohol detox
now with 2 witnessed generalized tonic clonic seizures.
Neurology is consulted to rule out epileptic disease. Patient's
presentation is most consistent with alcohol withdrawal seizure,
although changes to benzo dozing and her use and subsequent
withdrawal of fioricet can also lower seizure threshold. Her
stable pineal cyst is not likely to be epileptogenic, and she
has no familial or personal history of seizure disorder. This is
likely a provoked seizure in the context of alcohol withdrawal,
and anti-epileptic therapy is not indicated at this time. Would
recommend routine EEG to more definitively rule out
epileptogenic origin of these episodes.
PLAN:
-Routine EEG
-No AEDs at this time
-Please continue CIWA protocol to monitor for signs of
withdrawal and treat per protocol.
___, MD
___ rotator
___ ___
DISCHARGE LABS
___ 08:24AM BLOOD WBC-5.2 RBC-4.19* Hgb-12.4 Hct-38.2
MCV-91 MCH-29.5 MCHC-32.4 RDW-13.3 Plt ___
___ 08:24AM BLOOD Glucose-83 UreaN-7 Creat-0.6 Na-140 K-3.9
Cl-104 HCO3-27 AnGap-13
Brief Hospital Course:
___, a ___ yo F with PMHx EtOH Dependence and Pineal
Gland Cyst presented with two generalized seizures. Her
seizures were managed, Neurology consulted and felt she was
having ethanol withdrawal seizures, and she was discharged
asymptomatic with instructions to not drive and abstain from
ethanol.
# ETHANOL WITHDRAWAL SEIZURE: In ICU, initially unclear etiology
of seizure. It is possible that she is having an alcohol
withdrawal seizure, though she denies any recent alcohol use,
even after explaining that this would change medical management.
Furthermore, she does not appear to be actively withdrawing,
given normal heart rate and blood pressure, no tremulousness or
diaphoresis. Another possible cause is her pineal cyst, which is
a brain structural abnormality that could serve as a seizure
focus. However, given the stable nature of the cyst, it seems
unlikely that a seizure would present now. Another possible
cause is medication induced. She did have a recent increase in
her Effexor dose, which can interact with other drugs that lower
the seizure threshold. However, Effexor itself is not
particularly associated with seizures. Other causes of seizure
include infection (no signs of infection, except for mildly
elevated white count, which is likely a result of the seizure
itself), metabolic derangements (low phos, but otherwise normal,
including glucose), toxins (negative tox screen), or trauma (no
evidence of trauma).
Neurology consult felt that pineal gland cyst was small and
unchanged in size, had no personal or significant family history
of epilepsy, and had a clear history of ethanol dependence with
recent reduced use. They recommended routine EEG and no
anti-epileptic drugs. Patient was instructed to followup with
her neurologist and to not drive until she was cleared by her
PCP or neurologist. Patient had no further seizures in ICU or
on medical floor. Neurology will followup with EEG reading.
# ETHANOL USE: Patient reports heavy alcohol use, but entered
detox 3 weeks ago and has denied alcohol use since. Had ethanol
withdrawal seizures. Was maintained on CIWA with diazepam 10mg
for CIWA >10 (scored around 6 for chronic headaches and anxiety,
no tachycardia or altered mental status or tremors). She was
discharged with instructions to abstain from alcohol and with
resources for substance use disorders, along with
folate/thiamine/multivitamin supplementation.
# Hypophosphatemia: 1.5 on initial labs; repleted in ICU.
# Anxiety/Depression: Chronic stable issue continued on home
venlafaxine and prn lorazepam.
# Code Status: Full Code confirmed. HCP is her mother ___
___ at ___.
# Disposition: Home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 225 mg PO DAILY
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. Omeprazole 20 mg PO BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
4. Omeprazole 20 mg PO BID
5. Venlafaxine XR 225 mg PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Ethanol Withdrawal Seizures
SECONDARY:
Ethanol Dependence
Pineal Gland Cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
were having seizures because of alcohol withdrawal. You were
seen by Neurology, got an EEG, your seizures were managed, you
were monitored to signs of further withdrawal, and you were
discharged feeling better. Best of luck to you in your future
health.
Please do not drink any more alcohol. You should talk to your
primary care provider to find out additional options for alcohol
cessation.
Do not drive until you have been seen by your neurologist or
primary care provider. Please take all medications as
prescribed, attend all doctor appointments as scheduled, and
call a doctor if you have any questions or concerns.
Followup Instructions:
___
|
19623574-DS-19
| 19,623,574 | 21,130,411 |
DS
| 19 |
2202-06-01 00:00:00
|
2202-06-01 22:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with PMH HFpEF (EF 40-45% ___, CKD w/ unclear
baseline Cr brought in by ambulance for extreme shortness of
breath after smoking a cigarette at his housing complex. Odd
affect and very poor historian. Denies any chest pain. Unclear
about if he has had similar symptoms in the past. Denies any leg
swelling. No fevers or chills that he is aware of.
Reportedly per ___, hasn't been taking care of himself. Has
chronic foley that stays in 4 weeks at a time. Stays capped
until patient needs to urinate and uncaps it. Unclear when last
time he uncapped the foley was.
In the ED, initial vitals were: T 98.0 HR 92 BP 122/38 RR 18 O2
98% RA
Exam notable for crackles in bases with minimal wheezing
Labs notable for Hgb 7.1, BNP 32000 (prev ___ Cr 7.1, BUN 97,
Trop .06, UA with >182 WBC, many bacteria
Imaging notable for
Patient was given
-Lasix 20mg IV
-Cefepime 2g
-Vancomycin 1g
Patient was seen by who recommended cardiology who recommended
admission to medicine as primary problem seemed more c/w renal
failure and chest pain free- revascularization would risk
destroying remaining renal function.
Decision was made to admit for volume overload
Vitals notable for briefly on BiPAP in ED but weaned off
More than 1L of urine to 20mg IV Lasix with straw colored urine
and light sediment at bottom of bag.
On the floor, he continues to be a very poor historian with an
odd affect asking "I go tomorrow, right?" When asked to explain
what brought him here he says "I was short of breath, then I'm
here." He denies any other medical problems, and declined to
talk about what medications he is taking. Denied any
fevers/chills, chest pain, shortness of breath, abdominal pain,
n/v/d, or problems with his catheter.
Of note he has a poor history of ___ with both his
cardiology and nephrology appointments. His last nephrology note
states that he has been declining further therapy and was
refusing renal replacement therapy, also declined hospice.
Past Medical History:
Ischemic Cardiomyopathy due to LAD infarction
Systolic Congestive Heart Failure EF40-45%
Coronary Artery Disease with left anterior descending-territory
perfusion defect
Chronic Kidney Disease Stage IV
Schizophrenia (patient denies but has guardian and is on depot
formulation haloperidol)
Tobacco use
BPH s/p TURP
Atonic bladder requiring foley
Chronic bilateral Hydronephrosis
Recurrent UTIs
Colon Cancer (s/p R hemicolectomy ___ per Dr. ___
Possible TIA
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98, HR 76, BP 153/75, RR 24, O2 97% RA
Gen: Odd affect, non-cooperative with interview and exam
CV: RRR, no m/r/g
Pulm: CTAB
Abd: +BS, soft, nt, nd
GU: Foley in place draining clear yellow urine
Ext: No ___ edema
Skin: Warm and dry
Psych: Odd affect, very poor historian. Answers questions
tangentially and seems to have very poor insight into his
condition
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.0, HR 75, BP 145/78, RR 19, O2 97% RA
Is/Os: ___
Gen: Odd affect, comfortable
CV: RRR, no m/r/g
Pulm: CTAB
Abd: +BS, soft, nt, nd
GU: Foley draining clear yellow urine
Ext: No ___ edema
Skin: Warm and dry
Psych: Odd affect. Answers questions tangentially. Continues to
have poor insight.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:05AM BLOOD WBC-8.5# RBC-2.37* Hgb-7.1* Hct-22.5*
MCV-95 MCH-30.0 MCHC-31.6* RDW-16.0* RDWSD-55.1* Plt ___
___ 10:05AM BLOOD Neuts-88.2* Lymphs-3.5* Monos-5.2 Eos-2.5
Baso-0.2 Im ___ AbsNeut-7.46*# AbsLymp-0.30* AbsMono-0.44
AbsEos-0.21 AbsBaso-0.02
___ 10:05AM BLOOD Glucose-94 UreaN-97* Creat-7.1*# Na-134
K-5.1 Cl-101 HCO3-12* AnGap-25*
___ 10:05AM BLOOD CK-MB-7 ___
DISCHARGE LABS:
===============
___ 06:54AM BLOOD WBC-6.8 RBC-2.51* Hgb-7.8* Hct-24.6*
MCV-98 MCH-31.1 MCHC-31.7* RDW-15.9* RDWSD-55.3* Plt ___
___ 06:48AM BLOOD Glucose-91 UreaN-74* Creat-5.1* Na-140
K-5.2* Cl-101 HCO3-22 AnGap-22*
IMAGING/STUDIES:
================
CXR ___:
Mild pulmonary vascular congestion. Patchy opacities within the
lung bases may reflect atelectasis, but infection or aspiration
cannot be excluded.
Brief Hospital Course:
___ y/o man with PMH HFpEF, CKD bordering on ESRD, HTN,
schizophrenia brought in after episode of acute dyspnea found to
be in worsening renal failure with mild volume overload, both of
which resolved after diuresis.
#CKD, stage IV-V (ESRD- refusing HD) with acute on chronic renal
failure: Follows with Dr. ___. Per last visit note had
been declining consideration of RRT or hospice and difficult to
medically manage given multiple comorbidities and poor insight
and compliance. No urgent need for dialysis on admission despite
creatinine of 7 (baseline 5). Guardian was against dialysis on
multiple conversations and nephrology consult did not feel good
candidate. Acute kidney injury resolved and he developed
significant post-ATN diuresis with UOP 4+ L/day that resolved
prior to discharge. Cr improved to his presumed baseline of 5.1
on discharge.
#Hyponatremia: Developed likely hypovolemic hyponatremia in
setting of post-ATN diuresis. Sodium gradually improved as UOP
decreased. FeNa 2.1% consistent with intrinsic renal disease. No
signs of volume overload and exam and urine osm
#HFpEF: EF 40-45% in ___. BNP elevated at 32,000 on admission
(last 23,000). Clinical exam without overt volume overload.
Lying flat in bed comfortably, lungs clear, no edema. Difficult
to assess JVP given affect and lack of cooperation with exam.
Cardiology evaluated in ED. Low concern for ischemia, troponin
elevation likely in setting of CKD. Diuresed in ED, put on PO
Lasix for a few days which was discontinued in setting of
aggressive post-ATN diuresis and hypovolemia. Discharge weight
128.5 lbs.
#HYPERKALEMIA: Developed mild hyperkalemia to 5.5 day prior to
discharge. No ECG changes. Received kayexalate. Improved to 5.2
day of discharge. Was receiving high potassium supplements in
diet. Also felt he was likely hypovolemic from ongoing
significant post-ATN diuresis with mild increase in creatinine
prior to discharge that likely further impaired potassium
excretion on top of his existing kidney disease. Discharged with
low potassium diet instructions and close PCP ___.
#Anemia: Chronic anemia but 7.1 on admission. Likely in the
setting of CKD/ESRD. Received 1 unit pRBCs ___, with hgb 6.8 ->
8.2. Stable.
#Chronic urinary retention: Has had foley for atonic bladder
dating back to at least ___ and per chart review declined
further urological management. Home foley in for 4 weeks at a
time and uncaps when he need to urinate. Initially treated with
abx for dirty UA but discontinued after culture negative. Foley
exchanged ___, will need changed every 4 weeks. Sent home with
bag instead of prior system of capping and uncapping as needed
to urinate.
#Schizophrenia: Reportedly receives Haldol IM q4h weeks. Per
discussion with outpatient nurse ___, mental status
currently at baseline. Continued home citalopram
#HTN: Continued home carvedilol, hydralazine, isosorbide
mononitrate
TRANSITIONAL ISSUES:
====================
[] Please re-check potassium, determine whether low potassium
diet needs to be continued
[] Continue ___ discussion regarding possible hospice in setting
of not pursuing dialysis for ESRD
[] F/u ___ home safety evaluation at group home
[] Due for Haldol week of ___ (q monthly injections)
# CODE: DNR/DNI confirmed with guardian
# CONTACT: ___, sister/guardian ___ Cell
phone: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Citalopram 20 mg PO QPM
5. Haloperidol Decanoate (long acting) 75 mg IM EVERY 4 WEEKS
(MO)
6. HydrALAZINE 50 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
9. Aspirin 81 mg PO DAILY
10. Ferrous GLUCONATE 236 mg PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Citalopram 20 mg PO QPM
7. Ferrous GLUCONATE 236 mg PO DAILY
8. Haloperidol Decanoate (long acting) 75 mg IM EVERY 4 WEEKS
(MO)
9. HydrALAZINE 50 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Sodium Bicarbonate 650 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
====================
-Acute kidney injury on chronic kidney disease
SECONDARY DIAGNOSES:
====================
-Hyponatremia
-Anemia
-Schizophrenia
-Chronic urinary retention
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
Why was I admitted to the hospital?
-You were short of breath and tired
-Your kidney function was worse than usual
What happened while I was in the hospital?
-Your blood count was low and you received a blood transfusion
-Your catheter was changed as we were concerned there was an
infection
-Your kidney function improved back to your normal baseline
-You were evaluated by physical therapy and occupational therapy
What should I do after leaving the hospital?
-Please follow a low potassium diet. Foods to avoid include
bananas, oranges, whole grain bread, and dairy products. Your
primary doctor ___ re-check your potassium level and let you
know if you need to keep following a low potassium diet.
-Please ___ with your primary doctor ___ Dr. ___ as
scheduled below
-Please use a bag for your catheter instead of capping it and
uncapping it to urinate.
Thank you for allowing us to be part of your care, we wish you
all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19623595-DS-10
| 19,623,595 | 23,681,241 |
DS
| 10 |
2158-08-09 00:00:00
|
2158-08-09 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Codeine
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ with h/o HTN, DM2, HLD, morbid obesity, presenting with 2
weeks of worsening DOE. Pt was in her USOH until two week ago,
when she noticed worsening shortness of breath on mild exertion.
Pt has poor baseline functional capacity, is not physically
active. She typically can walk 75 feet without dysnpea. She
needs help with most iADL and some ADL (dressing, bathing). In
the past two weeks, she gets SOB more easily, with less than 50
feet walk per her daughter. She usually cannot lie flat and
sleep with 3 pillows, which has not changed. She denies PND. Pt
otherwise denies CP, jaw pain, N/V/D. Of note, pt loves salt and
fatty food. She had a period of weight loss, but recently gained
10 lbs in the past two months. Pt reported a history of CAD and
stated had multiple small MIs.
Today, pt was brought in by her daughter for ___ class I-II
symptoms with SOB and chest pressure. While in the ED, her VS
were: 98.4 82 169/84 18 96% RA. EKG in the ED showed new onset
LBBB with L axis deviation, that does not meet Sgarbossa
criteria. The new onset LBBB was felt concerning for STEMI
equivalent. She was given aspirin ___ u heparin bolus,
duoneb and sent to the cath lab. Famotidine, methylprednisolone
and benadryl were given in the ED, because pt had a documented
history of iodione allergy. During the cath lab, no flow
restricting coronary artery diseases were found. However, pt was
noted to have severe systemic hypertension with SBP reaching
200. She had preserved cardiac index. Nitro gtt was started,
with appropriate response to SBP to 150s. Pt tolerated the cath
well, and subsequently sent to the floor.
On review of systems, pt has chronic LLE swelling, that she has
not been talking lasix as instructed. She has joint pain in L
hip and bilateral shoulders. She had three mechanical falls in
the past year, but no syncope. She denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
Past Medical History:
1. Hypertension.
2. Diabetes type II on medications.
3. Hypercholesteremia.
4. COPD.
5. CAD.
6. DJD.
7. Obesity.
8. OSA on CPAP + oxygen
9. Osteoarthritis.
10. Peripheral neuropathy.
11 Breast Ca ___ (DICS)s/p surgery and xrt, w/ neg ongoing
followup w/ oncology
12. Spinal stenosis
13. Hx polio
14. H. pylori
15. s/p left TKR
16. s/p ccy
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=98.1 BP=157/89 HR=70 RR=20 O2 sat=97% on 2L
GENERAL: WDWN, 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: JVP not well visualized in supine position
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2 with prominent P2. Not S4 appreciated.
No m/r/g. No thrills, lifts.
LUNGS: Limited anterior exam, no w/r/rh appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: 2+ pitting edema to knee on left side, no pitting
edema on right side
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP 2+ ___ 2+ bilaterally
DISCHARGE PHYSICAL EXAM
VS: T: 98.1, HR 81, BP 140/71, RR 20, O2 sat 100% on RA
I/O: 24hr: ___ overnight: ___
GENERAL: WDWN, 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: JVP not well visualized in supine position
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2 with prominent P2. Not S4 appreciated.
No m/r/g. No thrills, lifts.
LUNGS: Good air movement bilaterally, no w/r/rh appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: 2+ pitting edema to knee on left side, no pitting
edema on right side
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP 2+ ___ 2+ bilaterally
Pertinent Results:
ADMISSION LABS
___ 05:15PM BLOOD WBC-7.6 RBC-4.02* Hgb-11.4* Hct-35.9*
MCV-89 MCH-28.4 MCHC-31.8 RDW-13.7 Plt ___
___ 05:15PM BLOOD Neuts-64.5 ___ Monos-4.7 Eos-2.2
Baso-0.4
___ 05:15PM BLOOD Glucose-130* UreaN-15 Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-26 AnGap-13
___ 03:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.6
___ 05:28PM BLOOD Lactate-2.1*
DISCHARGE LABS
___ 03:50AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.6* Hct-36.6
MCV-88 MCH-27.9 MCHC-31.6 RDW-14.1 Plt ___
___ 07:33AM BLOOD Glucose-129* UreaN-31* Creat-1.1 Na-143
K-3.9 Cl-103 HCO3-33* AnGap-11
___ 07:33AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.2
PERTINENT STUDIES
CORONARY CATHETERIZATION ___
Assessment & Recommendations
1.Patent coronary arteries
2.Severe hypertension (208/100 mmHg ___ 160/85 with NTG
gtt)
3.Mildly increased left and right-sided filling pressures
4.Mild pulmonary arterial HTN
5.Preserved cardiac output and cardiac index
6.Patent IVC and IVC filter
7.Patient received NTG gtt and Furosemide 40 mg iv during the
procedure.
8.The R CFA and CFV sheaths were removed manually with adequate
hemostasis
___ Rx for hypertensive heart disease and heart failure
CXR ___
FINDINGS: Cardiac silhouette is mildly enlarged accompanied by
pulmonary
vascular congestion, mild perihilar edema, and an area of more
confluent
opacity in the left retrocardiac area which probably reflects a
combination of pleural effusion and atelectasis. Small right
pleural effusion is also demonstrated.
ECHO ___
Conclusions
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (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
right ventricular free wall is hypertrophied. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
low-normal left ventricular systolic function. Probable
diastolic dysfunction with elevated filling pressures. Mild
aortic regurgitation. Mild to moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___,
the estimated pulmonary artery pressures are more elevated.
There is more evidence to support diastolic dysfunction on the
current study.
Brief Hospital Course:
___ yo F with h/o HTN, HLD, DM2, presenting with DOE and new
onset LBBB, concerning for ACS.
ACTIVE ISSUES
# r/o ACS: Pt presented with DOE and new onset LBBB, although
there were no EKG changes that meet the Sgarbossa criteria. The
clinical presentation was deemed concerning for ACS with STEMI
equivalent. Mr. ___ therefore underwent immediate cardiac
catheterization. During the cath, all coronary arteries were
found to be patent. We continued her aspirin 81 mg and
atorvastatin 10 mg daily for primary prevention of coronary
artery disease.
# Acute on Chronic diastolic heart failure: During the cardiac
catheterization, pt was found to have elevated BP to 208/100.
On reviewing of her previous medical records, we felt that pt
had inadequately controlled hypertension. Her ECHO cardiogram
also demonstrated worsening diastolic dysfunction compared to
the study in ___. We felt that her exacerbation was consistent
with acute on chronic diastolic heart failure secondary to
hypertensive cardiomyopathy. Post cath, pt was given 40 mg iv
lasix and started on nitroglycerin gtt. Her antihypertensive
medications were transitioned to carvedilol 3.125 mg twice a day
and lisinopril 20 mg daily. She also received diuresis
initially with iv lasix, and subsequently po 40 mg lasix on the
second hospital day. Pt tolerated the treatment very well.
CHRONIC ISSUES
# COPD: Pt has known history of COPD. We continued her advair
and ipratropium.
# OSA: She was provided with CPAP at night.
# Diabetes: Appears well controlled. Her blood glucose was
controlled with sliding scale insulin.
TRANSITIONAL ISSUES
# CODE STATUS: Full
# MEDICATION CHANGES:
- STARTED carvedilol 3.125 mg bid
- STARTED lisinopril 20 mg qd
- STARTED furosemide ___ mg daily
# PENDING STUDIES
- None
# FOLLOWUP PLAN
- Pt will be seen in Dr. ___ clinic on ___
- Please check electrolytes given recent initiation of
lisinopril and escalation of furosemide, especially Cr, K, Mg
- Please adjust furosemide dose accordingly
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 10 mg PO DAILY PRN edema
2. Ipratropium Bromide MDI 2 PUFF IH Q4-6H wheeze
3. Metoprolol Tartrate 25 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Aspirin 81 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
10. Acetaminophen 500 mg PO HS pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ipratropium Bromide MDI 2 PUFF IH Q4-6H wheeze
3. Atorvastatin 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Furosemide 40 mg PO ONCE Duration: 1 Doses
RX *furosemide 20 mg ___ tablet(s) by mouth qAM Disp #*45 Tablet
Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
7. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
9. Acetaminophen 500 mg PO HS pain
10. Vitamin D 800 UNIT PO DAILY
11. Geritol Complete *NF* (mv, min #36-iron,carbonyl-FA) 16 mg
iron- 0.38 mg Oral qd
12. Gold Bond *NF* (corn starch-kaolin-zinc
oxide;<br>menthol-dimeth-aloe ___ E;<br>menthol-zinc
oxide;<br>pramoxine-menthol) ___ % Topical bid
13. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
14. Outpatient Occupational Therapy
Please provide AFO for left foot drop
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- acute on chrnoic diastolic heart failure
Secondary diagnosis
- hypertension
- diabetes
- hyperlipidemia
- obstructive sleep apnea
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 our hospital for shortness of breath. You
underwent emergent cardiac catheterization, which did not reveal
any coronary artery disease that require immediate intervention.
You were treated with iv and later po medications to remove
excessive fluid in your lung. We also gave you medication to
better control your hypertension. You tolerated these treatment
very well.
Please note the following changes in your medication:
- START carvedilol 3.125 twice a day
- START lisinopril 20 mg daily
- INCREASE furosemide (lasix) to 40 mg daily, and followup with
your primary care physician for titration
- STOP metoprolol
We also arranged the following appointments for you.
Followup Instructions:
___
|
19623595-DS-11
| 19,623,595 | 26,478,396 |
DS
| 11 |
2158-12-20 00:00:00
|
2158-12-21 06:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Codeine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH HTN, DM2, HLD, morbid obesity, COPD (on 2L Home O2
at night), DVT s/p IVC filter (___), who presents with right
sided chest pain since 4 am this morning. No radiation. No N/V,
dizziness. No SOB. Feels dull, mainly right side of chest, not
positional, not worse with inspiration. Does report carrying
heavy bags lately and straining her muscles a little. No reflux
symptoms.
She reports her last episode of chest pain was in ___ but it
was slightly different, at that time she had new LBBB but
cardiac cath neg for any CAD.
For this episode of CP, she was given asa 325mg by EMS as well
as 2 SL nitro with improvement in discomfort from ___.
SOB feels at baseline per patient.
In the ED, initial vitals:98.7 60 141/103 16 99% 3L NP
D-dimer 2,500, BNP 270, trop <0.01
Guiac neg
Labs: K 6.8->4.9 with green top but hemolyzed, Cr 1.2. CBC wnl.
INR and PTT wnl.
UA: sg 1004
CXR:pending
She did not get CTA in ED since history of contrast allergy.
Thus, she was started on heparin gtt and transfered to the
floor.
Vitals prior to transfer:57 107/58 23 100%
Currently, pt is well appearing. Reports a mild twinge of chest
discomfort on right side. Otherwise feels well.
Past Medical History:
1. Hypertension.
2. Diabetes type II on medications.
3. Hypercholesteremia.
4. COPD.
5. CAD- this is per OMR however recent cath showed patent
vessels
6. DJD.
7. Obesity.
8. OSA on CPAP + oxygen
9. Osteoarthritis.
10. Peripheral neuropathy.
11 Breast Ca ___ (DICS)s/p surgery and xrt, w/ neg ongoing
followup w/ oncology
12. Spinal stenosis
13. Hx polio
14. H. pylori
15. s/p left TKR
16. s/p ccy
17. diastolic heart failure
18. pituitary adenoma- followed in ___ clinic, sp
transphenoidal surgery in ___ with no recurrence of adenoma and
no requirement of hormonal replacement
Social History:
___
Family History:
she is not aware of her parents medical prob
Physical Exam:
Admission:
VS - 98.1, 137/81, 57, 20, 97%ra
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - no murmurs. Does have reproducible chest pain on
palpation.
LUNGS - CTAB,
ABDOMEN - soft, non tender, obese
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3,
Discharge exam;
Gen: nad, comfortable, well appearing
Cardiac: RRR, no murmurs
Pulm: clear to auscultation
Abd: soft, non tender
Ext: no edema, some tenderness when palpating left shin
Pertinent Results:
Preliminary MRA Chest read: no pulmonary embolism
CXR:
No acute cardiopulmonary process
___:
No evidence of deep vein thrombosis in the left lower extremity.
Brief Hospital Course:
___ with PMH HTN, DM2, HLD, morbid obesity, COPD (on 2L Home
O2), DVT s/p IVC filter (___), who is admitted for right sided
chest pain.
Chest pain: ACS ruled out as trop neg x3, EKG shows a likely
incomplete LBBB (does have a known LBBB). Recent cardiac cath
from a few months ago was negative for any lesions. PE was
considered given known history of DVT and pos D-dimer, however
MRA Chest was negative for PE (pt had MRA chest since allergy to
contrast and has underlying lung disease so not a candidate for
CTA or VQ scan). Pneumonia unlikely as CXR and MRA unremarkable.
COPD exacerbation considered but no increase sputum and no SOB.
Given reproducible nature of chest pain and complete resolution,
this is likely costochondritis or musculo-skeletal. Pt had no
further symptoms during hospitalization.
Leg pain: pt has chronic left shin pain. ___ neg for DVT.
Chronic issues:
HLD: continued atorva 10mg
HTN/dHF: continued home carvedilol 3.125mg BID, lisinopril 20mg,
lasix 40mg
OSA: Continued CPAP at night
COPD: Continued advair 250-50 BID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
hold SBP<100, HR<55
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Furosemide 40 mg PO DAILY
5. Ipratropium Bromide MDI 2 PUFF IH Q6H sob
6. Lisinopril 20 mg PO DAILY
hold SBP<100
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold: somnolence
8. Acetaminophen 500 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
hold SBP<100, HR<55
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 40 mg PO DAILY
7. Ipratropium Bromide MDI 2 PUFF IH Q6H sob
8. Lisinopril 20 mg PO DAILY
hold SBP<100
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold: somnolence
10. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chest pain NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure providing care for you during your
hospitalization. You were admitted to the hospital for chest
pain. An EKG of your heart and blood tests showed us that you
did NOT have a heart attack. We monitored your heart rhythm on
telemetry and it did not show any arrythmias. You had imaging of
your heart lungs and it did not show any clots. You also had
imaging of your left leg that showed no clots.
The physical therapists saw you and recommend home physical
therapy.
Please resume your home medications as usual.
Followup Instructions:
___
|
19623595-DS-14
| 19,623,595 | 24,018,718 |
DS
| 14 |
2162-05-08 00:00:00
|
2162-05-08 19:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Codeine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo female w/ h/o CHF, Pituitary surgery, h/o breast
cancer (___), DM, COPD, who presents with 2 days of epigastric
abdominal pain, n/v, and coffee ground emesis per EMS. She
denies any recent diarrhea. The patient also reports that she
has been feeling more confused recently. She also complains of L
hip pain that has been worsening recently. She has baseline
dyspnea related to her COPD but does not report any acute
worsening, new orthopnea, PND. She has slightly increased pedal
edema b/l.
In the ED, initial vitals were: 97.1 60 182/81 16 97% RA
Exam notable for: suprapubic tenderness
Labs notable for: unremarkable UA, sodium 120->123, K 6.3->4.7,
CBC wnl, troponin negative, Ulytes: UreaN:327 Creat:31 Na:103
Osmolal:420
Imaging notable for: CT A/P: 1. Within the limitations of a
noncontrast study. No acute intra-abdominal process. 2. Chronic
changes of diverticulosis, renal cysts, and a severe
levoscoliosis.
Patient was given: 1L NS, insulin/D50, calcium gluconate,
carvedilol
Decision was made to Admit for treatment of hyponatremia
Vitals prior to transfer: 98.0 63 144/76 18 100% RA
On the floor, the patient is AOx3 but continues to feel slightly
confused. She reports that her nausea and abdominal pain is
improved. Otherwise complaining only of persistent L hip pain.
ROS:
(+/-) Per HPI
Past Medical History:
1. Hypertension.
2. Diabetes type II on medications.
3. Hypercholesteremia.
4. COPD.
5. CAD- this is per OMR however recent cath showed patent
vessels
6. DJD.
7. Obesity.
8. OSA on CPAP + oxygen
9. Osteoarthritis.
10. Peripheral neuropathy.
11 Breast Ca ___ (DICS)s/p surgery and xrt, w/ neg ongoing
followup w/ oncology
12. Spinal stenosis
13. Hx polio
14. H. pylori
15. s/p left TKR
16. s/p ccy
17. diastolic heart failure
18. pituitary adenoma- followed in ___ clinic, sp
transphenoidal surgery in ___ with no recurrence of adenoma and
no requirement of hormonal replacement
Social History:
___
Family History:
She is not aware of her ___ medical problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 147/68 64 98.6 100%RA 16
General: AOx3 but having difficulty recalling PMH and meds.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild bibasilar crackles, good air movement
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 98.5 113/56 72 18 96%RA
General: AOx3.
HEENT: Sclera anicteric, significant arcus senilis, MMM
Neck: Neck supple, JVP not elevated
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Mild bibasilar crackles, good air movement
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Warm, well perfused, 2+ pulses, no ___. Mild tenderness to
palpation of left leg, worsened my movement. No cords palpated.
Neuro: CNII-XII intact, ___ strength upper extremities, grossly
normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:45PM WBC-6.5 RBC-3.99 HGB-11.2 HCT-34.9 MCV-88
MCH-28.1 MCHC-32.1 RDW-13.9 RDWSD-44.8
___ 02:45PM NEUTS-48.1 ___ MONOS-13.4* EOS-2.5
BASOS-0.6 IM ___ AbsNeut-3.13 AbsLymp-2.28 AbsMono-0.87*
AbsEos-0.16 AbsBaso-0.04
___ 02:45PM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.6
MAGNESIUM-1.8
___ 02:45PM LIPASE-20
___ 02:45PM ALT(SGPT)-13 AST(SGOT)-34 ALK PHOS-44 TOT
BILI-0.2
___ 02:45PM GLUCOSE-97 UREA N-21* CREAT-0.9 SODIUM-120*
POTASSIUM-6.3* CHLORIDE-85* TOTAL CO2-29 ANION GAP-12
___ 03:19PM LACTATE-0.9 K+-4.5
___ 04:35PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM
___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:35PM URINE HOURS-RANDOM UREA N-327 CREAT-31
SODIUM-103
___ 05:45PM ___ PTT-31.7 ___
___ 05:45PM cTropnT-<0.01
___ 05:45PM GLUCOSE-105* UREA N-20 CREAT-0.9 SODIUM-121*
POTASSIUM-5.4* CHLORIDE-84* TOTAL CO2-28 ANION GAP-14
___ 10:45PM GLUCOSE-96 UREA N-18 CREAT-0.9 SODIUM-123*
POTASSIUM-7.1* CHLORIDE-94* TOTAL CO2-20* ANION GAP-16
___ 10:46PM K+-4.7
DISCHARGE/PERTINENT LABS:
=========================
___ 06:40AM BLOOD WBC-6.9 RBC-3.58* Hgb-10.2* Hct-31.8*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.6 RDWSD-47.5* Plt ___
___ 06:40AM BLOOD Glucose-86 UreaN-46* Creat-1.0 Na-129*
K-5.3* Cl-97 HCO3-23 AnGap-14
___ 06:40AM BLOOD Calcium-9.9 Phos-3.5 Mg-1.7
___ 05:24AM URINE Hours-RANDOM Creat-69 Na-47
___ 05:24AM URINE Osmolal-384
___ 06:40AM BLOOD Cortsol-5.1
CORTISOL STIM TEST
___ 04:34AM BLOOD Cortisol-2.9
___ 05:40AM BLOOD Cortisol-16.6
___ 06:08AM BLOOD Cortisol-21.5*
MICROBIOLOGY:
=============
___ 4:35 pm URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
CT HEAD W/O CONTRAST
There is no evidence of acute territorial infarction,
hemorrhage, edema, or mass. The ventricles and sulci are mildly
enlarged suggesting age related atrophy. Mild periventricular
and subcortical white matter hypodensities are nonspecific but
likely sequela of chronic small vessel disease. Expansion of
the sella is compatible with postoperative changes, as seen
previously.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable. There
are cavernous carotid calcifications bilaterally.
CT ABD/PELVIS
1. Within the limitations of a noncontrast study. No acute
intra-abdominal process.
2. Chronic changes of diverticulosis, renal cysts, and severe
levoscoliosis.
3. Unchanged left adnexal 1.5 cm cyst. Given the patient's
postmenopausal
status, ___ year follow-up pelvic ultrasound is recommended if
clinically
indicated.
HIP XRAY
Very severe left, severe right hip osteoarthritis. Remodeling
of the left
facet and flattening of the left femoral head is progressive
compared to prior radiographs. Superimposed avascular necrosis
is not excluded. No discrete fracture line is seen in the
femoral neck. If concern for metastasis, avascular necrosis or
occult fracture, further assessment with MRI can be performed.
BILATERAL LOWER EXTREMITY US
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Limited visualization of the bilateral calf veins.
CT CHEST
Suspected tracheomalacia.
No evidence of pulmonary nodules or other findings that might
potentially
explain hypernatremia.
Substantial distension of pulmonary artery that might be
consistent with
pulmonary hypertension.
Brief Hospital Course:
___ yo w with PMHx of pituitary adenoma s/p resection in ___
with good residual pituitary function, breast cancer (___), DM,
COPD, who presented with 2 days of diffuse abdominal pain found
to have hyponatremia with Na of 120.
# Hyponatremia/Hyperkalemia:
Patient found to have a sodium of 120 on admission. Likely a
combination of factors including CHF, increased free water
intake and low solute intake, as well as an element of
iatrogenic secondary adrenal insufficiency given the patient's
history of steroid injections for hip osteoarthritis. Urine
lytes with Na>40, UOsm>100 in line with SIADH vs. adrenal
insufficiency. TSH normal. Chest CT done not suggest a pulmonary
source for SIADH. Potassium also uptrending during this
admission reaching a high of 6.0. Corticotropin stimulation test
was performed with adequate response. ACTH measured before stim
test was 6, lower limit of normal. Na measured at the end of the
stim test showed an increase in sodium from 125 to 130 (highest
the patient had been since admission). Patient was started on a
trial of prednisone 3mg PO daily with improvement of her sodium
and potassium (Na 120 and K 5.3 at discharge). Plan for
discharge with prednisone 3mg PO with possible taper and
follow-up with Dr. ___ as an ___.
# Abdominal Pain:
Patient presented with diffuse abdominal pain. CT not remarkable
for acute process. Description of pain suggestive of excessive
gas. Improved with simethicone. At discharge, patient was not
complaining of any residual abdominal pain.
# L-hip osteroarthritis
Patient with known severe osteoarthritis, slowly worsening,
having difficulty moving hip with severe pain. Patient not a
surgical candidate. History of cortisone injections. Maintained
on tramadol for pain. Evaluated by ___ who suggested discharge to
rehab facility.
***TRANSITIONAL ISSUES***
# Patient discharged on prednisone 3mg PO daily. Requires
follow-up with endocrinologist Dr. ___.
# Lisinopril dose reduced and furosemide was held. Blood
pressures inpatient stable. Would evaluate need for continued
therapy or alternative blood pressure management given
hyperkalemia/hyponatremia on admission
# Patient started on vitamin D and calcium on discharge.
Consider addition of PPI if continued steroid therapy.
# CODE: Full (confirmed)
# Emergency Contact: Daughter (______
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Lisinopril 20 mg PO DAILY
3. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN RASH
4. Gabapentin 300 mg PO TID
5. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
6. clotrimazole-betamethasone ___ % topical BID:PRN rash
7. Carvedilol 6.25 mg PO BID
8. Atorvastatin 10 mg PO QPM
9. Furosemide 20 mg PO DAILY
10. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Aspirin 81 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. PredniSONE 3 mg PO DAILY
RX *prednisone 5 mg/5 mL 3 ml by mouth ONCE DAILY Refills:*0
3. Lisinopril 5 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Carvedilol 6.25 mg PO BID
8. clotrimazole-betamethasone ___ % topical BID:PRN rash
9. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN RASH
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Gabapentin 300 mg PO TID
12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
13. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Iatrogenic secondary adrenal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you had low sodium
and high potassium levels in your blood. In the hospital, we
gave you some fluids and stopped your diuretics. We also started
you on a low dose of steroids because your body was not
producing enough steroids. This will help correct your sodium
and potassium.
You should follow-up with your endocrinologist Dr. ___
___ a week.
We wish you a speedy recovery,
Your ___ Care Team
Followup Instructions:
___
|
19623595-DS-16
| 19,623,595 | 23,018,839 |
DS
| 16 |
2163-01-13 00:00:00
|
2163-01-15 13:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Codeine
Attending: ___.
Chief Complaint:
PCP: ___
___: ___ CARE EXTENDED COMMUNITY
PRACTICE
Address: ___, ___
Phone: ___
Fax: ___
Email: ___
CC: ___ pain, ___
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ woman with a history of chronic sCHF with LVEF 42%,
pituitary adenoma (s/p transphenoidal surgery ___, COPD (on 2L
O2 PRN at home) who presented to the ED with fever, abdominal
pain and SOB.
The patient and her caregiver provide history. The patient
reports that her primary issue has been her breathing which has
been steadily worsening for the past week. The breathing is
worse when she lays flat or when she tries to exert herself. She
reports only occasional cough, non-productive and she has not
been coughing more than usual. She also reports left shoulder
pain and neck pain as well. More recently she has been feeling
unwell all day with nausea and epigastric as well as right upper
quadrant abdominal pain. She also had a fever up to 102. Lastly,
she indicates that her legs have been swelling more over the
last week as well, this is despite increase in her diuretics and
close follow up with outpatient cardiologist.
In the ED, initial vitals were: ___ pain 99.0 82 151/70 26
100% Non-Rebreather. Labs notable for Na of 127, WBC of 15.4
with predominantly PMNs and elevated proBNP of 1360. Exam was
notable for rales in bases of lungs bilaterally. Her skin was
hot to touch. CXR showed bilateral pulmonary edema and pleural
effusion for which she received IV CTX and Azithromycin for
pneumonia. Given her abdominal pain and leukocytosis, CT A/P was
performed which revealed diverticulitis.
On the floor, ___ feels well after being given pain
medications in the ED. She reports her SOB is improved now that
she is seated more inclined because she felt like "I was going
to suffocate" when she had to lay flat for CT. She denies chest
pain at present. Abdominal pain is located in RUQ and she denies
left sided symptoms. She also reports feeling cold and is asking
for more blankets.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss. Denies headache,
sinus tenderness, rhinorrhea or congestion. No dysuria. Denies
arthralgias or myalgias. Otherwise ROS is negative
Past Medical History:
- Chronic sCHF with LVEF 40%
- CAD - this is per OMR however recent cath showed patent
vessels
- Hypertension
- Diabetes type II
- Hypercholesteremia
- COPD on 2L NC
- Breast Ca ___ (DICS)s/p surgery and xrt, w/ neg ongoing
followup w/ oncology
- Peripheral neuropathy.
- Spinal stenosis
- Hx polio
- H. pylori
- Pituitary adenoma- followed in ___ clinic, s/p
transphenoidal surgery in ___ with no recurrence of adenoma and
no requirement of hormonal replacement
Surgical History
- s/p left TKR
- s/p ccy
- s/p transphenoidal surgery in ___
Social History:
___
Family History:
She is not aware of her ___ medical problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals:98.6 134/75 77 96%RA
Pain Scale: ___
General: Patient appears stable, she is robust in appearance
given her age and comorbidities but appears as if she feels
unwell, asking for more blankets though she already has about 5
on her, blankets pulled up to her chin before she feels better.
Alert, oriented and in no acute distress. She is alert and
oriented x3 but her history is tangential and circumferential
HEENT: Edentulous
Neck: JVP elevated to mandible
Lungs: Bilateral rales throughout all lung fields extending
about ___ up posterior lung fields
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, tender to palpation in RUQ but no tenderness in
LLQ, non-distended, normoactive bowel sounds throughout, no
rebound or guarding
Ext: Bilateral tense, pitting edema with shiny, taught skin,
edema extending to distal thighs bilaterally
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
DISCHARGE PHYSICAL EXAM:
==========================
___: 99.1 ___ 18 97% RA
___: 98.8 115-130/78-64 ___ 98% CPAP 96%
24H I/O: ___ w/1 loose BM
Weight: 93 kg --> 94.5 kg --> 91.5 (bed weight) --> 84.8 kg -->
weight pending
? dry weight 79.5 kg
Telemetry: No alarms on telemetry
GENERAL: WDWN, obese, 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, has JVP 8-10 cm.
CARDIAC: RRR, normal S1, S2. No murmurs.
LUNGS: CTAb.
ABDOMEN: Soft, nontender. Obese habitus.
EXTREMITIES: Bilateral lower extremity trace pitting edema.
Neuro: Hard of hearing. L hand/wrist/elbow weaker than R (this
is her baseline), shoulder exam limited by pain.
Psych: Odd affect, nonlinear discussion
Pertinent Results:
Admission Labs:
========================
___ 08:04PM BLOOD WBC-15.4*# RBC-4.15# Hgb-11.2# Hct-35.8#
MCV-86 MCH-27.0 MCHC-31.3* RDW-15.6* RDWSD-49.1* Plt ___
___ 08:04PM BLOOD Neuts-82.9* Lymphs-10.2* Monos-5.9
Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.81*# AbsLymp-1.58
AbsMono-0.91* AbsEos-0.04 AbsBaso-0.03
___ 08:04PM BLOOD ___ PTT-42.2* ___
___ 08:04PM BLOOD Glucose-103* UreaN-17 Creat-0.8 Na-127*
K-5.4* Cl-87* HCO3-25 AnGap-20
___ 08:04PM BLOOD ALT-11 AST-30 CK(CPK)-51 AlkPhos-64
TotBili-0.4
___ 08:04PM BLOOD Lipase-17
___ 08:04PM BLOOD Albumin-3.9 Calcium-9.9 Phos-3.0 Mg-1.7
___ 08:04PM BLOOD CK-MB-1 proBNP-1360*
___ 08:04PM BLOOD cTropnT-<0.01
___ 08:14PM BLOOD Lactate-2.7* K-4.6
Imaging:
=====================
LENIs: ___:
No evidence of deep venous thrombosis from the groins to the
knees. The calf veins are not visualized due to edema.
CT A/P: ___
1. Acute cecal diverticulitis. Locule of air adjacent to
inflamed diverticula is not definitely intraluminal. No large
fluid collection.
2. Left adnexal cyst demonstrates up to 1.9 cm. If not already
performed, nonemergent ultrasound would be warranted in a
patient of postmenopausal status.
CXR: ___
1. Mild to moderate pulmonary edema with a probable trace left
pleural effusion.
2. Retrocardiac and right basilar atelectasis, but infection is
not excluded in the correct clinical setting.
TTE: ___
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 40-45 %). The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
DISCHARGE LABS:
=================
___ 05:35AM BLOOD WBC-10.3* RBC-3.33* Hgb-8.9* Hct-27.7*
MCV-83 MCH-26.7 MCHC-32.1 RDW-15.1 RDWSD-46.1 Plt ___
___ 05:35AM BLOOD ___ PTT-40.9* ___
___ 05:35AM BLOOD Glucose-96 UreaN-31* Creat-1.1 Na-130*
K-4.4 Cl-87* HCO3-28 AnGap-19
___ 04:25AM BLOOD ALT-6 AST-16 LD(LDH)-209 AlkPhos-55
TotBili-0.3
___ 05:35AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.8*
Brief Hospital Course:
___ is an ___ hx HF (LVEF 40-45%, mild MR 1+,
mild-moderate TR ___, on ___, CAD, LBBB, OSA (CPAP w/ 2L
O2 at home at night), hypertension, obesity, chronic
hyponatremia, type 2 diabetes, extensive DVTs ___ admitted
with HF exacerbation and cecal diverticulitis for which she is
now on stable oral diuretic & PO abx, with ongoing improvement.
# Acute on chronic CHF (borderline EF, mostly preserved EF of
40-45%)
Chronic boarderline sCHF/dCHF, LVEF 40-45%, ___ class III.
Patient presented on ___ with increased shortness of
breath, chest pain and nausea with associated increase in ___
despite increase in home diuretics consistent with an acute
exacerbation. Last cardiology follow up was ___ when her
Lasix dose was increased to BID. Nausea initially may have been
related to increase right sided filling pressures though CT with
diverticulitis is compelling alternative explanation. CXR
showing bilateral pulmonary edema and pleural effusion with an
associated increased in proBNP (albeit lower than her last
hospitalization for CHF exacerbation) all consistent with CHF
exacerbation. Unclear trigger at this time, she has been taking
her home medications, there is no change in her diet, there are
no elevations in Trop or MB and her EKG appears to be at
baseline. Per her family she does have inconsistent dietary
compliance. The patient was initially treated with Lasix 20mg IV
BID. Despite this increase in diuretics, her creatinine
increased and weight increased. The patient was seen by
cardiology who recommended discontinuing Lisinopril and
spironolactone and starting Hydralazine for afterload reduction
in addition to IV Lasix 40mg IV BID. The patient was
subsequently transferred to the heart failure service.
After transfer to the heart failure service, patient received IV
diuresis with good effect. She will be discharged on Aspirin
81mg, Atorvastatin 10mg daily, Torsemide 60mg daily, Carvedilol
12.5mg BID, Spironolactone 12.5mg daily.
# Sepsis: Fever to 102, WBCs to 15k
# Diverticulitis, uncomplicated
Nausea, abdominal pain and fever with CT findings suggesting
cecal uncomplicated diverticultis. The patient was started on
clear liquids and antibiotics, Cipro, flagyl. She was seen by
surgery given concern for extraluminial air who recommended
continued conservative management. After transfer to the heart
failure service, her abdominal pain steadily improved. She
should take cipro/flagyl x14d (started ___ with and end date
of ___.
# Hyponatremia
Baseline serum Na apparently ___ mEq/L. Hx pituitary
adenoma s/p transsphenoidal resection c/b postop hemorrhage in
___. Per OMR, pituitary function was subsequently assessed and
deemed normal. Multiple unremarkable workups by nephrology &
endocrinology in previous admissions (TSH, ___ stim test),
though pt received steroids for concern for adrenal
insufficiency, and was thought to be likely hypovolemic & poor
nutritional intake. Improved with diuresis.
#Acute Renal Failure overlying CKD: Improved with Lasix, holding
lisinopril, was likely cardiorenal in nature. Continue diuresis
as above.
#Hypertension. Stable. See heart failure management above. As
patient is preserved ejection fraction, she does not need
lisinopril at this time particularly in context of renal
dysfunction. Can consider restarting as outpatient if needed.
# Diabetes type II
Chronic, well controlled with A1c of 5.6% ___, complicated by
peripheral neuropathy. In fact, she has not had an A1c 6.5% or
greater since ___ and she is not on diabetic medications, she
may no longer having glucose intolerance as she did previously
and we may be able to remove this problem. Admission random
glucose is 103
- Consider removing this diagnosis off her medical problem list
- No need to monitor ___ or treat with HISS in house
#Hx DVTs: Extensive right ___ deep venous thrombosis during prior
admission for which she was started on warfarin which was
subsequently transitioned to Rivaroxoban. Stopped lovenox (last
dose ___. Her bilateral LENIS were negative, but did not
visualize the calf veins, however patient already on
anticoagulation.
- Rivaroxaban 20 mg daily ( less than 6mo since DVT in ___,
can discuss as outpatient how long to continue anticoagulation
#CAD. ___ cath showed non-obstructive. Stable.
- ASA 81mg
#OSA. Stable.
Stable. Continue home CPAP and 2L O2 at night.
#HLD
Stable. Continue atorvastatin.
TRANSITIONAL ISSUES:
========================
- Patient placed on torsemide 60mg daily for her CHF, may need
further adjustments as outpatient. If weight increases >3 lbs,
would take 60mg BID for 2 days. If this does not bring weight
back down to baseline then would call ___ cardiology at
___.
- Patient should follow up in the heart failure clinic, see
appointment information below.
- Ciprofloxacin and Flagyl should be continued ONLY through
___
- Please monitor CHEM panel ___
- Consider outpatient GI follow-up for diverticulitis
DISCHARGE WEIGHT: 86.7kg
HCP ___: ___, ___
CODE STATUS: FULL CODE
Medications on Admission:
___ does not remember any of her medications, in response to
the list I provided she says "they give me those pills and I
take them" but she could not clearly confirm or deny the below
list. The below list is based on outpatient notes and OMR
medication list.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 300 mg PO TID
7. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
8. Vitamin D 1000 UNIT PO DAILY
9. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
10. Rivaroxaban 15 mg PO DAILY
11. Lisinopril 5 mg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Magnesium Oxide 400 mg PO DAILY
14. Bisacodyl 10 mg PO DAILY:PRN constipation
15. Furosemide 20 mg PO BID
16. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
2. MetroNIDAZOLE 500 mg PO Q8H
3. Torsemide 60 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
6. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth once
a day Disp #*15 Tablet Refills:*0
7. TraMADol 25 mg PO Q6H:PRN pain
___ OK.
RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth
q6h:prn Disp #*12 Tablet Refills:*0
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 10 mg PO QPM
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Calcium Carbonate 500 mg PO BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Gabapentin 300 mg PO TID
15. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
16. Magnesium Oxide 400 mg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Heart Failure w/Preserved EF (acute on chronic, w/exacerbation)
Acute renal failure overlying chronic CKD
Chronic hyponatremia
Cecal diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
You came to ___ with abdominal
pain and trouble breathing, you were ultimately found to have
diverticulitis (inflammation of the colon), along with heart
failure. You recovered with antibiotics and also with IV Lasix
to remove the extra fluid. At the time of discharge you were
feeling much better.
Please limit your oral intake to 2 liters daily.
It has been a pleasure caring for you, and we wish you all the
best.
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19623697-DS-7
| 19,623,697 | 22,993,127 |
DS
| 7 |
2185-10-03 00:00:00
|
2185-10-05 14:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute liver injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/ hx of anxiety/depression, IVDA now on methadone (x2
months) who initially presented to ___ with jaundice, mild
abdominal pain and dark urine found to be in acute liver
failure. Patient was hospitalized at ___ for one week where he
was newly diagnosed with acute Hep B. He became increasingly
lethargic and his LFTs continued to trend upwards at ___ so he
was transferred to ___ for liver transplant evaluation. Prior
to transfer, pt left ___ AMA and smoked crack cocaine but was
convinced to return to the hospital by family and friends. On
arrival to SICU, pt was HD stable, jaundiced and somewhat
lethargic (arousable to verbal stimulation). He is not a
transplant candidate due to his poor social situation and active
drug use. As his LFTs were noted to be downtrending, he was
transferred to ET for further care.
Currently, patient notes diffuse abdominal pain and nausea,
especially in the lower quadrants. No emesis or diarrhea. Also
with bothersome pruritus. Per patient, he never shares needles
and had been tested for hepatitis previously. No ingestion EtOH,
tylenol, or new drugs that could have precipitated this liver
insult.
.
ROS: per HPI, endorses chills, denies fever, night sweats,
headache, cough, shortness of breath, chest pain, dysuria
Past Medical History:
Depression
Anxiety
Insomnia
Social History:
___
Family History:
Not obtained
Physical Exam:
VS: 97.7 54 102/55 15 98%RA
GENERAL: Well appearing in NAD. Jaundiced. AOx3, alert and
appropriate
HEENT: Sclera icteric. MMM. PERRLA
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Soft, not distended. Tender to palpation over lower
quadrants bilaterally without guarding or rebound. Tympanic and
non-tender to percussion. No HSM
EXTREMITIES: no edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEUROLOGY: no asterixis, 2 beat clonus in left ankle, none in
right, normal and symmetric reflexes
SKIN: grossly jaundiced, erythema and excoriations over upper
abdomen from scratching
Pertinent Results:
___ 06:00AM BLOOD WBC-4.5 RBC-4.10* Hgb-12.5* Hct-37.7*
MCV-92 MCH-30.4 MCHC-33.0 RDW-16.0* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-139 K-3.9
Cl-103 HCO3-29 AnGap-11
___ 02:05AM BLOOD ALT-2374* AST-1650* AlkPhos-151*
TotBili-20.5*
___ 02:45AM BLOOD ALT-2345* AST-1605* AlkPhos-149*
TotBili-19.7*
___ 09:35AM BLOOD ALT-2582* AST-1536* LD(LDH)-317*
AlkPhos-165* TotBili-22.8*
___ 05:44AM BLOOD ___ AST-1024* LD(LDH)-243
AlkPhos-141* TotBili-20.3*
___ 06:00AM BLOOD ALT-1446* AST-635* AlkPhos-136*
TotBili-19.8*
___ 06:00AM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.6 Mg-2.3
___ 09:35AM BLOOD HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 09:35AM BLOOD Smooth-POSITIVE *
___ 09:35AM BLOOD ___
___ 09:35AM BLOOD HIV Ab-NEGATIVE
___ 02:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
HSV pending
Hep delta pending
.
RUQ U/S:
RIGHT UPPER QUADRANT ULTRASOUND: Liver is normal in
echogenicity, without
focal lesions. There is normal hepatopetal flow in the portal
vein. The IVC
is also patent. No intrahepatic biliary dilation, and the
common duct
measures 2 mm. Gallbladder is contracted. There are no stones,
sludge, or pericholecystic
fluid. Ultrasonographic ___ sign is negative. Pancreatic
head and proximal body are normal, and the distal body and tail
are not well visualized due to shadowing bowel gas. 17.9 cm
splenomegaly is present. There is no free fluid.
IMPRESSION:
1. Patent portal vein. No ascites.
2. Contracted gallbladder.
3. 17.9 cm splenomegaly.
Brief Hospital Course:
___ with acute liver injury due to acute Hepatitis B infection
.
# ACUTE LIVER INJURY: Patient w/ serological evidence of acute
hepatitis B infection at outside hospital. This was presumed to
be due to IV drug use. He was initially admitted to the ICU due
to concern for acute liver failure. However, he never developed
encephalopathy during this hospital course. He was not a
transplant candidate due to recent IV drug use. He was started
on tenofavir in the ICU but this was stopped at discharge. HIV
negative, Hepatitis C viral load negative, acute EBV negative,
CMV negative. Liver function tests were still elevated although
trending down at discharge (AST: 635, ALT: 1446, T-Bili: 19.8).
Tests pending at discharge include smooth muscle antibody,
ALKM-1, and hep delta. His cholestasis induced pruritis was
managed w/ sarna lotion w/ good effect. We discussed the
importance of ETOH avoidance.
.
#HISTORY OF DRUG USE: He was continued on home dose of
methadone. For nausea prior to administration he was given
zofran.
.
CHRONIC ISSUES:
# Depression/anxiety: He was restarted on home seroquel,
clonazepam, neurontin, wellbutrin.
.
TRANSITIONAL ISSUES:
1. will need to f/u smooth muscle antibody, ALKM-1, and hep
delta that are pending at discharge
Medications on Admission:
1) wellbutrin
2) clonazepam 2mg TID
3) neurontin 600mg TID
4) seroquel 100mg qhs
5) clonidine patch
6) methadone 35mg daily
Discharge Medications:
1. Methadone 35 mg PO DAILY
2. Quetiapine Fumarate 100 mg PO QHS
3. Clonazepam 2 mg PO TID
hold for sedation
RX *clonazepam 2 mg three times a day Disp #*42 Each Refills:*0
4. Gabapentin 300 mg PO TID
hold for sedation
5. Sarna Lotion 1 Appl TP TID:PRN pruritis
RX *Anti-Itch 0.5 %-0.5 % TID PRN Disp #*1 Tube Refills:*2
6. Promethazine 25 mg PO Q8H:PRN NAUSEA
RX *promethazine 25 mg q8 Disp #*24 Each Refills:*0
7. BuPROPion (Sustained Release) 100 mg PO QAM
RX *Wellbutrin SR 100 mg DAILY Disp #*30 Each Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute liver injury
Acute hepatitis B infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
to ___ with jaundice (yellow skin), itching, and fatigue. You
were found to have acute liver injury due to hepatitis B
infection. You were started on a medication to treat the
hepatitis B. Your symptoms improved and your were discharged
home. It can take some time (weeks to months) for your liver
function tests to improve and the jaundice to resolve. Please
avoid alcohol.
Continue your home medications with the following changes:
1. START sarna lotion as needed for itching
Followup Instructions:
___
|
19623767-DS-10
| 19,623,767 | 26,501,383 |
DS
| 10 |
2154-11-07 00:00:00
|
2154-11-07 15:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / colchicine / shellfish
derived
Attending: ___
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is an ___ right handed woman with a history of HTN
and HLD who presents with waxing and waning speech difficulties.
She was last in her normal state of health last night. This
morning she awoke and when she first tried to speak, her speech
was garbled. She was able to get the words out but they were
slurred. She denies using incorrect words and was able to say
the words she wanted to say. She called EMS and per their
report, she initially had garbled speech and a right sided
facial droop. Within 5 minutes of their arrival, the garbled
speech subsided and had resolved upon arrival to the ___.
In the ___ she had recurrence of the same symptoms
with slurred speech, which lasted "a short period of time." In
total, it recurred ___ times at the OSH. NIHSS while symptomatic
was 2 for slurred speech at the OSH. CTA was done and showed a
left M2 occlusion with distal reconstitution. She was
transferred to ___ for further care.
Currently, she feels her speech is at baseline and denies having
any other symptoms like numbness, weakness, and diplopia. Today
she has also had vomiting that began after her CTA.
Past Medical History:
- HTN
- spinal stenosis s/p 3 spine operations (neck and low back)
- asthma
- gout
- HLD
Social History:
___
Family History:
Denies neurologic disease in the family
Physical Exam:
On admission:
Vitals: 98.0 70 188/88 18 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Pulmonary: breathing comfortably on RA
Cardiac: RRR on bedside monitor
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects on the stroke card. Described the ___ jar picture
with detail. 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:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally. VFF to confrontation with
finger counting.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: Subtle left pronation but no drift. Mild action tremor
seen. Some contractures at the ankles.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ ___ ___ 3 5 2 2
R ___ ___ 5- 4- 5 4 4
-DTRs:
Bi Tri ___ Pat Ach
L 1 2 1 2 4
R 1 2 1 2 2
- Toes were mute on right, upgoing on left
- there were a couple beats of clonus at the left ankle with
reflex testing
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS visually.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: deferred given bedrest
On discharge:
Oriented to name, "Deaconess," ___, repeats, able to
name knuckles, follows complex commands to point to ceiling
after she points to floor.
Smile symmetric, Pupils 3-->2 ___, V2 sensation ok.
LUE: ___ (delt not tested due to pain); RUE: 4+ delt, 5 bic, 4+
tric, 5 ECR, 4+ IP, ham 4+. no drift.
No extinction to DSS>
Pertinent Results:
___ 07:05AM BLOOD Triglyc-216* HDL-52 CHOL/HD-5.3
LDLcalc-179*
___ 07:05AM BLOOD %HbA1c-5.3 eAG-105
___ 07:05AM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD CK(CPK)-205*
MRI/MRA head ___:
1. Multiple small acute infarctions in the left corona radiata
with some
extension into the left frontal subcortical white matter,
slightly increased
in number and extent compared to approximately 20 hr earlier on
___.
No associated mass effect or evidence for blood products.
2. No evidence for flow-limiting stenosis in the cervical
arteries.
3. Technically limited brain MRA. On the gadolinium enhanced
neck MRA, the
multiple foci of stenosis in bilateral M2 branches of the middle
cerebral
arteries, including the severe stenosis of the superior division
branch 3 mm
distal to its origin with distal reconstitution, do not appear
significantly
changed compared to the recent CTA allowing for differences in
modalities.
MRI head ___: Acute infarctions in the left corona radiata.
TTE ___: No cardiac source of embolus identified.
NCHCT ___: 1. No significant change in the subacute infarcts
within the left corona
radiata, which is superimposed upon the background of chronic
small vessel
ischemic changes throughout the supratentorial white matter. No
mass effect
or acute hemorrhage.
2. Chronic infarcts at the right caudate and bilateral lentiform
nuclei.
Brief Hospital Course:
Ms. ___ is a ___ woman with HTN and HLD admitted
___ for waxing and waning slurred speech. CTA was
significant for a left M2 occlusion, and MRI showed a stroke in
the left corona radiata. She is likely perfusion dependent for
her collateral circulation leading to her waxing and waning
symptoms. Repeat MRI showed additional acute infarcts in the L
corona radiata with some extension into the left frontal white
matter, and MRA showed multiple foci of stenosis in bilateral M2
branches and severe stenosis of superior division. She has had
multiple transfers to the ICU for changes in neuro exam, and she
appeared to be perfusion dependent as her exam was much better
with higher blood pressures (SBP >60). Her HOB was flat for the
first two days. Her exam steadily worsened as her blood pressure
autoregulated into the 140s, so she was transferred to the ICU
for pressors with goal SBP >160. Pressors were not started, and
she was slowly sat up in bed through the day. She was
transferred back to ___ when she vaso-vagaled while having
a bowel movement. This caused her to become unresponsive, heart
rate dropped to the ___, and BP went to ___. And ICU consult
was called, and she was given 0.5mg atropine and started briefly
on levophed. She was transferred to the ICU, where she was
stabilized. Her exam improved and now only has slight hesitation
with naming, a mild R lower facial droop, and a R pronator
drift. She subsequently came out to SDU, was able to tolerate
sitting up with symptoms or vital sign changes, and was
transferred to the floor where she remained stable.
Transitional issues:
[ ] monitor HR and BP
[ ] add back home antihypertensives as tolerated; currently on
lisinopril 10mg daily (home dose 40mg), atenolol 50mg daily
(home dose 100mg), and off HCTZ
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Diclofenac Sodium ___ 75 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Atenolol 50 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ezetimibe 10 mg PO DAILY
10. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
12. Diclofenac Sodium ___ 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic infarcts
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear Ms. ___,
You were admitted with waxing/waning slurred speech. You had
occlusion of one of the blood vessels in your brain and a stroke
on the left side of your brain. A repeat MRI showed additional
strokes on the left side. You should continue Plavix and
Aspirin. We have restarted your atenolol at a lower dose (50mg
instead of 100mg) and your lisinopril at a lower dose (10mg
instead of 40mg). Your hydrochlorothiazide was held. These
medications can be slowly added back by your physicians as
tolerated. We have made a follow-up appointment for you (see
below).
It was a pleasure meeting you!
Your ___ Team
Followup Instructions:
___
|
19623767-DS-11
| 19,623,767 | 20,788,277 |
DS
| 11 |
2157-05-15 00:00:00
|
2157-05-15 16:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / colchicine / shellfish
derived
Attending: ___.
Chief Complaint:
Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical
history of hypertension, spinal stenosis status post 3 spine
operations, hyperlipidemia, stroke with residual right-sided
deficits and aphasia, presents today from outside hospital with
hematuria. From reports, patient has been having hematuria for
the last several months. Patient had an outpatient ultrasound
today which showed multiple blood clots in the bladder and was
sent to the hospital for 3 way bladder irrigation and for
cystoscopy. Three-way Foley placed at ___. Initial
hemoglobin of 10 -> 8.8 and outside hospital.
While in the emergency department, patient was triggered for
hypotension while waiting to be seen by MD. On arrival, patient
was bradycardic in the ___, and had a blood pressures of 40-60s.
Patient was given fluids. After 3 minutes, blood pressures
returned to ___ and heart rates in the ___. Mental
status slowly returned to baseline. On evaluation of previous
hospital admissions, patient had a similar episode in the
setting
of a bowel movement. During a ___ admission, patient had a
bowel
movement, and had heart rates dropped into the ___ and blood
pressures in the ___. Patient was given atropine and
Levophed
and was admitted to the ICU for further monitoring. Mental
status
slowly returned. Given this, and patient also having a bowel
movement while in the emergency department, ED felt the episode
earlier today was likely vasovagal.
Past Medical History:
- HTN
- spinal stenosis s/p 3 spine operations (neck and low back)
- asthma
- gout
- HLD
Social History:
___
Family History:
Denies neurologic disease in the family
Physical Exam:
Admission exam:
============
VITALS: 97.9F, 155/73, HR 77, RR 16, 98%RA
General: Alert, oriented, no acute distress, aphasic
HEENT: Sclerae anicteric, dry mucus membranes, oropharynx clear,
EOMI, PERRL, neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, tender in
suprapubic region and right flank
GU: Foley draining fruit punch colored urine, no clots seen in
bag
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Strength intact in upper extremities, right foot
internally rotated but able to lift both legs off the bed
against
gravity for >5 seconds
Discharge exam:
============
V/S: T 97.4 BP 147/63 HR 65 RR 16 O2 97% on RA
GENERAL: Alert Caucasian female, pleasant and cooperative.
Some aphasia
HEENT: atraumatic, normocephalic.
CARDIAC: Regular rate and rhythm, normal S1/S2, no m/r/g
PULMONARY: Clear to auscultation anteriorly.
ABDOMEN: NABS, soft, mildly tender in the suprapubic area
without
guarding. There is no rebound tenderness.
EXTREMITIES: no peripheral edema, R foot drop which is baseline
per Pt.
NEURO: AAOx3. Moves all four extremities with purpose. Some
aphasia. No pronator drift.
Pertinent Results:
Admission labs:
============
___ 12:52AM BLOOD WBC-10.5* RBC-2.92* Hgb-8.5* Hct-26.9*
MCV-92 MCH-29.1 MCHC-31.6* RDW-13.4 RDWSD-45.3 Plt ___
___ 12:52AM BLOOD ___ PTT-25.2 ___
___ 12:52AM BLOOD Glucose-109* UreaN-44* Creat-1.4* Na-140
K-4.4 Cl-106 HCO3-18* AnGap-16
___ 07:05PM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5* Cholest-146
Discharge labs:
===========
___ 05:10AM BLOOD WBC-8.4 RBC-2.74* Hgb-7.8* Hct-25.8*
MCV-94 MCH-28.5 MCHC-30.2* RDW-14.0 RDWSD-47.8* Plt ___
___ 05:10AM BLOOD Glucose-96 UreaN-20 Creat-1.1 Na-146
K-4.4 Cl-112* HCO3-23 AnGap-11
___ 05:10AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
Studies:
======
___ CTU
1. Diffusely and irregularly thickened bladder wall with mucosal
hyperemia and
surrounding fat stranding, concerning for cystitis. Foci of air
within the
urinary bladder may be related to Foley placement or continuous
bladder
irrigation. Hyperdense material within the urinary bladder is
consistent with
hematoma.
2. Right hydroureteronephrosis and left hydroureter without
obstructing stone
or urothelial lesion identified. The etiology of obstruction is
not specific
but may be due to hematoma or inflammation involving the urinary
bladder.
Presence of bladder malignancy cannot be excluded by this study.
___ CT head w/o contrast:
1. No acute intracranial abnormality on noncontrast CT head.
Specifically no
acute large territory infarct or intracranial hemorrhage. No
intracranial
mass effect.
2. Sequela of chronic infarcts and small vessel ischemic disease
are unchanged
in appearance from examination of ___.
3. Additional findings described above.
___ CTA head and neck w/ contrast:
1. No acute intracranial findings.
2. Chronic infarct right basal ganglia.
3. Severe chronic small vessel ischemic changes.
4. Extensive intracranial atherosclerotic changes, areas of
severe narrowing
anterior, posterior circulation, mildly worsened at left M1.
5. Unchanged 3 mm aneurysm arising from the right cavernous ICA.
6. A 2 mm triangular irregularity along the left cavernous ICA
may represent
an additional small aneurysm versus infundibulum.
7. Left high cervical ICA fibromuscular dysplasia.
8. Moderate narrowing origin bilateral bilateral vertebral
arteries, similar.
___ MRI head w/o contrast:
1. No evidence of acute territorial infarction or hemorrhage.
2. Moderate chronic microvascular ischemic changes, progressed
compared to
___. Unchanged chronic right putaminal lacunar infarct.
3. 13 mm right sphenoid wing meningioma, similar to slightly
increased in size
from prior exam.
___ CT A/P W/ and W/O CONTRAS:
1. Marked circumferential bladder wall thickening with mucosal
hyperenhancement and perivesicular stranding/free fluid,
consistent with acute
cystitis.
2. No evidence of emphysematous cystitis or pyelonephritis.
3. Interval resolution of bilateral hydronephrosis.
4. Cholelithiasis.
5. Severe atherosclerosis with mild/moderate narrowing of the
left renal
artery.
PERTINENT MICRO:
UCx (___):
___ 7:26 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Brief Hospital Course:
Brief hospital summary:
=======================
___ PMH HTN, spinal stenosis s/p multiple cervical fusion
operations, CVA ___ ago who presented w/ hematuria, ___ and
relative hypotension causing recrudescence of aphasia. She had a
brief ICU stay for maintenance of her blood pressure greater
than 140 systolics. Started on midodrine 15mg TID while holding
home antihypertensives. With SBPs>140, aphasia resolved and
patient returned to baseline. Hematuria treated with CBI and
with CTX x5 days for presumed UTI, ultimately transitioned to
augmentin given Enterococcus on urine Cx. Able to urinate on own
prior to leaving the hospital.
Active issues:
=============
#Relative hypotension w/ recrudescence of stroke:
Per son, her SBP at home is 160s-170s while on 3
anti-hypertensive medications which she is compliant with at
home. During her hospital stay, Pt became aphasic with
right-sided hemiparesis in the setting of blood pressure < 140.
A code stroke was called, which did not show any new hemorrhage
or ischemia but multiple areas of severe vascular narrowing. Per
neurology consult, likely recrudescence of prior stroke symptoms
from relative hypotension. Was started on midodrine, briefly
transferred to the ICU for further blood pressure augmentation.
Pt was discharged on a dose of 10mg midodrine TID, and remained
off her antihypertensives.
Highly consider trialing a statin again (ie rosuvastatin 20mg or
pravastatin 40mg final doses), long term LDL goal <70,
outpatient stroke neurology follow up in 3 months.
#Hematuria:
#Cystitis, ?UTI:
CTU showed bladder wall inflammation, bladder clot, and acute
cystitis.
- For hematuria management: Pt had three-way foley with CBI for
hematuria and obstructive uropathy (had bilateral hydronephrosis
on CTU). Her hematuria improved, and she was able to void well
at discharge. Pt had an outpatient urologist who she planned to
follow up with for outpatient cystoscopy per urology
recommendations.
- For cystitis treatment: She was started on CTX while awaiting
culture data. She completed a 5d course of CTX but had return of
low-grade fevers and leukocytosis. Repeat UCx eventually grew
___ CFU of Enterococcus, for which Pt was started on a 7d
course of amox-clav (D1 ___ - D7 ___.
___: Her ___ was most likely post-obstructive uropathy in the
setting of obstructing clots; subsequently in the setting of
being mildly prerenal I/s/o infection. Cr returned to normal
baseline. Labs should be rechecked by ___ to ensure that
creatinine remains at baseline.
#History of CVA, on DAPT. Held aspirin and Plavix initially
given hematuria. Was restarted in setting of recrudescence of
stroke symptoms. No concerns with recurrence of hematuria for
rest of hospital stay.
#HLD:continued Ezetimibe. Had a rash and muscle aches previously
on atorvastatin. Per neurology team given her recrudescence of
prior stroke symptoms with relative hypotension iso vascular
stenoses, they strongly recommend re-trialing another statin
such as rosuvastatin 20mg or pravastatin 40mg final doses
(titrate up).
#GERD: continued on PPI while in the hospital. Back to
omeprazole home dose upon discharge.
Transitional issues:
====================
[] Inpatient neurology recommendations regarding recrudescence
of prior stroke symptoms when SBP <140: maintain SBP >140,
continue aspirin 81mg daily and Plavix 75mg daily. Highly
consider trialing a statin again (ie rosuvastatin 20mg or
pravastatin 40mg final doses), long term LDL goal <70,
outpatient stroke neurology follow up in 3 months
[] Held lisinopril, atenolol, and hydrochlorothiazide given
recrudescence of prior stroke symptoms when SBPs <140 (read
above).
[] Started midodrine 10mg TID to maintain SBP >140 (read above).
Titrate on outpatient basis accordingly.
[] Follow up labs: Please check chem-7 by ___, or at next
follow-up appointment with PCP. Please fax results to ___
___ (FAX ___.
[] Consider EP consult on outpatient basis if symptomatic
bradycardia noted.
[] Hematuria with blood clots in bladder requiring CBI. Will
need outpatient cystoscopy for complete work up for hematuria.
[] MRI head on ___ revealed 13mm right sphenoid wing
meningioma, similar to slightly increased in size from prior
exam. Follow up on outpatient basis recommended.
[] Moderate pulmonary hypertension noted on TTE on ___
I personally examined Ms. ___ today and she is medically
cleared for discharge to home with home ___.
More than 30 minutes were spent on her discharge planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second
Line
5. Ezetimibe 10 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*5 Tablet Refills:*0
2. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - Second
Line
7. Ezetimibe 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. HELD- Atenolol 100 mg PO DAILY This medication was held. Do
not restart Atenolol until seen by PCP
10. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until seen by PCP
11. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until seen by PCP
12.Equipment
R60.0: Lower extremity edema
Please dispense small ___ stockings.
13.Outpatient Lab Work
N17.9: Acute kidney ijury
Please check chem-7 by ___, or at your primary care doctor's
office. Please fax results to ___, MD (___).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
==================
-Relative hypotension with recrudescence of stroke
-Urinary tract infection due to Enterococcus
-Acute kidney injury
Secondary diagnoses:
=================
History of hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___
___!
Why was I admitted to the hospital?
- You were admitted because you had blood clots in your bladder
that needed to be irrigated and cleaned out.
What was done for me while I was in the hospital?
- You received a foley catheter that flushed your bladder with
water to wash out the blood clots. You also received antibiotics
for a urinary tract infection. By the time you left the
hospital, you were able to urinate on your own again.
- While you were in the hospital, you had difficulty finding
words. We think this was due to low blood pressure, leading to
a return of your old stroke symptoms.
- We stopped all your blood pressure medications and started a
new medication called midodrine that increased your blood
pressure.
What should I do when I leave the hospital?
-Please follow up with your doctors as listed below.
-Please make a follow up appointment with your urologist.
-Please take your medicines as prescribed
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19623993-DS-25
| 19,623,993 | 26,430,719 |
DS
| 25 |
2141-03-15 00:00:00
|
2141-03-15 20:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Heparin Agents
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ pmh liver transplant for
autoimmune hepatitis ___, DMII, gastroparesis and renal
insufficiency presents with nausea, vomiting, abdominal pain,
and headache.
Her symptoms began with headache for past ___ days. She states
that she gets a headache very rarely, last a few years ago. She
states the headache she has been having has been pretty
constant, is on the top of her head and around her temples, and
is the most severe of her life. She's not sure if this is the
location of her priors but she knows this is more severe. She
had no aura prior to it, and no visual changes. She does state
that she has had more dysequilibrium and balance issues for the
past few days, although she is able to walk fine she says.
Today, she developed nausea for most of the day and vomiting
around 4pm. Nonbloody and non-bilous. She has not been able to
tolerate PO since then. She states that her PO intake has been
down today. She has mid-epigastric abdominal pain. She has been
taking her tacrolimus as prescribed twice daily. No bowel or
bladder changes.
In the ED, triage vitals were 97.8 73 157/79 20 100% RA
No meningismus on exam.
Labs denoted normal coagulation studies, normal lactate, Na 140,
K 4.5, Cl 105, CO2 22, BUN 34, Cr 1.3 (recent b/l 1.5-1.7),
glucose 173. Alk phos 123, lipase 96. Tacrolimus level pending.
Liver U/s w/ doppler ___
Normal appearance of the liver. CBD of normal caliber. Patent
vasculature withappriopriate directionality of flow.
Patient received zofran, metoclopramide and dilaudid, with pain
relief. Still unable to tolerate POs so admission was requested
for patient.
Vitals prior to transfer:
97.8 65 109/54 18 97%
Upon arrival to the floor, the patient states that all of her
maladies are improving. She does, however, still have a headache
and still with some abdominal pain. She states that her husband
recently had surgery and is requiring significant care at home.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Cirrhosis and ESLD ___ seronegative autoimmune hepatitis/primary
biliary cirrhosis c/b HCC
Hyponatremia
Ascites
Hepatic encephalopathy - now s/p OLT ___
HTN
DM2
Diabetic gastroparesis
Dental caries #12, 13, 14 (s/p removal)
Mild regional LV systolic dysfunction w negative stress echo
(___)
PSH: D&C (1990s), TAH (___), (OLT ___, Abdominal
closure (___)
Social History:
___
Family History:
Mother: ___ CA (___); Father: ___ CA (___); Sister w/
breast CA (___)
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
98.5 117/59 65 18 96%RA
GENERAL: Well appearing in NAD
HEENT: Sclera anicteric. MM dry
NECK: FROM, no meningeal signs
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: non-Distended, obese, Soft, mild tenderness to
palpation in epigastrium.
EXTREMITIES: no edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEUROLOGY: no asterixis; AOx3; PERRL; EOMI; no deficits on
cranial nerve exam; sensation and strength of upper and lower
extremities ___ gait deferred
DISCHARGE PHYSICAL EXAMINATION:
afebrile 98.4 119/56 HR 62 sat 96% on RA
GENERAL: Well appearing in NAD
HEENT: clear OP
NECK: supple
CARDIAC: NR, RR with no excess sounds appreciated
LUNGS: CTAB with no wheezing, rales, or rhonchi.
ABDOMEN: NT, ND, soft
EXTREMITIES: no edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEUROLOGY: no asterixis; AOx3; PERRL; EOMI; no deficits on
cranial nerve exam; sensation and strength of upper and lower
extremities ___ gait deferred
Pertinent Results:
LABS:
On admission:
___ 11:50PM BLOOD WBC-8.0 RBC-3.60* Hgb-10.7* Hct-31.5*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.3 Plt ___
___ 11:50PM BLOOD Neuts-75.8* Lymphs-14.6* Monos-6.9
Eos-2.2 Baso-0.5
___ 11:50PM BLOOD Glucose-173* UreaN-34* Creat-1.3* Na-140
K-4.5 Cl-105 HCO3-22 AnGap-18
___ 11:50PM BLOOD ALT-29 AST-33 AlkPhos-123* TotBili-0.3
___ 11:50PM BLOOD Lipase-96*
___ 11:50PM BLOOD Albumin-4.3
On discharge:
___ 05:25AM BLOOD WBC-6.3 RBC-3.18* Hgb-9.4* Hct-28.1*
MCV-88 MCH-29.4 MCHC-33.3 RDW-13.9 Plt ___
___ 05:25AM BLOOD ___ PTT-30.2 ___
___ 05:25AM BLOOD Glucose-119* UreaN-33* Creat-1.4* Na-133
K-4.4 Cl-101 HCO3-25 AnGap-11
___ 05:25AM BLOOD ALT-26 AST-28 AlkPhos-106* TotBili-0.3
___ 05:25AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7
___ 05:25AM BLOOD tacroFK-8.7
MICRO:
none
IMAGING:
___ RUQ ultrasound with dopplers
IMPRESSION:
1. Normal sonographic appearance of the transplanted liver.
2. Patent hepatic vasculature without evidence of portal vein
thrombosis or arterial stenosis.
___ CT head:
IMPRESSION:
Normal study.
Brief Hospital Course:
Mrs ___ is a ___ yo woman with a history of liver
transplant (autimmune hepatitis) in ___, DMII, gastroparesis
and renal insufficiency who presented with ___ days of nausea,
vomiting, abdominal pain, and headache.
ACTIVE ISSUES BY PROBLEM:
# Headache; nausea/vomiting: Unclear cause -- possibile viral
etiology. Ruled out space occupying lesion with CT scan, no
meningeal signs, did not suspect CNS infection or bleed. GI sx
possibly related to patient's known diabetic gastroparesis.
Checked tacrolimus levels to ensure not toxic or low in level,
and was 8.6 which does not explain sx. The patient did have a
mildly elevated lipase (< 100), but it had normalized and was
more likely due to dehydration rather than pancreatitis.
Deferred MRI head at this time, low suspicion with no lesions on
CT. Given Zofran, Reglan, dilaudid PRN. Tolerated regular diet.
Headache, nausea, and vomiting all resolved the day following
admission.
# s/p liver transplant: RUQ u/s unremarkable. No RUQ tenderness.
Otherwise, LFTs normal aside from elevated lipase. Tacro level
wnl at 8.6. Continued tacrolimus, prednisone, azathioprine, and
dapsone.
# DMII: Serum glucose mildly elevated, 173. Given HISS.
# Hyperlipidemia: Continued simvastatin. Triglycerides 194 this
admission.
# Depression: Continued celexa.
### TRANSITIONAL ISSUES ###
- will follow up with Liver Transplant clinic ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azasan *NF* (azaTHIOprine) 150 mg Oral qd
2. Citalopram 20 mg PO DAILY
3. Chelated Zinc *NF* (zinc) 50 mg Oral qd
4. Multivitamins 1 TAB PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Dapsone 100 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. PredniSONE 4 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Tacrolimus 3.5 mg PO Q12H
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Dapsone 100 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. PredniSONE 4 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Tacrolimus 3.5 mg PO Q12H
10. Azasan *NF* (azaTHIOprine) 150 mg Oral qd
11. Chelated Zinc *NF* (zinc) 50 mg Oral qd
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Viral gastroenteritis
Secondary diagnoses:
Autoimmune hepatitis s/p liver transplant
Diabetes mellitus type II
Hyperlipidemia
Depression
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 ___.
You were admitted to the hospital for headaches, nausea, and
vomiting. Your blood tests, imaging, and head scan did not show
any causes. We believe that you may have had a viral illness
and you improved with hydration and nausea/pain medication.
Followup Instructions:
___
|
19624082-DS-18
| 19,624,082 | 28,770,320 |
DS
| 18 |
2188-01-24 00:00:00
|
2188-01-25 17:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD/endoscopy
History of Present Illness:
___ yo male with history of sarcoidosis (on steroids), hepatitis
C and alcohol induced cirrhosis who presented to the ED this
morning with complaint of severe epigastric pain. Pt reports
that he woke from sleep this morning with lots of mucous, and
then developed coughing fit. This was followed by sudden onset
sharp epigastric pain, that has persisted, and has been
associated with nausea and one episode of vomiting. His appetite
has been good, denies any constipation, states he has been
taking lactulose as prescribed (though mom states only taking
once a day.) He denies any fevers, no chest pain or shortness of
breath. At baseline, pt uses 2 L of oxygen at night, with no
recent change in oxygen requirement. No worsening of abdominal
distension, though he does report that his lower extremity edema
has worsened. Pt reports that he has been told by his mother
that he has been jaundiced for the past 2 weeks, though he has
not noticed that himself.
.
Of note, pt recently had labs performed as an outpatient which
demonstrated an increased bilirubin. Because of this, he had an
MRI and MCRP of his liver, which showed cholelithiasis (no
obstruction), cirrhosis with portal hypertension, no ascites,
and splenomegaly. His chest CT scan showed improving
intrathoracic lymphadenopathy and diffuse lung abnormalities in
keeping with sarcoidosis. He also had a TTE which showed mild
LVH with normal global and regional biventricular systolic
function, no significant valvular disease.
.
In the ED, initial vitals were ___ 70 130/66 20 98%. He
had a RUQ u/s which was essentially unchanged from prior,
showing cirrhotic liver, reversed flow in portal veins, no
ascites,
multiple gallstones but gall blader nondistended with no
pericholycystic fluid. He received morphine and zofran in the
ED. His labs were notable for total bili 7.7 (down from 10.2 on
___ but elevated from baseline ___, AST 210, ALT 92 (also
elevated from baseline 40-60s), and lipase of 142.
.
Currently, pt states that his pain is unbearable, but is lying
comfortably in bed. He states that the medication he got in the
ED did not help him at all. He is no longer feeling nauseated,
and he is hungry.
Past Medical History:
history of alcoholism
anxiety
hypertension
hepatitis C
sarcoidosis with resultant hypercalcemia
ulnar neuropathy
cirrhosis ___ Etoh, HCV
splenomegaly
Social History:
___
Family History:
Father has cancer, unknown type, also with MI and CABG at ___ yo
Mother healthy
___ grandmother and grandfather with alcoholism.
Physical Exam:
ADMISSION EXAM:
VS: 98.1 122/70 68 20 98% RA
GENERAL: Well appearing obese ___ yo M who appears stated age.
Comfortable, appropriate. mildly jaundiced
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but soft, tender to deep palpation over
epigastric area, no rebound or guarding.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
___ bilaterally to knees.
.
DISCHARGE EXAM:
VS: - Tm 98.3 115/60 (103-122/59-71) 59 (59-65) 18 96/RA
I/O: ___ 2 BM 3500/4225 x 5BM
GENERAL: Well appearing obese ___ yo M who appears stated age.
Comfortable, appropriate. mildly jaundiced
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but soft, no tenderness to palpation, no
rebound or guarding.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
___ bilaterally to knees.
Pertinent Results:
ADMISSION LABS:
___ 06:11AM BLOOD WBC-7.4 RBC-5.05 Hgb-14.7 Hct-47.2 MCV-93
MCH-29.1 MCHC-31.2 RDW-17.7* Plt ___
___ 06:11AM BLOOD Neuts-79.3* Lymphs-11.1* Monos-5.3
Eos-3.5 Baso-0.7
___ 06:11AM BLOOD ___ PTT-22.4* ___
___ 06:11AM BLOOD Glucose-142* UreaN-15 Creat-1.2 Na-136
K-5.8* Cl-101 HCO3-22 AnGap-19
___ 06:11AM BLOOD ALT-92* AST-210* AlkPhos-116 TotBili-7.7*
___ 06:11AM BLOOD Lipase-142*
___ 06:11AM BLOOD cTropnT-<0.01
___ 06:11AM BLOOD Albumin-3.8
___ 05:50AM BLOOD WBC-5.9 RBC-4.47* Hgb-12.9* Hct-41.5
MCV-93 MCH-29.0 MCHC-31.2 RDW-17.3* Plt ___
___ 05:50AM BLOOD ___ PTT-32.4 ___
___ 05:50AM BLOOD Glucose-78 UreaN-11 Creat-0.9 Na-135
K-3.8 Cl-101 HCO3-26 AnGap-12
___ 05:50AM BLOOD ALT-75* AST-122* AlkPhos-109 TotBili-7.5*
___ 06:45AM BLOOD Lipase-62*
___ 05:50AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.9
.
IMAGING:
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
The liver is of heterogeneous echotexture, compatible with
patient's known history of underlying cirrhosis. No discrete
hepatic lesion is identified. There is no evidence of
intrahepatic or extrahepatic biliary ductal dilatation. The CBD
is of normal caliber measuring 4 mm. The gallbladder is
incompletely distended. The gallbladder wall appears prominent
measuring 4 mm. Multiple gallstones are seen within its lumen.
No pericholecystic fluid collection. Pancrease is largely
obscured by overlying bowel gas. There is no ascites.
Color flow and spectral analysis demonstrates patent portal vein
with
hepatofugal flow. Similarly, there is reversed flow in right and
left hepatic veins. IVC is patent. Hepatic artery demonstrates
appropriate arterial waveform.
IMPRESSION:
1. Heterogeneous liver echotexture compatible with patient's
known history of underlying cirrhosis. No ascites. No discrete
hepatic lesion is noted.
2. Gallbladder is not distended. There is no pericholecystic
fluid
collection. Multiple gallstones and equivocal gallbladder wall
edema is
chronic in nature and is likely related to underlying the liver
disease.
.
EGD ___
Findings: Esophagus:
Protruding Lesions 2 cords of grade I varices were seen in the
lower third of the esophagus.
Stomach:
Mucosa: Erythema and mosaic appearance of the mucosa were noted
in the whole stomach. These findings are compatible with Portal
Hypertensive Gastropathy.
Duodenum: Normal duodenum.
Impression: 2 cords of small (grade 1) varices at the lower
third of the esophagus
Portal Hypertensive Gastropathy
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ yo male with history of hep C and alcoholic cirrhosis,
sarcoidosis on steroids, who was admitted with abdominal pain
with lab abnormalities.
.
ACTIVE ISSUES:
# Musculoskeletal abdominal pain: Pt reported a sudden onset
abdominal pain prior to admission associated with a coughing
fit, raising concern for musculoskeletal etiology. Because of a
mildly elevated lipase, pt was initially made NPO and received
IV fluid resuscitation. His diuretics were initially held as
well. Pt's diet was advanced and was tolerating full diet by HD
3. He had an EGD to evaluate for possible gastric pathology,
which was unraveling. His pain resolved by HD 3. He was
continued on his PPI and was resumed on his diuretics prior to
discharge.
.
# Cholelithiasis: Pt had multiple gallstones noted on RUQ, but
the gallbladder was not distended, no pericholecystic fluid, no
evidence of obstruction and equivocal gallbladder wall edema
that was chronic. Because of his abdominal pain, surgery was
consulted and recommended outpatient elective cholecystectomy.
He was continued on ursodiol.
.
CHRONIC ISSUES:
# Cirrhosis: His cirrhosis is secondary to HCV and alcohol
abuse, with a history of encephalopathy and esophageal varices.
He has had elevated LFTs for the past month. His work-up to date
has been unrevealing, and included MRI and TTE. It is possible
that his worsening LFTs are secondary to worsening liver disease
versus alcohol use, though pt denies any current alcohol use.
However, even if his lab abnormalities are secondary to
worsening liver disease, he is likely not a transplant candidate
given continued illicit drug use. His labs remained stably
elevated during his hospitalization. He was continued on
propranolol, lactulose, and xifaxin. His diuretics were
initially held but resumed prior to discharge.
.
# sarcoidosis: Pt with history of sarcoidosis, currently well
controlled on CellCept and steroids. His most recent CT scan
showed diffuse thoracic lymphadenopathy with diffuse lung
abnormalities, which are improving from previous imaging. Pt has
history of hypercalcemia, though currently wnl. He was continued
on his CellCept, prednisone and Bactrim prophylaxis.
.
# pain control: Pt has chronic pain neuropathic pain for which
he is on methadone and gabapentin. He was continued on these
medications during his hospitalization.
.
TRANSITIONAL ISSUES:
# Pt should have repeat labs checked in 1 week, to be faxed to
Dr. ___ at the ___.
.
# He should follow up with surgery for elective outpatient
evaluation for cholecystectomy.
Medications on Admission:
Albuterol sulfate two puffs as needed
amlodipine 10 mg once daily
budesonide 180 mcg one puff twice daily
folic acid 1 mg daily
furosemide 20 mg every morning
gabapentin 600 mg one tablet three times per day
lactulose two tablespoons three times per day
methadone 5 mg three times per day
CellCept 500 mg two tablets twice a day
omeprazole 20 mg one tablet daily
prednisone 10 mg per day - per patient, he has only been taking
5 mg daily for the past 6 weeks (he self tapered this because he
thought it was causing weight gain)
propranolol 40 mg twice a day
spironolactone 50 mg two tablet daily (increased from 1 tablet
___
Bactrim Double Strength one tablet ___ and
___
ursodeoxycholic acid ___ mg twice a day
Ambien 10 mg for sleep
magnesium oxide 400 mg three times per day
thiamine 100 mg one tablet daily.
xifaxin 500 mg BID
.
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. budesonide 180 mcg/actuation Aerosol Powdr Breath Activated
Sig: One (1) puff Inhalation twice a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (___).
11. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. spironolactone 50 mg Tablet Sig: Two (2) Tablet PO once a
day.
18. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
19. Outpatient Lab Work
Please have labs checked in 1 week: CBC, chemistry 10, AST, ALT,
Alk phos, bilirubin, PTT, ___. ICD-9: ___ Fax results to
Dr. ___ in the ___ (fax: ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
musculoskeletal abdominal pain
SECONDARY:
cirrhosis
sarcoidosis
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 abdominal pain. We treated
your pain with medications and advanced your diet. You had an
EGD which showed chronic changes consistent with your underlying
liver disease. We also had surgery evaluate you for gallstones,
and they recommended following up as an outpatient for possible
removal of your gallbladder. You were tolerating food well and
we felt it was safe for you to be discharged home. We think your
symptoms were caused by muscle pain.
We have made no changes to your medications. Please continue to
take all medications as prescribed.
Please have labs checked in one week at your follow with Dr.
___ have results faxed to Dr. ___: ___
Followup Instructions:
___
|
19624082-DS-20
| 19,624,082 | 28,325,286 |
DS
| 20 |
2188-03-17 00:00:00
|
2188-03-17 18:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with hx of ETOH and HCV cirrhosis,
complicated by esophageal varices and hepatic encephalopathy, hx
of sarcoidosis, cholelithiasis, neuropathy presenting with
diffuse abdominal pain for 10 days. Pain described as as sharp
and crampy, localized to the RLQ and LLQ and has been constant
for 10 days, associated with nausea occasionally unchanged with
eating. He does endorse an episode of vomiting two days ago,
nonbloodly and nonbilious. Reports occasional loose brown
stools, denies BRBPR/melena. Also reports chills at night.
Reports normal appetite, pain not excerbated by eating. He
denies any fevers/chillls at home. Occasional dysuria, no
hematuria. States he has not used cocaine since ___. Was on
Augmentin recently, completed the course as prescribed.
Of note, he was hospitalized on transplant surgery service from
___ for abdominal pain, started on Unasyn and
transitioned to Augmentin on discharge for a total two week
course, presumably for cholangitis vs cholecystitis but unclear
from discharge summary. He was previously admitted to the
hospital ___ with abdominal pain, thought to be
musculoskeletal in origin, and cholelithiasis with question of
need for outpatient cholecystectomy.
In the ED, initial vitals were as follows: 99.6 73 125/65 16 98%
RA.
Labs were notable for lipase 112, sodium 132, creatinine 1.3,
TBili 5.0 (improved from prior). Bedside ultrasound showed no
drianable fluid collection. Vitals in ED prior to transfer to
floor were as follows: 97.9 65 16 92/58 100%RA.
ROS:
Patient endorsed pain in lower abdomen with urination and
chills. He denied
fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
diarrhea, constipation, BRBPR, melena, hematochezia, hematuria.
Past Medical History:
ETOH and HCV Cirrhosis
- not transplant candidate due to positive cocaine screen in
___
sarcoidosis with resultant hypercalcemia
anxiety
hypertension
ulnar neuropathy
splenomegaly
Social History:
___
Family History:
Father has cancer, unknown type, also with MI and CABG at ___
years old.
Mother healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
Admit Exam:
VS: T 98.7 BP 106/57 HR 67 RR 18 O2 96 RA
GENERAL: Well appearing ___ M who appears stated age.
HEENT: Sclera nonicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles or rhonchi. Several
scattered wheezes.
ABDOMEN: Active bowel sounds. Typmanytic to percussion.
Distended but Soft. Tender in LLQ and RLQ.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
___ bilaterally.
Discharge Exam:
Pertinent Results:
Admission Labs:
___ 09:27AM BLOOD WBC-7.9 RBC-4.39* Hgb-13.5* Hct-40.0
MCV-91 MCH-30.7 MCHC-33.7 RDW-16.5* Plt ___
___ 09:27AM BLOOD Neuts-78.6* Lymphs-9.3* Monos-7.9 Eos-3.6
Baso-0.6
___ 09:27AM BLOOD Glucose-101* UreaN-11 Creat-1.3* Na-132*
K-4.0 Cl-96 HCO3-23 AnGap-17
___ 09:27AM BLOOD ALT-34 AST-67* AlkPhos-107 TotBili-5.0*
___ 09:27AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 06:45AM BLOOD WBC-6.0 RBC-4.15* Hgb-12.6* Hct-38.6*
MCV-93 MCH-30.3 MCHC-32.5 RDW-16.8* Plt ___
___ 10:20AM BLOOD Glucose-121* UreaN-12 Creat-1.2 Na-133
K-3.5 Cl-98 HCO3-25 AnGap-14
___ 06:45AM BLOOD ALT-29 AST-59* LD(LDH)-262* AlkPhos-90
TotBili-4.3*
STUDIES:
DUPLEX DOPP ABD/PEL Study Date of ___ 10:13 AM
IMPRESSION:
1. Cholelithiasis without definite cholecystitis. Gallbladder
wall edema is nonspecific in the setting of cirrhosis. If there
is continued concern for cholecystitis, HIDA scan may be
obtained for further evaluation.
2. Right portal vein not well visualized. Main portal and left
portal veins are patent with reversed flow, similar to prior.
Patent hepatic artery and hepatic veins. If there is continued
concern for right portal venous thrombosis, then a CT or MRI of
the liver can be obtained.
3. Cirrhotic liver without new focal lesion. Splenomegaly. No
ascites.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 3:23 ___
IMPRESSION:
1. No acute abdominal pathology, especially no evidence of
appendicitis.
Subtle fat stranding in the peripancreatic region, may relate to
acute
pancreatitis, in the presence of laboratory confirmation of the
same. In the absence these findings can be explained by portal
hypertension.
2. Cirrhotic liver, splenomegaly with evidence of portal
hypertension.
Brief Hospital Course:
Mr. ___ is a ___ year old man with hx of HCV and ETOH
cirrhosis, complicated by esophageal varices and hepatic
encephalopathy, who presents with abdominal pain, unclear
etiology, attributed to gas pains.
ACTIVE ISSUES:
# Abdominal Pain
Unclear etiology but improved by time of discharge but was
attributed to gas pains, localized to lower quadrants, and he
was discharged with a trial of simethicone. Of note, recent
hospitalization on transplant surgery service for RUQ abdominal
pain, which may have been attributed to cholangitis (diagnosis
unclear from prior discharge summary), as he was discharged on a
two week course of Augmentin at that time. RUQ ultrasound
showed patent portal vein, cholelithiasis but no cholecystitis
or CBD dilation. Alk phos and TBili were within normal limits.
Lipase was mildly elevated but no epigastric tenderness on exam,
and patient tolerated meals well, so clinically did not have
pancreatitis. No significant fluid collection on ultrasound
made SBP very unlikely. CT scan showed no signs of
appendicitis. C diff was negative. Tox screen negative for
cocaine use.
# Lip Lesions
Cold sores versus herpes. Recommended PCP evaluation to
consider outpatient trial of Valacyclovir for potential herpes.
INACTIVE ISSUES:
# ETOH and HCV Cirrhosis
Complicated by hepatic encephalopathy and esophageal varices.
Not a transplant candidate in setting of recent illicit drug
use. LFTs were within normal limits. He was continued on
rifaximin, lactulose, and mental status remained clear. He was
continued on propranolol. He was continued on his home
diuretics of lasix and spironolactone. No significant ascites
was seen on ultrasound.
# Sarcoidosis
Most recent CT scan was ___ and showed diffuse thoracic
lymphadenopathy with diffuse lung abnormalities, though improved
from prior. Also has history of hypercalcemia, though currently
normal. He was continued on CellCept and prednisone. Was
continued also on bactrim prophylaxis.
# Chronic Neuropathy
Patient has of chronic neuropathic pain, which is currently at
baseline. He has been tapering his methadone as an outpatient.
He was continued on his current methadone dose of 5mg daily and
gabapentin.
TRANSITIONAL ISSUES:
- incidental finding: high riding right testicle seen on CT --
recommended followup with urology
- consider trial of Valtrex for lip lesions which may be
herpetic
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. PredniSONE 5 mg PO DAILY
2. Gabapentin 600 mg PO TID
pls hold for sedation
3. Mycophenolate Mofetil 1000 mg PO BID
4. Rifaximin 550 mg PO BID
5. Propranolol 30 mg PO TID
pls hold for hr<55 or sbp<100
6. Amlodipine 10 mg PO DAILY
7. Methadone 5 mg PO DAILY Start: In am
8. Budesonide (Nasal) *NF* 180 mcg/Actuation NU BID
pls rinse your mouth out after use
9. Furosemide 20 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Lactulose 30 mL PO TID
please titrate to ___ BMs per day
13. Magnesium Oxide 400 mg PO DAILY
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
15. Ursodiol 300 mg PO BID
16. Thiamine 100 mg PO DAILY
17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
___
18. Omeprazole 40 mg PO BID
19. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheeze
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
pls hold for sedation
4. Lactulose 30 mL PO TID
please titrate to ___ BMs per day
5. Methadone 5 mg PO DAILY
6. Mycophenolate Mofetil 1000 mg PO BID
7. Omeprazole 40 mg PO BID
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheeze
9. Budesonide (Nasal) *NF* 180 mcg/Actuation NU BID
pls rinse your mouth out after use
10. Amlodipine 10 mg PO DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
13. PredniSONE 5 mg PO DAILY
14. Rifaximin 550 mg PO BID
15. Spironolactone 100 mg PO DAILY
16. Propranolol 30 mg PO TID
pls hold for hr<55 or sbp<100
17. Ursodiol 300 mg PO BID
18. Thiamine 100 mg PO DAILY
19. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
___
20. Simethicone 40 mg PO QID:PRN gas
You may take this medication as-needed if it has helped relieve
your gas pains. If you have obtained no relief from the
medication, you do not need to continue it.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Hepatitis C and Alcoholic Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having lower
abdominal pain. You had a CT scan and an ultrasound of your
abdomen which did not show an etiology of your pain. You also
had a stool sample tested for infection which was normal. It is
reassuring that there is nothing dangerous causing your pain.
Please avoid fatty foods. Also, avoid using cocaine as this can
cause spasm of the blood vessels in your intestines and
potentially death of the bowel, serious infection and even
death.
Your CT revealed that your right testicle is located higher in
your scrotal sac than normal. This was confirmed on exam.
Please discuss with your primary care physician (PCP) about a
referal to a urologist for further evaluation. The number for
___ Urology is below.
During your visit, you also had an outbreak of likely coldsores
on and around your lips. Please discuss with your primary care
physician (PCP) whether or not treatment with medication is
warranted.
We have given you one dose of simethicone for gas pains this
morning. If this medication has helped relieve the gas,
consider getting simethicone over-the-counter. A pharmacist can
help direct you to the correct medication. Please take as
directed.
You have an appointment with Dr. ___ as below in ___.
Please call on to schedule an appointment in the next ___ weeks.
The phone number is ___.
Followup Instructions:
___
|
19624082-DS-22
| 19,624,082 | 20,622,078 |
DS
| 22 |
2189-07-16 00:00:00
|
2189-07-16 14:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intra-abdominal bleed
Major Surgical or Invasive Procedure:
Exploratory laparotomy and cholecystectomy
History of Present Illness:
___ w/EtOH cirrhosis, hepC, and sarcoidosis p/w hypotension
likely from intraabdominal bleed from liver laceration s/p fall.
Patient fell approximately ___ feet from standing on a ladder
earlier in the day. Afterwards had abdominal pain which he
contributed to reflux. He then proceeded to a bar to watch the
___ game and had a few drinks. Per report he fell from a bar
stool, although the patient does not seem to remember this. He
was brought to the ___, where he was hypotensive to the
___ systolic. He was mentating well. He was given 2L
crystalloid,
2U blood, 100mg of hydrocortisone. Hct 25 at the time, INR 1.3.
Non-con CT showed blood in the abdomen, with layering anterior
to
the liver, and fluid around the spleen, likely had a liver
laceration. He was then transferred to BI on dopamine. On
arrival, he was stable on pressors, mentating well, and
diffusely
tender. He was taken directly to the operating room for an
ex-lap
with ACS.
Past Medical History:
- ETOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus. Portal Hypertensive Gastropathy
Last colonoscopy (___):
Edema in the colon (biopsy)
Mosaic appearance in the rectum compatible with portal colopathy
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
-sarcoidosis with resultant hypercalcemia
-anxiety/depression
-hypertension
-ulnar neuropathy
-splenomegaly
- Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father has cancer, unknown type, also with MI and CABG at ___
years old.
Mother healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
Admission Physical Exam:
Vitals: 68, 88/47 (on dopamine 5), 14, 100%
GEN: A&O, NAD
HEENT: scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, distended, diffusely tender, +guarding
Discharge Physical Exam:
98.4 62 125/68 20 96%RA
Gen: NAD, alert, responsive
Pulm: CTAB
CV: RRR
Abd: soft, minimally tender, nondistended, incision site c/d/i
Ext: no c/c/e
Pertinent Results:
___ 08:27PM TYPE-ART PO2-116* PCO2-37 PH-7.34* TOTAL
CO2-21 BASE XS--5
___ 08:27PM LACTATE-2.0
___ 08:00PM HCT-31.3*
___ 06:29PM TYPE-ART PO2-92 PCO2-33* PH-7.37 TOTAL
CO2-20* BASE XS--4
___ 05:56PM TYPE-ART PO2-93 PCO2-34* PH-7.35 TOTAL
CO2-20* BASE XS--5
___ 05:21PM TYPE-ART COMMENTS-GREEN TOP
___ 05:21PM LACTATE-1.8
___ 02:05PM TYPE-ART PO2-111* PCO2-37 PH-7.35 TOTAL
CO2-21 BASE XS--4
___ 02:00PM GLUCOSE-109* UREA N-18 CREAT-1.4* SODIUM-133
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-20* ANION GAP-8
___ 02:00PM CALCIUM-8.7 PHOSPHATE-4.8* MAGNESIUM-2.0
___ 01:40PM HCT-27.8*
___ 10:23AM TYPE-ART PO2-99 PCO2-32* PH-7.35 TOTAL
CO2-18* BASE XS--6
___ 10:23AM LACTATE-2.0
___ 10:23AM freeCa-1.26
___ 07:36AM TYPE-ART PO2-110* PCO2-35 PH-7.33* TOTAL
CO2-19* BASE XS--6
___ 07:36AM GLUCOSE-118* LACTATE-2.6*
___ 07:31AM HCT-29.7*
___ 05:32AM TYPE-ART PO2-82* PCO2-29* PH-7.27* TOTAL
CO2-14* BASE XS--11
___ 05:32AM LACTATE-3.8*
___ 05:32AM freeCa-1.11*
___ 04:33AM TYPE-ART PO2-62* PCO2-34* PH-7.24* TOTAL
CO2-15* BASE XS--11
___ 03:57AM TYPE-ART PO2-83* PCO2-37 PH-7.20* TOTAL
CO2-15* BASE XS--12
___ 03:57AM GLUCOSE-86 LACTATE-6.0* K+-4.5
___ 03:57AM O2 SAT-94
___ 03:57AM freeCa-1.29
___ 03:45AM GLUCOSE-89 UREA N-16 CREAT-1.3* SODIUM-137
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-14* ANION GAP-20
___ 03:45AM ALT(SGPT)-31 AST(SGOT)-102* LD(LDH)-255* ALK
PHOS-105 TOT BILI-5.6*
___ 03:45AM ALBUMIN-2.4* CALCIUM-10.2 PHOSPHATE-4.9*#
MAGNESIUM-1.2*
___ 03:45AM WBC-9.4 RBC-3.43* HGB-10.2* HCT-30.3* MCV-89
MCH-29.7 MCHC-33.6 RDW-16.0*
___ 03:45AM PLT COUNT-127*
___ 03:45AM ___ PTT-32.5 ___
___ 03:45AM ___
___ 02:41AM TYPE-ART PO2-323* PCO2-35 PH-7.18* TOTAL
CO2-14* BASE XS--14 INTUBATED-INTUBATED VENT-CONTROLLED
___ 02:41AM GLUCOSE-100 LACTATE-7.6* NA+-131* K+-4.9
CL--110*
___ 02:41AM HGB-8.1* calcHCT-24 O2 SAT-99
___ 02:41AM freeCa-0.88*
___ 02:03AM GLUCOSE-97 LACTATE-5.4* NA+-131* K+-5.1
CL--109*
___ 02:03AM HGB-9.8* calcHCT-29 O2 SAT-99
___ 02:03AM freeCa-0.90*
___ 12:30AM ___ COMMENTS-GREEN TOP
___ 12:30AM GLUCOSE-78 LACTATE-5.0* NA+-134 K+-4.8
CL--111* TCO2-13*
___ 12:26AM URINE COLOR-DkAmb APPEAR-Hazy SP ___
___ 12:26AM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:26AM URINE HYALINE-29*
___ 12:26AM URINE MUCOUS-OCC
___ 12:20AM UREA N-20 CREAT-1.9*
___ 12:20AM estGFR-Using this
___ 12:20AM LIPASE-103*
___ 12:20AM ASA-NEG ETHANOL-19* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:20AM WBC-13.2*# RBC-3.24* HGB-9.5* HCT-30.4*
MCV-94 MCH-29.5 MCHC-31.3 RDW-18.1*
___ 12:20AM PLT COUNT-240#
___ 12:20AM ___ PTT-28.6 ___
___ 12:20AM ___
Brief Hospital Course:
___ was admitted to ___ on ___ from ___ with
hypotension from intraabdominal bleed from liver laceration
following a fall. He had fallen approximately ___ feet from
standing on a ladder earlier that day. He subsequently proceeded
to a bar to watch the ___ game and had a few drinks, at which
time he fell from a bar stool. He was brought to the ___,
where he was hypotensive to the ___ systolic. He was mentating
well. He was given 2L crystalloid,
2U blood, 100mg of hydrocortisone. Hct 25 at the time, INR 1.3.
A non-contrast CT demonstrated blood in the abdomen, with
layering anterior to the liver, and fluid around the spleen,
likely had a liver laceration. He was then transferred to BI on
dopamine. On arrival, he was stable on pressors, mentating well,
and diffusely
tender. He was taken directly to the operating room for an
ex-lap with ACS.
The patient underwent an exploratory laparotomy and
cholecystectomy. Surgery revealed a rupture of the gallbladder
fundus with avulsion from the gallbladder fossa and significant
hemorrhage, as well as a liver hematoma. The patient was taken
directly from the operating room to the trauma ICU. He was
transfused 2 units of PRBCs and 2 units of FFP postoperatively.
A hepatology consult was placed, per their recommendations, he
was started on ceftriaxone for intra-abdominal bleeding,
lactulose for hepatic encephalopathy, and liver function tests
were monitored. On ___, he was extubated, and re-started
on subcutaneous heparin. On ___, he was stable, and was
transferred to the floor. The next day, he was advanced to
regular diet, his foley and CVL were removed, he was no longer
requiring restraints. His mental status was also noted to be
improved on ___ as well. The patient was seen by physical
therapy who thought the patient was ok to discharge to home with
assistance from his family.
Upon discharge, the patient's pain was well controlled. He was
tolerating regular diet, and had normal bowel function. His
mental status was improved. He was ambulating with minimal
assistance. He was discharged with instructions to follow-up at
his scheduled appointment in the acute care surgery clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. PredniSONE 7.5 mg PO DAILY
4. Propranolol 30 mg PO TID
5. Rifaximin 550 mg PO BID
6. Spironolactone 50 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO M, W, F
8. Ursodiol 300 mg PO BID
9. Gabapentin 300 mg PO TID
10. FoLIC Acid 1 mg PO DAILY
11. Hydroxychloroquine Sulfate 200 mg PO BID
12. Lactulose 30 mL PO TID
13. Omeprazole 40 mg PO BID
14. Zolpidem Tartrate 10 mg PO HS:PRN sleep
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Lactulose 30 mL PO TID
6. Omeprazole 40 mg PO BID
7. PredniSONE 7.5 mg PO DAILY
8. Propranolol 30 mg PO TID
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. Sulfameth/Trimethoprim DS 1 TAB PO M, W, F
12. Ursodiol 300 mg PO BID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Docusate Sodium 100 mg PO BID
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
16. Senna 1 TAB PO BID
17. Hydroxychloroquine Sulfate 200 mg PO BID
18. Zolpidem Tartrate 10 mg PO HS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
Gallbladder avulsion with hepatic hemorrhage s/p exploratory
laparotomy and cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital following a fall with a
laceration to your liver and ruptured gallbladder. You were
taken emergently to the operating room and had your gallbladder
removed. You are now being discharged to continue your recovery
with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bath tubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of 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. Your incisions may be slightly red
around the staples. This is normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
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:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
___: Colonoscopy
History of Present Illness:
Mr. ___ is a ___ yo male with ETOH induced cirrhosis,
Hepatitis C, sarcoidosis (on CellCept and Prednisone), ongoing
substance abuse who is presenting with bright red blood per
rectum associated with lightheadedness. He was recently
admitted to ___ from ___ for an exploratory laparotomy
and cholecystectomy after patient sustained a fall resulting in
a liver laceration and avulsion of his gallbladder. His
recovery was complicated by a post surgical wound infection.
The patient has since been following up with his regular
outpatient providers.
On ___ patient saw his PCP with ___ complaint of BRBPR. At
that time patient did not have any signs of hemodynamic
instability. His bleed was thought to be most likely from his
internal hemorrhoids which the patient has secondary to portal
hypertension. He was given Anusol suppositories x7 days. A CBC
at that time showed improvement since his hospital discharge.
The patient now reports continued BRPBR on a daily basis. He
notes that the blood covers the toilet bowl and he has some
blood on the toilet paper as well. He reports that every day he
was finding more and more blood after defecating. He has had
stomach pain as well, ___ which he reports as a sharp pain in
the middle of his abdomen. This pain is improved by not eating
and is worsened by taking Lactulose. He avoids taking Lactulose
for this reason. He has been noncompliant with this medication
but notes that at his last hospitalization he had some confusion
which improved after using the Lactulose.
In the days preceding admission he was feeling more fatigued, he
had no energy. He was concerned that the Lactulose was
contributing to the bleed so he avoided this medication. He
also notes that he was straining to urinate and to defecate
which is a new problem for him. He denies any N/V or fevers.
No diarrhea. His stools have been well formed despite the
bleeding. Never had any dark, tarry stools.
In the ED, initial vitals were 98.8 81 121/67 20 94% RA. He
complained of generalized weakness and lethargy and an episode
of dizziness in the morning. He was transfused 1unit pRBCs. He
was additionally given Ceftriaxone for concern of upper GI
bleed. A urine tox screen was negative. ACS was consulted and
noted an actively oozing internal hemorrhoid on anoscopic exam
as well as multiple grade 1 internal hemorrhoids.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- ETOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus. Portal Hypertensive Gastropathy
-Grade 1 internal hemorrhoids
-sarcoidosis with resultant hypercalcemia
-anxiety/depression
-hypertension
-ulnar neuropathy
-splenomegaly
-Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
Exam on Admission:
VS- 98.4 121/61 65 18 99%RA 99.1kg
General- Pleasant, pale appearing man, NAD
HEENT- mild scleral icterus, PERRL, MMM, O/P clear
Neck- Supple, no carotid bruits
CV- RRR, no m/r/g
Lungs- CTAB no w/r/r
Abdomen- + NABS, slightly distended, soft, well healed midline
scar, mild tenderness to palpation in LLQ with voluntary
guarding, no rebound tenderness.
GU- No Foley
Ext- trace nonpitting edema bilaterally, warm, 2+ peripheral
pulses
Neuro- A&Ox3, CN II-XII grossly intact, 4+/5 strength bilateral
lower extremities, no asterixis present
Skin- no rashes or lesions noted
Exam at Discharge:
VS- 98.3 107/55 82 18 100%RA
General- Pleasant, pale appearing man, NAD
HEENT- pale, PERRL, MMM, O/P clear
Neck- Supple, no carotid bruits
CV- RRR, no m/r/g
Lungs- CTAB no w/r/r
Abdomen- + NABS, slightly distended, soft, well healed midline
scar, tender to palpation diffusely very distractable.
GU- No Foley
Ext- trace nonpitting edema bilaterally, warm, 2+ peripheral
pulses
Neuro- A&Ox3, CN II-XII grossly intact, 4+/5 strength bilateral
lower extremities, no asterixis present
Skin- no rashes or lesions noted
Pertinent Results:
Labs on admission:
___ 11:55AM ___ PTT-32.6 ___
___ 11:55AM PLT SMR-NORMAL PLT COUNT-212
___ 11:55AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
___ 11:55AM NEUTS-64 BANDS-0 ___ MONOS-8 EOS-7*
BASOS-0 ___ MYELOS-0
___ 11:55AM WBC-4.4 RBC-3.17* HGB-9.0* HCT-28.9* MCV-91
MCH-28.5 MCHC-31.2 RDW-16.3*
___ 11:55AM ALBUMIN-2.9*
___ 11:55AM LIPASE-86*
___ 11:55AM ALT(SGPT)-22 AST(SGOT)-62* ALK PHOS-120 TOT
BILI-4.4*
___ 11:55AM GLUCOSE-75 UREA N-12 CREAT-1.2 SODIUM-138
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
___ 12:04PM LACTATE-2.4*
___ 02:55PM URINE ___ WBC-0 BACTERIA-FEW YEAST-NONE
EPI-NONE
___ 02:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 02:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:50PM HCT-32.0*
Pertinent labs:
___ 08:50PM BLOOD Hct-32.0*
___ 06:13AM BLOOD WBC-3.0* RBC-2.81* Hgb-8.0* Hct-24.7*
MCV-88 MCH-28.3 MCHC-32.2 RDW-16.1* Plt ___
___ 10:30AM BLOOD Hct-23.4*
___ 05:15PM BLOOD Hct-33.9*#
___ 12:00AM BLOOD Hct-29.5*
___ 05:15AM BLOOD WBC-2.2* RBC-2.88* Hgb-8.4* Hct-25.6*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.7* Plt ___
___ 05:15PM BLOOD Hct-27.3*
___ 06:13AM BLOOD ALT-21 AST-55* AlkPhos-99 TotBili-3.7*
___ 05:15AM BLOOD ALT-21 AST-53* AlkPhos-96 TotBili-3.4*
___ 05:15PM BLOOD CRP-16.2*
___ 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 06:10AM BLOOD WBC-3.4*# RBC-3.39* Hgb-9.6* Hct-29.9*
MCV-88 MCH-28.2 MCHC-32.0 RDW-15.7* Plt ___
___ 06:10AM BLOOD ___ PTT-32.8 ___
___ 06:10AM BLOOD Glucose-110* UreaN-8 Creat-1.0 Na-133
K-4.2 Cl-105 HCO3-20* AnGap-12
___ 06:10AM BLOOD ALT-22 AST-67* AlkPhos-118 TotBili-4.2*
___ 06:10AM BLOOD Calcium-8.8 Phos-1.8* Mg-1.5*
Imaging:
Final Report ___ RUQ U/S
HISTORY: Cirrhosis. Rule out portal vein thrombosis.
COMPARISON: CT dated ___ and ultrasound dated ___.
TECHNIQUE: Grayscale and Doppler ultrasound images of the
abdomen were
obtained.
FINDINGS:
The liver has a nodular contour, consistent with cirrhosis. No
focal liver
lesions are identified. No intra or extrahepatic duct
dilatation. The common bile duct measures 4 mm in diameter.
The patient is status post
cholecystectomy. There is small volume ascites within the right
lower
quadrant.
The main portal vein is small in caliber but is patent with
hepatopetal flow. The right portal vein is also small in
caliber but is patent with hepatopetal flow. There is reversed
flow (hepatofugal) within the left portal vein. The main
hepatic artery is patent with a resistive index of 0.76. The
hepatic veins are patent.
The spleen measures 20.3 cm and has homogeneous echotexture.
Large splenic
varices are identified. The right kidney measures 10.7 cm and
the left kidney measures 9.5 cm. No hydronephrosis, masses or
stones. The visualized portions of the aorta and inferior vena
cava appear normal.
IMPRESSION:
1. Small caliber main portal vein, similar to the recent CT.
No evidence of portal vein thrombosis. Reversed flow within the
left portal vein.
2. Cirrhotic liver with evidence of portal hypertension
(splenomegaly and
splenic varices).
3. Small volume ascites.
Brief Hospital Course:
Mr. ___ is a ___ yo male with ETOH induced cirrhosis,
Hepatitis C, sarcoidosis (on CellCept and Prednisone), ongoing
substance abuse who is presenting with bright red blood per
rectum associated with lightheadedness.
Active Issues:
# BRBPR: On admission ddx included Lower GI Bleed, potentially
from known internal hemorrhoids vs. portal colopathy. Also
included in the differential was a brisk UGIB and hemobilia from
previous liver/GB injury. On exam in ED, noted an actively
oozing internal hemorrhoid on anoscopy as well as other internal
hemorrhoids. Patient received 1 unit pRBCs in ED for elevated
lactate, 1 additional unit on the floor. Colonoscopy showing
patchy erythematous areas in ascending colon and cecum which
were biopsied, large internal hemorrhoids. As these were
thought to be source of the bleed, EGD was not pursued this
admission. In 24 hours prior to discharge patient had no more
bloody stools. His hematocrit was stable. His pain was treated
with his home Oxycodone regimen. He was discharged with
instructions to continue with a good bowel regimen including
Colace, Senna and Hydrocortisone suppositories. He will have a
repeat hematocrit checked on ___.
# Hypokalemia: Likely secondary to lower GI losses, diarrhea and
bowel prep for colonoscopy. Was corrected with PO potassium.
Chronic Issues:
# HEPATIC ENCEPHALOPATHY: Patient does have history of hepatic
encephalopathy at last admission per his report and was started
on Lactulose. He refuses to take the medication currently, has
no signs of encephalopathy on exam, but is generally poor
historian. Continued with Rifaximin and regular bowel regimen
without Lactulose. No scoring on CIWA this admission.
# GIB/VARICES: Patient has history of varices. Last EGD ___
showed small varicose. Propranolol was held given continued
bleeding during the admission and lower BPs. He continued on
Omeprazole 40mg BID.
# CIRRHOSIS: Due to ETOH, HCV. Patient also has Sarcoidosis.
MELD on admission was 15, on discharge was 14. He continued
home diuretics and Ursodiol.
# Sarcoidosis: On prednisone and Cellcept. Followed by ___
Endocrinology for his hypercalcemia. He continued home
medications here and Bactrim for prophylaxis. Advised patient
to follow up with outpatient Endocrinologist as he was
questioning his diagnosis in absence of current symptoms.
# Cataracts: continued outpatient Plaquenil 200mg BID.
Transitional Issues:
# follow up Hematocrit from ___
# Patient advised to return to ED if continued bleeding at home
# patient will need to have ___ follow up, biopsy
results explained
# Consider restarting Amlodipine in outpatient setting if BPs
can tolerate
# Advised patient to follow up with his Endocrinologist who is
following him for his hypercalcemia related to Sarcoidosis.
Currently very stable on medication regimen.
# Patient has been ETOH free since life threatening accident in
___, would continue to encourage sobriety, refer to
substance abuse programs, social work as needed
# CODE: Full
# CONTACT: Patient, Father, ___
(home)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Omeprazole 40 mg PO BID
5. Propranolol 30 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO MWF
11. Ursodiol 300 mg PO BID
12. Zolpidem Tartrate 10 mg PO HS:PRN sleep
13. PredniSONE 6 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Lactulose 30 mL PO TID
5. Omeprazole 40 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
7. PredniSONE 6 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO DAILY
10. Sulfameth/Trimethoprim DS 1 TAB PO MWF
11. Ursodiol 300 mg PO BID
12. Zolpidem Tartrate 10 mg PO HS:PRN sleep
13. Hydrocortisone Acetate Suppository ___AILY
RX *hydrocortisone acetate [Anucort-HC] 25 mg 1 suppository(s)
rectally daily Disp #*30 Suppository Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
15. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Propranolol 30 mg PO TID
17. Outpatient Lab Work
Please Check a CBC.
Please fax results to Dr. ___ Office.
Phone: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower GI Bleed
Secondary: HCV/ETOH Cirrhosis
Sarcoidosis
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 at ___
___. You were admitted after you noticed
more bright red blood while having bowel movements. You felt
dizzy and light headed because of this. You received two units
of blood this admission for your low blood counts as a result of
the bleeding. A colonoscopy was done on ___ which showed that
you had large internal hemorrhoids and some ulceration in the
large intestine that could have been causing the bleed.
Biopsies were taken of these ulcerations to better assess
whether they are being caused by an infection. We advise that
you take stool softeners at home to lessen the irritation of the
hemorrhoids when you are having bowel movements and ensure that
you are having regular bowel movements daily. You may also try
using ___ baths at home which may also help with the
irritation.
Your blood pressures were a little low during this admission,
likely because of the bowel prep for colonoscopy, so we stopped
your Amlodipine. We recommend It is important that you continue
taking your medications as prescribed. Please follow up at the
appointments listed below. We wish you the best.
Your ___ Team
Followup Instructions:
___
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, headache, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hepatitis C (genotype 3 cirrhosis, on
treatment week 8 of sofosbuvir and ribavirin) and
sarcoid-induced cirrhosis with a history of heavy alcohol abuse
in the past who presented to ___ ED with with nausea,
vomiting, headache, fatigue for 3 days.
Patient was in his usual state of health until last ___
when he started feeling unwell and then on ___ developed ___
episodes of nonbloody nonbilious vomiting. He took his weekly
trip to ___ in hopes that symptoms would resolve, but
they persisted such that he had to immediately return home.
Nausea/vomiting got worst yesterday evening.
He has not had any measured fever at home, but think he may have
had some subjective fever and chills possibly from the heating
blanket he was using at home. Denies any weight loss from
baseline (fluctuates 200-220lbs) but has had some anorexia due
to significant nausea. Also reports nonproductive cough and
some increased dyspnea on exertion. He denies confusion,
forgetfulness (has been off lactulose for ___ year). Denies
melena, BRBPR, last BM this morning, no blood.
In ___ ED, intial VS 98.8 76 136/66 18 98% RA, Labs notable
for
Chem-7 with Na 132 and Cr 1.1, LFTs ALT 40 AST 85 AP 118 TB 4.9
Lipase 114, CBC with pancytopenia to WBC 1.5, H/H 9.7/31.3 Plt
86, lactate 1.9. UA negative for infection, UCx and BCx pending.
RUQ US with dopplers showed cirrhosis, patent protal
vasculature, stable splenomegaly and splenic varices. CXR by my
read with persistent peribronchial opacities but otherwise
without clear effusion (although L costophrenic angle is not
visualized), consolidation. Patient subsequently admitted for
further management. VS prior to transfer 99.4 72 138/73 16 100%
RA.
Upon arrival to the floor, VS 99.5 99/57 70 22 98%RA. Patient
appears pale but comfortable. He denies any current fevers,
chills, chest pain, abdominal pain, nausea, and
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- ETOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus. Portal Hypertensive Gastropathy
-Grade 1 internal hemorrhoids
-sarcoidosis with resultant hypercalcemia
-anxiety/depression
-hypertension
-ulnar neuropathy
-splenomegaly
-Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 99.5 99/57 70 22 98%RA
GEN: AOx3, jaundiced middle aged man, in mild distress secondary
to nausea
HEENT: Jaundiced, scleral icterus, MMM, oropharynx clear
NECK: supple, JVP not elevated
CV: RRR, normal s1, s2
PULM: Wheezing bilaterally over lower lobes, increased work of
breathing
ABD: Soft, nontender, nondistended. splenomegaly. midline
surgical scar intact. No CVA tenderness.
EXT: trace edema in feet, ankles, warm well perfused.
NEURO: AOX3, no asterixis.
SKIN: jaundiced, spider angiomas over chest, abdomen. no
gynecomastia.
Discharge:
24H Events: none
S: No complaints this am. Still feels fatigue and malaise.
O:98.8/99.8 130/67 92
GEN: AOx3, jaundiced middle aged man,NAD
HEENT: Jaundiced, scleral icterus, MMM, oropharynx clear
NECK: supple, JVP not elevated
CV: RRR, normal s1, s2
PULM: CTAB, no w/r/r
ABD: Soft, nontender, nondistended. splenomegaly. midline
surgical scar intact. No CVA tenderness.
EXT: trace edema in feet, ankles, warm well perfused.
NEURO: AOX3, no asterixis.
SKIN: jaundiced, spider angiomas over chest, abdomen. no
gynecomastia.
Pertinent Results:
___ 06:55PM GLUCOSE-129* UREA N-14 CREAT-1.3* SODIUM-134
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16
___ 08:51AM URINE HOURS-RANDOM
___ 08:51AM URINE UHOLD-HOLD
___ 08:51AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:51AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:32AM COMMENTS-GREEN TOP
___ 08:32AM LACTATE-1.9
___ 08:26AM ___ PTT-31.3 ___
___ 08:24AM ALT(SGPT)-40 AST(SGOT)-85* ALK PHOS-118
AMYLASE-108* TOT BILI-4.9*
___ 08:24AM LIPASE-114*
___ 08:24AM ALBUMIN-3.1*
___ 07:00AM GLUCOSE-98 UREA N-13 CREAT-1.1 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-19* ANION GAP-15
___ 07:00AM estGFR-Using this
___ 07:00AM ETHANOL-NEG
___ 07:00AM WBC-1.5* RBC-3.02* HGB-9.7* HCT-31.3*
MCV-104* MCH-32.2* MCHC-31.0 RDW-17.9*
___ 05:05AM BLOOD WBC-2.3* RBC-2.59* Hgb-8.2* Hct-27.0*
MCV-105* MCH-31.7 MCHC-30.4* RDW-20.5* Plt Ct-91*
___ 05:05AM BLOOD Neuts-63.1 ___ Monos-7.9 Eos-1.4
Baso-0.4
___ 05:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL Burr-1+ Tear Dr-OCCASIONAL
___ 05:05AM BLOOD Plt Ct-91*
___ 05:05AM BLOOD ___ PTT-41.7* ___
___ 05:05AM BLOOD Glucose-142* UreaN-15 Creat-0.8 Na-133
K-3.7 Cl-104 HCO3-21* AnGap-12
___ 05:05AM BLOOD ALT-28 AST-59* AlkPhos-113 TotBili-4.3*
___ 05:05AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.8
___ 05:00PM BLOOD Cortsol-15.9
___ 03:10PM BLOOD Cortsol-9.1
___ 07:30PM BLOOD HIV Ab-NEGATIVE
Brief Hospital Course:
___ with sarcoidosis (on cellcept, pred on admission) and Hep C
cirrhosis (genotype 3), Childs C MELD 14, presented with fevers
and pancytopenia, found to have primary CMV infection.
# febrile neutropenia: ___ CMV (107,000 on admission dropping to
70,900 by discharge) plus MMF in combination with ribavirin
causing anemia. We ruled out Lyme, EBV, Parvo B19, underlying
hematolgical disorders, C.diff, and full respiratory panel was
negative. UA negative. Fevers likely ___ CMV itself. Cefepime
stopped as blood cultures were consistently negative.
-increased Pred from 5 to 10 for evidence of adrenal fatigue.
-conted ganciclovir IV (will need a total of 2 weeks treatment)
-PICC line and discharge with OPAT follow up on ___. ID will
assess length of treatment based on CMV viral load.
-restarted ribavirin at low dose 200mg daily after stopping soon
after admission for anemia and evidence of hemolysis, a known
side effect of Ribavirin.
# Pancytopenia: Likely ___ CMV plus MMF in combination with
ribavirin causing anemia Fevers likely ___ CMV itself. Improved
on ganciclovir.
-contd to hold MMF
-monitored clinically
#Back Pain - Patient has complained of non-localizing back back
for several days. He can recount a specific day last week where
he pulled a muscle in his back after twisting while lifting a
heavy bag. He does experience some occasional pins and needles.
Abscess unlikely; presentation consistent with acute pinched
nerve.
- monitored for changes in physical exam--none.
# HCV/Sarcoid/EtOH Cirrhosis: Well-compensated of recent, though
has a history of decompensation with ascites, hepatic
encephalopathy. His last liver ultrasound from ___
did not show any focal liver lesion. Last endoscopy was done in
___ and showed grade 1 varices for which he is on
propranolol. Currently, MELD 8, ___ class B without
evidence of decompensation by hepatic encephalopathy, GI
bleeding, or SBP.
- Continued home lactulose and rifaximin
- Held beta-blocker in the setting of potential infection
- Held diuretics in the setting of potential
infection/hypovolemia
# HCV: Genotype 3. Currently on treatment with sofosbuvir and
ribavirin, the latter of which was decreased in dose given
anemia requiring transfusion. Will continue current treatment,
but discuss decreasing/changing given pancytopenia per above
- Continue HCV treatment with sofosbuvir 400mg daily; will
supply while he is inpatient.
- RESTARTING ribavirin at 200mg daily; started holding original
dose of 600 DAILY on ___. Went 3 days without Ribavirin.
# Sarcoid: Complicated by hypercalcemia, hepatic cholestasis,
lung involvement. Currently on immunosuppressive regimen of
prednisone, cellcept.
- Will continue to hold MMF (his pulmonologist agrees) in light
of suppressed bone marrow. Counts increasing.
- per pulm and rheum, can hold mmf indefinitely at this point,
as his Sarcoid is mild.
- Continue home prednisone 5mg daily, though he will temporarily
need a 10mg dose while he fights his CMV infection
- Continued home Bactrim infection ppx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Epoetin Alfa 40,000 unit/mL SC QWEEK
3. FoLIC Acid 3 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Lactulose 30 mL PO TID
7. Mycophenolate Mofetil 1000 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
10. PredniSONE 5 mg PO DAILY
11. Propranolol 30 mg PO TID
12. Ribavirin 400 mg PO QAM
13. Ribavirin 200 mf PO QPM
14. Rifaximin 550 mg PO BID
15. Sofosbuvir 400 mg PO DAILY16
16. Spironolactone 50 mg PO DAILY
17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
18. Ursodiol 300 mg PO BID
19. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
20. Ferrous Sulfate 325 mg PO TID
21. Senna 8.6 mg PO HS
Discharge Medications:
1. Epoetin Alfa 40,000 unit/mL SC QWEEK
2. Ferrous Sulfate 325 mg PO TID
3. FoLIC Acid 3 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
8. PredniSONE 10 mg PO DAILY
9. Ribavirin 200 mg PO DAILY
10. Senna 8.6 mg PO HS
11. Sofosbuvir 400 mg PO DAILY16
12. Spironolactone 50 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
14. Ursodiol 300 mg PO BID
15. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
16. Rifaximin 550 mg PO BID
17. Ganciclovir 470 mg IV Q12H
RX *ganciclovir sodium 500 mg 470 mg IV every 12 hours Disp #*30
Vial Refills:*0
18. Lactulose 30 mL PO TID
19. Outpatient Lab Work
Please check CBC with diff, chem 10, ___, PTT, INR, LFTs, CMV
viral load and fax result to Dr. ___ at ___
___. Fax ___
20. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Acute CMV infection with high load viremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted with fevers,
headaches, muscle aches and found to have a viral infection
called CMV. You were seen by our infectious disease team who
recommended IV Ganciclovir as treatment. You will continue IV
ganciclovir for at least two more weeks. You are scheduled to
follow up with infectious disease doctors on ___ for
further management. As part of your treatment, you should have
your labs checked on ___.
Followup Instructions:
___
|
19624082-DS-28
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DS
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2191-08-05 00:00:00
|
2191-08-05 21:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Tylenol
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ M with a history of ETOH, HCV, cirrhosis, C5-C7
ACDF, cholycystectomy, unlar decompression, and recurrent falls
complicated by recent ___ (___), who was admitted on ___ for
acute multifactorial encephalopathy (acute on chronic SDH,
hepatic encephalopathy, opioid and benzodiazepine
intoxication,ETOH withdrawal), acute renal failure, and
rhabdomyolysis. The ARF and rhabomyolysis resolved and his
encephalopathy was slowly improving, but he continued to have
poor insight into his illness. The primary team was looking for
a dual diagnosis rehab when he eloped from the hospital on the
morning of ___.
___ Security was unable to find the patient. A ___ was
completed and faxed to the BPD.
His mother found him in a bar in ___ and ___ him to
___ 2 where he was found to be acutely intoxicated and sent to
the ED.
In the ED, initial vitals were: 99.5 68 110/48 20 96% RA
- Labs were significant for
Urine Benzos POS
Urine Cocaine Pos
Urine Oxycodone Pos
Urine Barbs, Opiates, Amphet, Mthdne Negative
Serum EtOH 48
Serum Benzo POS
Serum ASA, Acetmnphn, Barb, Tricyc Negative
ALT: 91 AST 326 AP: 83 Tbili: 3.8 Alb: 4.5 Lip: 105
- Imaging revealed
-- CT head: Unchanged appearance of left frontoparietal
subdural hematoma without evidence
of interval hemorrhage since 3 days prior.
-- CT cspine: 1. No acute fracture or malalignment.
2. Superior endplate compression deformity of T1 as recently
described on prior CT scan.3. Partially visualized right pleural
effusion
- The patient was given
___ 18:43 PO Diazepam 10 mg ___
___ 21:15 PO Diazepam 10 mg ___
- Psych was consulted who felt he was 'disoriented,
inattentive, slurred speech, cannot provide any reliable or
coherent narrative of events, tremulous, appears lethargic and
irritable, +short term memory impairment (unable to identify
something he drew for me a few mins later) does not know why he
was here a few days ago, reports having 1 beer, but is
unreliable'. This was felt delirium ___ hepatic encephalopathy,
and he does not have capacity to leave AMA.
Vitals prior to transfer were: 70 110/48 19 98% RA
Upon arrival to the floor, he is requesting pain medication and
ambien. He does not remember or want to talk about what happened
earlier today
REVIEW OF SYSTEMS:
unable to obtain
Past Medical History:
- ETOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus. Portal Hypertensive Gastropathy
-Grade 1 internal hemorrhoids
-sarcoidosis with resultant hypercalcemia
-anxiety/depression
-hypertension
-ulnar neuropathy
-splenomegaly
-Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.2 111/58 67 16 98/RA
General: Alert, oriented x 3 but refusing to do months of the
year backwards. Tangential but generally answering questions
appropriately
HEENT: Sclera anicteric,dry mucous membranes. Bruising
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Claer anteriorly
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ edema
Neuro: not compliant with full exam. No asterixis
DISCHARGE EXAM:
Vitals: Tm98.2 BP126/60 HR82 18 96/RA
General: WDWN Male NAD, declining physical exam
HEENT: skin with mild jaundice, EOMI Look generally intact
Neuro: AandOx3 without overt tremor
EKG: Qtc 430 unchanged from previous
Pertinent Results:
ADMISSION LABS:
___ 05:34PM BLOOD WBC-4.3 RBC-3.30* Hgb-10.6* Hct-32.2*
MCV-98 MCH-32.1* MCHC-32.9 RDW-16.7* RDWSD-59.1* Plt Ct-86*
___ 05:34PM BLOOD Neuts-62.9 ___ Monos-9.3 Eos-2.6
Baso-0.7 Im ___ AbsNeut-2.71# AbsLymp-1.03* AbsMono-0.40
AbsEos-0.11 AbsBaso-0.03
___ 07:57AM BLOOD ___ PTT-33.4 ___
___ 03:45PM BLOOD Glucose-188* UreaN-13 Creat-1.1 Na-141
K-3.3 Cl-106 HCO3-22 AnGap-16
___ 05:34PM BLOOD ALT-91* AST-326* CK(CPK)-2124* AlkPhos-83
TotBili-3.8*
___ 03:45PM BLOOD CK(CPK)-4299*
___ 03:45PM BLOOD Calcium-10.5* Phos-2.1* Mg-1.3*
___ 05:34PM BLOOD ASA-NEG Ethanol-48* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 09:58PM BLOOD Lactate-2.0
DISCHARGE LABS:
___ 07:37AM BLOOD WBC-3.8* RBC-3.81* Hgb-12.2* Hct-36.2*
MCV-95 MCH-32.0 MCHC-33.7 RDW-16.6* RDWSD-57.4* Plt ___
___ 07:50AM BLOOD Glucose-90 UreaN-12 Creat-1.3* Na-135
K-3.8 Cl-102 HCO3-22 AnGap-15
___ 07:50AM BLOOD Calcium-11.0* Phos-2.8 Mg-1.2*
IMAGING/REPORTS:
___ HEAD CT:The left frontoparietal predominately iso to
hypoattenuating subdural hematoma is grossly unchanged. There
is no significant mass effect or new hyperattenuating components
to suggest interval hemorrhage. There is no mass, midline
shift, or acute major vascular territorial infarct. Gray-white
matter differentiation is preserved. Ventricles and sulci and
unremarkable. Basilar cisterns are patent.
Included paranasal sinuses and mastoids are clear. Skull and
extracranial soft tissues are unremarkable.
IMPRESSION:
Unchanged appearance of left frontoparietal subdural hematoma
without evidence of interval hemorrhage since 3 days prior.
CT C-SPINE:
Alignment is normal. No acute fractures are identified.
Anterior cervical
fixation hardware seen spanning C5 through C7. There is no
evidence of
lucency surrounding the hardware nor hardware fracture.
Compression of the superior endplate of T1 is again noted as
previously detailed. There is no prevertebral soft tissue
swelling.
Thyroid is unremarkable. There is partially visualized right
pleural
effusion.
IMPRESSION:
1. No acute fracture or malalignment.
2. Superior endplate compression deformity of T1 as recently
described on
prior CT scan.
3. Partially visualized right pleural effusion.
Brief Hospital Course:
Mr. ___ is a ___ M with ETOH and HCV cirrhosis, C5-C7
Anterior Cervical Discectomy and Fusion, cholycystectomy, unlar
decompression, and recurrent falls complicated by recent ___
(___), who presented from ___ office after an unwitnessed fall
and altered mental status found to have rhabdomyolysis and acute
kidney injury. He was treated as below until he eloped on
___ and was found by his mother at a bar and returned to
the emergency room at ___ at which time he was readmitted and
given a 24 hour sitter until a rehabilitation bed was found at
___.
# Toxic/metabolic encephalopathy: Due to ETOH withdrawal and
drug use (cocaine and benzodiazepines), hepatic encephalopathy
(patient was not taking lactulose at home), and chronic subdural
hematoma. Neurosurgery team was contacted and stated they did
not need to see him at that time secondary to stable imaging.
Lactulose
and rifaximin were prescribed while inpatient but patient
refused to take medication intermittently throughout his stay.
Ativan was prescribed for CIWA with patient scoring mostly for
anxiety, this was discontinued after acute alcohol withdrawal
danger had passed. Mental status improved with
lactulose/rifaximin and abstaining from benzos/opiates though
complex reasoning remains difficult.
# Resolving Rhabdomyolysis: Patient admitted after a fall with
CK 16K and renal injury (see below). S/p albumin and 2L NS in
ED. He was treated with LR at 250cc/hr though urine output was
not recorded due to patient declining measurement. By discharge
CK had decreased to 600s and patient was pain free.
# Acute Renal Failure: Cr elevated to 2.3 on admission. Most
likely ___ pigment injury from rhabdomyolysis but also a
pre-renal component from poor PO intake. Fluids were given as
above and nephrotoxins were avoided. Cr improved to 1.3 at
discharge.
# ETOH/Hep C Cirrhosis: MELD 22, ___ B
Lasix/spironolactone held for ___. Continued Propranolol 10 mg
PO/NG TID
#Poor nutrition c/b Hypokalemia/Hypo-phosphatemia: Patient with
K of 2.9 on admission up to 3.5 on discharge. Likely
nutritional. Nutrition was consulted and made recommendations
for supplements. Electrolytes were repleted as needed.
# Fall c/b head trauma and acute on chronic SDH: Patient unable
to explain
mechanism of fall. SDH stable on imaging. Fall likely related to
positive opioid and benzodiazepine screening on admission.
# Polysubstance abuse: Tox screen positive for opiates/benzos.
CIWA scale as above. Social work was consulted and worked with
patient and family closely to find dual diagnosis rehab bed as
above.
# Pain: Likely some from rhabdo and from ___ but also seems to
be
some narcotic seeking component. Oxycodone 5mg PRN Q4H was given
originally on admission but was discontinued after elopement.
Would avoid opiates as much as possible.
# Sarcoidosis. MMF held for ___ but restarted after resolution
of ___. Continued prednisone, Bactrim prophylaxis (due to MMF
use).
TRANSITIONAL ISSUES:
#Patient prescribed deleriogenic medications at home including
zolpiderm which should be discontinued.
#Patients GI doctor (___) confirmed that patient needs to
take lactulose TID and that it does not cause GI bleed contrary
to patient's belief.
#Patient has poor nutritional intake and should be encouraged to
see a nutritionist.
#Gabapentin 800 mg PO TID stopped secondary to concern for
contribution to delirium. Consider restarting if needed for
neurogenic pain control.
# CODE STATUS: Full
# CONTACT: Mother ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 4 mg PO DAILY
2. Lactulose 30 mL PO Q8H:PRN confusion
3. Gabapentin 800 mg PO TID
4. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
5. Propranolol 10 mg PO Q8H
6. Senna 8.6 mg PO QHS
7. Ursodiol 300 mg PO BID
8. Mycophenolate Mofetil 500 mg PO BID
9. Ferrous Sulfate 325 mg PO TID
10. Furosemide 10 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Omeprazole 40 mg PO BID
13. Rifaximin 550 mg PO BID
14. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
15. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Mycophenolate Mofetil 500 mg PO BID
5. Omeprazole 40 mg PO BID
6. PredniSONE 4 mg PO DAILY
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
10. Ursodiol 300 mg PO BID
11. Acetaminophen 1000 mg PO BID:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth BID PRN Disp #*60
Tablet Refills:*0
12. Magnesium Oxide 400 mg PO BID Duration: 1 Week
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
13. OLANZapine 5 mg PO QHS:PRN sleep
RX *olanzapine 5 mg 1 tablet(s) by mouth QHS PRN Disp #*14
Tablet Refills:*0
14. Potassium Chloride 20 mEq PO DAILY Duration: 1 Week
Hold for K >4
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
15. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Ferrous Sulfate 325 mg PO TID
17. Propranolol 10 mg PO Q8H
18. Haloperidol ___ mg PO Q4H:PRN agitation
RX *haloperidol 2 mg ___ tablet(s) by mouth TID PRN Disp #*60
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Acute encephalopathy (traumatic, hepatic, ETOH, cocaine,
opioid)
- Depression with suicidal ideation
Secondary:
- Traumatic acute on chronic SDH
- HCV s/p sofosbuvir and ribavirin w/ SVR
- HCV and ETOH cirrhosis with portal HTN and encephalopathy
- Recurrent GIB
- Pulmonary sarcoidosis c/b hypercalcemia on MMF and prednisone
- CMV viremia/pancytopenia secondary to immunosuppression
- Traumatic liver laceration and hemorrhagic shock ___
- Cervical spondylosis s/p C5-C7 ADCF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ after you went with your
mother to your primary care doctor to get medical clearance to
go to a rehabilitation center. Your PCP was concerned about your
oxygen level and your mentation. In the hospital, we found you
had rhabdomyolysis (muscle injury) from being on the ground for
a long time due to a fall while drinking. This also caused
injury to your kidney that improved with fluids. We encouraged
you to take your liver medications (lactulose, rifaxamin,
propranolol). Your mind cleared some but you left the hospital
to drink alcohol and use cocaine. You were re-admitted and all
medications that could cause mental confusion were stopped. We
kept you in the hospital because your confusion made it
difficult for you appreciate the consequences of not getting
treatment. We restarted the liver medications and your thinking
started to improve. You decided to seek rehabilitation so we
discharged you to ___. Take care and be well on your
journey to sobriety. Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19624082-DS-31
| 19,624,082 | 25,604,709 |
DS
| 31 |
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2192-10-29 21:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Haldol / heparin
Attending: ___
Chief Complaint:
chest tightness and dyspnea
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of ETOH and
HCV cirrhosis (s/p SVR) complicated by small varices /
splenomegaly / hepatopulmonary syndrome, sarcoidosis, anxiety /
depression, EtOH / substance abuse who presents with chest
pressure and dyspnea.
Over the last few days he has been more dyspnic, waited it out.
On the morning of presentation, he woke up feeling OK but then
had acute development of substernal pressure. He has chronic
hand numbness for which he has had several nerve release
surgeries, and is on gabapentin, however the left hand numbness
was worse associated with his chest pain. He also experienced
headache and nausea, with no vomiting.
His chest tightness is worse with deep breathing. He was
concerned about his blood pressure, but doesn't have a machine
at home so took one propranolol to see if it would help even
though he stopped taking it in ___ after his ___
appointment.
He reports he came off suboxone in early ___ because he
felt he was doing better from a substance abuse standpoint and
he had moved so he was 2 hours away from his psychiatrist.
However he is trying to get back on, but hasn't been able to
find a closer prescriber. He's had decreased energy since coming
off.
He denies a history of blood clots. He denies an MI or coronary
artery disease in the past. Denies sick contacts. No fevers, has
had chills. Has a dry cough for several days. No sputum.
Normally he can walk several blocks or more, currently be
believes he could walk <1 block, and he states he has not been
very mobile.
Initial vitals were 97.3 69 100/67 18 95% RA. Labs of note were
normal CBC, INR 1.2, Cr 2.3, T bili 2.9, albumin 3.3, trop
<0.01, BNP 346, ddimer 556, lactate 1.5.
Non con head CT showed no acute intracranial process.
Previously seen left frontal subdural hematoma has resolved in
the interval. No acute intracranial hemorrhage. CXR showed no
acute cardiopulmonary process. Consults placed were hepatology
who recommended admission to liver-kidney service. Patient was
given 50G IV albumin, 10mg metoclopramide IV. Transfer vitals
were 98.20 63 98/61 18 96% on 2L Nasal Cannula.
ROS:
(+) Bruising. Chills.
(-) Denies fever, night sweats, vision changes, rhinorrhea,
congestion, sore throat, abdominal pain, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- EtOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus; Portal Hypertensive Gastropathy.
- Grade 1 internal hemorrhoids
- Sarcoidosis with resultant hypercalcemia
- anxiety/depression
- hypertension
- ulnar neuropathy
- splenomegaly
- Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0 106/71 67 18 97 RA
Weight: 107.59 kg
GENERAL: Pleasant, well-appearing, in no acute distress. Arrived
on room air, saturation OK. Pt requested O2 for comfort.
HEENT: normocephalic, atraumatic. Nonicteric sclera
NECK: Supple, no LAD, no thyromegaly. Unable to assess JVP due
to habitus.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. Bedside US with no
ascites.
EXTREMITIES: Warm, well-perfused, no cyanosis, or clubbing.
Trace bilateral non-pitting edema.
SKIN: Without rash or track marks.
NEUROLOGIC: A&Ox3. Normal gait. Normal speech. No asterixis
DISCHARGE PHYSICAL EXAM
VS: T 98.4 BP 117/72 HR 79 RR 17 O2 94% on RA
Weight: 115.94kg (107.59 kg on admission)
I/O: ___
GENERAL: Obese Caucasian gentleman sitting up in bed,
nervous-appearing, in no acute distress
HEENT: normocephalic, atraumatic. Nonicteric sclera
NECK: Supple, no LAD.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Soft, endorses tenderness to palpation throughout all
four quadrants. Normoactive BS.
EXTREMITIES: Warm, well-perfused, no cyanosis, or clubbing.
Trace bilateral non-pitting edema.
NEUROLOGIC: A&Ox3. Normal speech. No asterixis
Pertinent Results:
ADMISSION LABS
==============
___ 01:58PM BLOOD WBC-9.4 RBC-4.48* Hgb-14.0 Hct-41.3
MCV-92 MCH-31.3 MCHC-33.9 RDW-15.6* RDWSD-52.5* Plt ___
___ 01:58PM BLOOD Neuts-69.3 Lymphs-17.4* Monos-10.2
Eos-1.8 Baso-0.8 Im ___ AbsNeut-6.53* AbsLymp-1.64
AbsMono-0.96* AbsEos-0.17 AbsBaso-0.08
___ 01:45PM BLOOD ___ PTT-30.7 ___
___ 03:45PM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 07:59PM BLOOD ___
___ 01:58PM BLOOD Glucose-85 UreaN-33* Creat-2.3* Na-135
K-4.2 Cl-98 HCO3-22 AnGap-19
___ 01:58PM BLOOD ALT-25 AST-66* AlkPhos-122 TotBili-2.9*
___ 01:58PM BLOOD proBNP-346*
___ 01:58PM BLOOD cTropnT-<0.01
___ 12:30AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:58PM BLOOD Albumin-3.3* Calcium-10.6* Phos-5.1*
Mg-1.8
___ 07:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8
___ 04:54PM BLOOD D-Dimer-556*
___ 02:04PM BLOOD Lactate-1.5
IMAGING
=======
CHEST (PA & LAT) ___
IMPRESSION:
No acute cardiopulmonary process
CT HEAD W/O CONTRAST ___
IMPRESSION:
No acute intracranial process. Previously seen left frontal
subdural hematoma has resolved in the interval. No acute
intracranial hemorrhage.
BILAT LOWER EXT VEINS ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
ABDOMEN US (COMPLETE ST) ___
IMPRESSION:
1. Liver cirrhosis with splenomegaly.
2. Patent main portal vein with reversed flow.
3. Bilateral renal cortices are echogenic, which may reflect
medical renal
disease. No hydronephrosis.
CT ABD & PELVIS W/O CON ___
IMPRESSION:
1. No evidence of swelling of the mons pubis. No cause for left
flank or
groin pain is identified. Specifically, no kidney or ureteral
stone.
2. Cirrhosis with evidence of portal hypertension.
3. Superior to the umbilicus there are multiple small fat
containing abdominal wall hernias, with mild stranding
SCROTAL U.S. ___
IMPRESSION:
Small left varicocele and left scrotal pearls. Otherwise,
unremarkable
scrotal ultrasound.
MICROBIOLOGY
============
___ 1:08 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:20 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:17 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
___ 6:35 am BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:55 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
==============
___ 03:42AM BLOOD WBC-4.2 RBC-3.09* Hgb-9.7* Hct-29.6*
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.3 RDWSD-53.6* Plt Ct-87*
___ 03:42AM BLOOD Plt Ct-87*
___ 03:42AM BLOOD ___ PTT-46.8* ___
___ 03:42AM BLOOD Glucose-129* UreaN-23* Creat-1.3* Na-135
K-3.7 Cl-95* HCO3-30 AnGap-14
___ 03:42AM BLOOD ALT-13 AST-30 AlkPhos-83 TotBili-1.5
___ 03:42AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ gentleman with history of ETOH and
HCV cirrhosis (s/p SVR) complicated by small varices /
splenomegaly / hepatopulmonary syndrome, sarcoidosis, anxiety /
depression, EtOH / substance abuse who presented with chest
pressure and dyspnea. Workup was notable for unremarkable EKG
and trop neg x3. His initial symptoms were felt to be due to
anxiety which improved with as needed Lorazepam. On admission,
the patient had acute kidney injury with Cr 2.3. Bladder
ultrasound was greater than 700 cc and he had a foley placed. He
was managed on Tamsulosin and Oxybutynin for urinary retention
and intermittent bladder spasms and his symptoms and Cr
improved. During this hospitalization, the patient's platelets
dropped to nadir of 67 (admission plts 150) concerning for
heparin-induced thrombocytopenia and thrombosis (HITT). His HIT
antibody was positive and he was started on bivalirudin gtt and
Coumadin. His serotonin release assay was borderline positive.
After discussion with Hematology, it was felt that the patient
did not truly have HITT (high false positive rates for HIT
antibody in cirrhosis population, only borderline positive
serotonin release assay) and all anticoagulants were
discontinued. The patient was volume overloaded during this
hospitalization and received IV Lasix with improvement. He was
discharged on half his outpatient diuretic regimen. Finally, the
patient had an EGD which revealed small varices. The patient was
started on Nadolol for variceal bleed prophylaxis at the time of
discharge.
# OBSTRUCTIVE UROPATHY/ACUTE KIDNEY INJURY: Improved after
placing foley catheter for urinary retention. Also improved
after getting albumin so may have had a pre-renal component as
well. Stable Cr at 1.3 prior to discharge, likely due to
overdiuresis so diuretic dose was decreased and he will follow
up to re-check Cr and titrate diuretic dose.
#Left flank/groin pain: CT negative for stones, other acute
pathology. Given repeated episodes of urinary retention,
otherwise normal prostate exam, rectal exam, thought secondary
to bladder spasm. Scrotal US with small varicocele on left.
Treated with oxybutynin, tamsulosin, gabapentin, cyclobenzaprine
and scrotal elevation. Patient was repeatedly seeking opiate
medications despite over-sedation and urinary retention and it
was felt that opiates are contra-indicated for his pain.
#Concern for HITT: During this hospitalization, the patient's
platelets dropped to nadir of 67 (admission plts 150) concerning
for heparin-induced thrombocytopenia and thrombosis (HITT). His
HITT antibody was positive and he was started on bivalirudin gtt
and Coumadin. His serotonin release assay was borderline
positive. After discussion with Hematology, it was felt that the
patient did not truly have HITT (high false positive rates for
HIT antibody in cirrhosis population, only borderline positive
serotonin release assay) and all anticoagulants were
discontinued.
# Volume overload: Patient with increased weight and ___ edema,
likely in the setting of holding home diuretics. He was
restarted on half home-dose diuretic regimen with follow up labs
as above.
# Chest pressure and dyspnea: Improved spontaneously during
admission.
Has family history of early CAD and has a chronic inflammatory
disorder but ruled out for ACS with 2 negative troponins and
unchanged EKGs. Consider stress testing given his risk factors,
although angina seems less likely than other diagnoses. Seems
more related to significant anxiety.
# Cirrhosis:
Secondary to hepatitis C virus infection, alcohol abuse, and
hepatic sarcoidosis. Complicated by esophageal varices (small),
hepatic encephalopathy (controlled on admit), ascites/volume
overload (no ascites on admit), and early hepatopulmonary
syndrome. RUQ US with patent portal vein with reversed flow and
no e/o ascites. He is no longer on propranolol since his
___ appointment due to cold extremities. Evidence of
decompensation with elevated bili above baseline, INR is at
baseline. Admit MELD-Na = 21. EGD with esophageal varices so
started nadolol prior to discharge. Otherwise continued home
Rifaximin and lactulose. Continued omeprazole, ursodiol.
#Sarcoidosis:
With pulmonary/bone involvement and hypercalcemia. On
immunosuppression. On Cellcept/prednisone since ___.
- continued Prednisone 4 mg daily
- continued MMF 500 mg BID
- held ppx Bactrim DS (___) in setting of ___, restarted prior
to discharge
# Substance abuse
Actively using EtOH, has had h/o polysubstance abuse in the
past. Desires resources to get back on suboxone after discharge.
Utox and Stox negative. Was repeatedly narcotic-seeking during
admission with poor insight and judgment. Continued home folic
acid.
#Fever: No clear infectious source. Treated empirically with IV
vancomycin/ceftazidime given immunosupressants but then
discontinued antibiotics as patient defervesced. Had no repeat
fevers and infectious workup was negative. DDx also included
sarcoid flare, medication side effect but had no repeat episodes
prior to discharge.
# Insomnia: Held zolpidem during admission and restarted on
discharge. Treated with trazodone while in-house.
#CMV prophylaxis:
High grade CMV viremia in ___ (100+k copies), on famciclovir
ppx since. Continued on discharge since non-formulary.
#Neuropathy:
Initially in arms only. recently starting to spread to feet.
Continued gabapentin.
# Depression / Anxiety: continued Escitalopram Oxalate 20 mg PO
DAILY
TRANSITIONAL ISSUES:
[]Discharge Weight: 115.9 kg
[]Discharge Diuretics: Torsemide 10 mg PO QDaily, Spironolactone
50 mg PO QDaily
[]Patient discharged on Nadolol 10 mg PO QDaily for variceal
bleed prophylaxis, plan for outpatient titration as tolerated
[]Patient discharged on Cyclobenzaprine 10 mg PO TID:PRN muscle
spasm pain, Oxybutynin 5 mg PO TID for bladder spasms, and
Tamsulosin 0.4 mg PO QHS for BPH/prevention of urinary retention
[]Recommend outpatient stress test
[]Patient will need Urology followup for urinary retention,
concern for BPH, and bladder spasms
[]Patient will need repeat Chem 7 on ___ with PCP
#CODE: Full (confirmed)
#CONTACT: Patient, emergency contact is his Mother ___
___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. famciclovir 250 mg oral DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 800 mg PO TID:PRN neuropathy symptoms
5. Lactulose 15 mL PO Q8H:PRN goal ___ BM/day
6. Mycophenolate Mofetil 500 mg PO BID
7. Omeprazole 20 mg PO BID
8. PredniSONE 4 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. Spironolactone 100 mg PO DAILY
11. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
12. Torsemide 20 mg PO DAILY
13. Ursodiol 300 mg PO BID
14. Zolpidem Tartrate 10 mg PO QHS
15. Ascorbic Acid ___ mg PO BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Senna 8.6 mg PO QHS:PRN constipation
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
2. Nadolol 10 mg PO DAILY
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Ascorbic Acid ___ mg PO BID
8. Escitalopram Oxalate 20 mg PO DAILY
9. famciclovir 250 mg oral DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 800 mg PO TID:PRN neuropathy symptoms
13. Lactulose 15 mL PO Q8H:PRN goal ___ BM/day
14. Mycophenolate Mofetil 500 mg PO BID
15. Omeprazole 20 mg PO BID
16. PredniSONE 4 mg PO DAILY
17. Rifaximin 550 mg PO BID
18. Senna 8.6 mg PO QHS:PRN constipation
19. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
20. Ursodiol 300 mg PO BID
21. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Urinary Obstruction
Bladder Spasms
Acute Kidney Injury
HCV/ETOH Cirrhosis
Esophageal Varices
SECONDARY
Sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Your were admitted with chest pain and shortness of breath. We
did tests which did not show any heart or lung problems. Your
kidney test was elevated likely because your were retaining
urine. We removed urine with a tube and gave you medications to
relax your bladder and urinary tract and your symptoms improved.
You were also volume overloaded and we gave you medications
called diuretics. Your platelet levels dropped and their was a
concern you had a condition called heparin-inducted
thrombocytopenia (HIT) and we initially treated you with blood
thinners. After discussion with the blood doctors, we felt you
did not have HIT and your blood thinners were discontinued.
Finally, we performed a procedure called an EGD to look at the
blood vessels of your GI tract and found small (called varices)
and we started a medication called nadolol. Please have your
labs rechecked when you followup with your primary care doctor.
Please take your medications as instructed. Please follow up
with your liver doctor, primary care physician, and other health
care providers.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19624082-DS-33
| 19,624,082 | 27,049,748 |
DS
| 33 |
2193-04-26 00:00:00
|
2193-05-02 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Haldol / heparin
Attending: ___
Chief Complaint:
Weight Gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a past medical history of
sarcoidosis, HCV s/p treatment, and cirrhosis c/b portal HTN,
hepatopulmonary syndrome, and 1 episode of ascites in ___ who
presented to the ___ ED for weight gain of 15 pounds and
edema.
Of note the patient was recently admitted for dyspnea, weight
gain and fluid overload from ___. He was diuresed and
was discharge 6L negative and on a diuretic regimen of Torsemide
10 mg QD and Spironolactone 200mg PO QD.
The patient spoke with his outpatient hepatologist (Dr. ___
today about his weight gain, and he recommended that he come
into
the ED. The patient reports a 15 pound weight gain over the 2
nights prior to admission. He states that he takes his daily
weights and has been keeping up with lactulose but seems to be
increasing in weight. His baseline is around 230-250 pounds and
on the day of admission was 290 on his scale. He has continued
to
take his regimen of Torsemide 10 mg daily and Spironolactone 200
mg daily as prescribed. He currently denies abdominal pain,
nausea, vomiting, fever, chills, chest pain, cough, and SOB.
Reports on lactulose so has loose stool at baseline.
Upon presentation to the ED the patient's vitals were
significant
for a T: 98.1, HR: 89, BP: 152/71, RR: 18, and O2 sat 94%. His
exam showed a RA incisional hernia is soft and full, can
compress
though not reducible. Labs were significant for a T. bili of
3.5,
an AST of 66, and plt count of 98. Reports Cr was up to 1.9, Cr
on admission was 1.3 (baseline 1.3-1.7). UA was negative. A CXR
was negative for any acute intrathoracic process and there was
no
evidence of pulmonary edema. Liver/ Gallbladder U/S was
unremarkable. He received IV Furosemide 40 mg and then IV
Morphine Sulfate 2 mg x2 doses. The case was discussed with the
hepatology fellow who recommended a medicine admission and TTE
as
an inpatient and further work up for volume overload as don't
believe due to HCV cirrhosis, although Hepatology will continue
to follow as inpatient.
Upon arrival to the floor, the patient reports that he is
feeling
overall well, but is still having severe lower extremity
neuropathic pain. He endorses pain and swelling as well as
dyspnea on exertion. He is hemodynamically stable, mentating
well, and in no acute distress. He denies abdominal pain except
for when he sits wrong and irritates his hernia. He denies chest
pain, palpitations, vision changes, confusion, diarrhea, melena
or hematochezia.
Past Medical History:
- EtOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus; Portal Hypertensive Gastropathy.
- Grade 1 internal hemorrhoids
- Sarcoidosis with resultant hypercalcemia
- anxiety/depression
- hypertension
- ulnar neuropathy
- splenomegaly
- Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
Admission Physical Exam
=======================
PHYSICAL EXAM:98.5, 120-150/60-80, 80-90s, RR 18, high ___ on RA
GEN: NAD. Sitting comfortably in bed.
HEENT: EOMI, PERRLA, Sclera anicteric. MMM.
CV: RRR with normal S1 and S2. No murmurs, rubs, or gallops.
RESP: CTAB without wheezes, rales or rhonchi
ABD: Soft, non-tender, non-distended. Normal bowel sounds. Large
incisional hernia to the right of the umbilicus.
EXT: Warm, 1+ nonpitting edema to the knee.
NEURO: A&Ox3. No asterixis.
Discharge Physical Exam
========================
Vitals: 97.6, BP 107/69, HR 78, RR 18, 92% RA
PHYSICAL EXAM:
GEN: NAD. walking around the hallway
HEENT: EOMI, PERRLA, Sclera anicteric. MMM.
CV: RRR with normal S1 and S2. No murmurs, rubs, or gallops.
RESP: CTAB without wheezes, rales or rhonchi
ABD: Soft, non-tender, obese abdomen, no fluid wave. Normal
bowel
sounds. Large incisional hernia to the right of the umbilicus,
not erythematous and reducible
EXT: Warm, 1+ nonpitting edema to the knee decreased from
yesterday.
NEURO: A&Ox3. No asterixis.
Pertinent Results:
Admission Lab
=============
___ 11:08AM BLOOD WBC-6.3 RBC-3.91* Hgb-12.9* Hct-36.7*
MCV-94 MCH-33.0* MCHC-35.1 RDW-16.4* RDWSD-55.7* Plt Ct-98*
___ 11:08AM BLOOD Neuts-71.1* Lymphs-12.1* Monos-12.7
Eos-2.5 Baso-0.8 Im ___ AbsNeut-4.47 AbsLymp-0.76*
AbsMono-0.80 AbsEos-0.16 AbsBaso-0.05
___ 11:08AM BLOOD Glucose-102* UreaN-16 Creat-1.3* Na-136
K-3.9 Cl-99 HCO3-20* AnGap-17*
___ 11:08AM BLOOD ALT-34 AST-66* AlkPhos-105 TotBili-3.5*
___ 11:08AM BLOOD Lipase-52
___ 07:26AM BLOOD proBNP-143*
___ 11:08AM BLOOD Albumin-3.9 Calcium-9.7 Phos-2.8 Mg-1.5*
Discharge Labs
===============
___ 06:47AM BLOOD WBC-6.3 RBC-3.97* Hgb-12.6* Hct-37.6*
MCV-95 MCH-31.7 MCHC-33.5 RDW-16.1* RDWSD-55.8* Plt ___
___ 06:47AM BLOOD Glucose-120* UreaN-25* Creat-1.4* Na-136
K-4.2 Cl-95* HCO3-27 AnGap-14
___ 06:47AM BLOOD ALT-32 AST-63* AlkPhos-99 TotBili-4.0*
___ 06:47AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.3 Mg-2.0
Micro
=====
-Urine culture (___): no growth
Imaging
=======
RUQ U/S (___): 1. Very limited evaluation of the main portal
vein. Antegrade flow is seen only in the region of the main
portal vein at the hepatic hilum. If there is clinical concern
for portal venous thrombosis, CT with contrast is recommended.
2. Stable septated cyst in the right hepatic lobe.
TTE ___ left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
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 estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen.
Wrist x-ray (___): A cast is in place, slightly obscuring
fine detail. Allowing for this, the left fifth metatarsal
fracture line remains visible, probably similar in alignment,
with some interval callus formation. As before, there is
flexion at the PIP joint of the small finger. Ossicle adjacent
to ulnar styloid again incidentally noted.
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical history of
sarcoidosis, HCV s/p treatment, and cirrhosis c/b portal HTN,
hepatopulmonary syndrome, and 1 episode of ascites in ___ who
presented to the ___ ED for weight gain of 15 pounds and
edema.
# Fluid Overload
# Weight Gain: Volume overload due to cirrhosis vs heart failure
vs nutrition. Patient endorses eating teriyaki steak tips prior
to coming into hospital. TTE was done and showed LVH but normal
systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen. He was diuresed
with repeated doses of IV Lasix 40mg with improvement in ___
edema. He was continued on home spironolactone throughout
admission. He was transitioned back to home dose of torsemide
(10mg) with close follow up with his hepatologist, Dr. ___.
Weight on discharge 125kg.
___ vs CKD: Cr elevated to 1.3 on admission, last normal Cr was
in ___ this year. Seems to range from 1.3-1.7 over this
year. Likely pre-renal from third spacing from volume overload
and possibly underlying chronic renal disease. Cr on discharge
was 1.4.
#Fifth Metacarpal Comminuted Fracture: Patient was seen by
orthopedic surgery who removed cast. A hand X-ray was done that
redemonstarted fracture and patients hand was re-cast. Plan to
follow up with Hand surgery as outpatient.
#Neuropathy: Throughout hospitalization patient complained of
pain in legs and feet with cramping and burning. Patient's home
gabapentin and tramadol were continued. He was also treated with
PRN oxycodone for pain. He will follow up with neurology as an
outpatient. He has a history of substance abuse so was not
discharged on oxycodone but was amenable to seeing pain
management as an outpatient to get symptoms under better
control.
# Cirrhosis:
Childs B, MELD 15 on admission. Secondary to hepatitis C virus
infection, alcohol abuse, and hepatic sarcoidosis. Complicated
by esophageal varices (small) and previous episodes of hepatic
encephalopathy (controlled on admit), ascites/volume overload in
___ (no ascites on admit), and early hepatopulmonary syndrome.
RUQ US with patent portal vein with reversed flow and no e/o
ascites. Not on propanolol due to previously cold extremities
d/c'ed in ___, had previously been prescribed nadolol, but
not currently on home medication list. No signs of active
bleeding or HE on exam. He was continued on home lactulose,
rifaxamin, omeprazole, urosdiol, and spironolactone. In
addition, nadolol 10mg was started for EV prophylaxis. This can
be titrated up per hepatology as outpatient.
#Sarcoidosis:
With pulmonary/bone involvement and hypercalcemia. On
Cellcept/prednisone since ___. Patient was continued on home
prednisone, cellcept, Ca/Vit D, and Bactrim DS (MWF).
#CMV prophylaxis: Has history of high grade CMV viremia in ___
(100+k copies). Continued home famciclovir.
# Insomnia: Continued home zolpidem.
Transitional Issues
====================
[] follow up with ortho for hand fracture
[] follow up with pain management
[] follow up with neurology for neuropathy
[] Consider starting on amitriptyline for neuropathic pain
[] Uptitration of nadolol as tolerated
[] Weight on discharge 125kg.
#Code status: Full
#Contact: ___
___: mother
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. famciclovir 250 mg oral DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 800 mg PO TID:PRN neuropathy symptoms
4. Lactulose 30 mL PO Q8H:PRN goal ___ BM/day
5. Magnesium Oxide 400 mg PO BID
6. Mycophenolate Mofetil 500 mg PO BID
7. Omeprazole 40 mg PO BID
8. PredniSONE 5 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. Ursodiol 300 mg PO BID
12. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
13. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
once daily, 4 hours apart from ursodiol and mycophenolate
14. Spironolactone 200 mg PO DAILY
15. Torsemide 10 mg PO DAILY
16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Medications:
1. Nadolol 10 mg PO DAILY
2. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
once daily, 4 hours apart from ursodiol and mycophenolate
3. famciclovir 250 mg oral DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 800 mg PO TID:PRN neuropathy symptoms
6. Lactulose 30 mL PO Q8H:PRN goal ___ BM/day
7. Magnesium Oxide 400 mg PO BID
8. Mycophenolate Mofetil 500 mg PO BID
9. Omeprazole 40 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. Spironolactone 200 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
14. Torsemide 10 mg PO DAILY
15. TraMADol 50 mg PO BID:PRN Pain - Moderate
16. Ursodiol 300 mg PO BID
17. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Volume Overload
Secondary Diagnosis
Cirrhosis
___ metacarpal fracture
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___
___ was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had weight gain
and leg swelling.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
You were given medication to remove the extra fluid on your legs
and abdomen.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with you Hepatologist Dr. ___
___ wish you the ___!
Your ___ Care Team
Followup Instructions:
___
|
19624129-DS-3
| 19,624,129 | 24,872,928 |
DS
| 3 |
2149-11-01 00:00:00
|
2149-11-01 13:34:00
|
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 leg and elbow pain
Major Surgical or Invasive Procedure:
___ (___): ex-fix, vascular repair, fasciotomy &
VAC
___ (___): ORIF L tib plateau
___ (___): L medial gastroc & STSG, VAC lateral wound
___ ___): Extensor mechanism repair,
fasciotomy closure, L radial head replacement
History of Present Illness:
___ who presents as a trauma evaluation after a fall off a room.
Fell approximately 15 feet. Main complaint is significant knee
pain. Denies LOC and reports remembering the whole incident. Per
ED the patient was having some difficulty recalling. Denies any
HA, neck pain, CP, SOB, abdominal pain, nausea, vomiting,
diarrhea. Complains of significant knee and lower leg pain. Able
to wiggle his toes and can feel light touch on his foot. Has
large open wound on his left calf.
Past Medical History:
None
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: Afebrile, stable
Gen: NAD, calm & comfortable
LUE:
In orthoplast splint
Sensation intact to light touch in axillary, radial, median &
ulnar nerve distributions
Motor intact for EPL, FPL, DIO
Radial pulse palpable, fingers warm & well perfused, brisk
capillary refill in all digits
LLE:
Incision VAC holding suction at -75mmHg
Ex fix in place
Sensation intact to light touch in saphenous, sural, deep
peroneal & superficial peroneal distributions
Motor intact for ___, FHL, GSC, TA
Dorsalis pedis palpable, toes warm & well perfused
Pertinent Results:
___ 06:30AM BLOOD WBC-6.1 RBC-2.80* Hgb-8.3* Hct-25.5*
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.0 RDWSD-46.7* Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery and acute care surgery
teams. The patient was found to have a left open tibial plateau
fracture with a pulseless left foot. ___ pulse initially returned
following fracture reduction but was then lost again and the
patient was taken emergently to the operating room for external
fixation of his tibial plateau fracture and open repair of a
popliteal artery injury using a saphenous vein graft, as well as
prophylactic four-compartment fasciotomy. He was admitted to the
orthopedic surgery service. On HD3 he returned to the OR for
ORIF of his tibial plateau fracture and medial gastrocnemius
flap coverage of the open injury, as well as partial closure of
the lateral fasciotomy site. He returned again on HD 6 for ORIF
of his tibial tubercle avulsion/extensor mechanism injury,
closure of fasciotomy sites, and left radial head arthroplasty.
For full details of these procedures please see the separately
dictated operative reports. On each occasion, the patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. His external fixator was left on throughout his hospital
course to stabilize his soft tissue and bony repairs. His pain
was initially managed with a morphine PCA, which was
transitioned to a PO pain regimen. To replace blood lost from
his injuries and surgeries, he received 1u PRBCs on HD1, 1u on
HD2, 2u on HD3, and 1u on HD6. The patient was given ___
and ___ antibiotics and anticoagulation per routine,
including both aspirin and Lovenox given his vascular repair.
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 and incisions were clean/dry/intact. The
patient is non-weight bearing in the left upper and lower
extremities, and will be discharged on Lovenox for DVT
prophylaxis and aspirin to prevent clotting of his vascular
repair. The patient will follow up with Drs. ___,
___, and ___. 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. He will remain in his
external fixator for four weeks to optimize healing of his left
lower extremity injuries. The patient was also given written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient expressed readiness for
discharge.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
5. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
6. Gabapentin 300 mg PO TID:PRN pain
7. LORazepam 0.5 mg PO QHS:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth qhs prn Disp
#*20 Tablet Refills:*0
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
10. Nicotine Patch 14 mg TD DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h prn Disp #*84
Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY constipation
13. Senna 8.6 mg PO BID constipation
14. TraZODone 25 mg PO QHS:PRN anxiety, insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L open Grade IIIC tibial plateau fracture with popliteal artery
injury
L tibial tubercle avulsion with complete extensor mechanism
disruption
L radial head fracture, comminuted
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.
- Please follow your weight bearing precautions strictly at all
times.
- You will remain in your external fixator for four weeks to
allow your injuries to begin to heal
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
- NWB LUE in posterior slab splint, ok for ROMAT
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 and aspirin 81mg daily
WOUND CARE:
- 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
Physical Therapy:
- NWB LLE
- NWB LUE in posterior slab splint, ok for ROMAT
Treatments Frequency:
VAC to 75mmHg suction
LUE dressing changes PRN (dry sterile dressings)
Elevate LLE. Continues in extension ws Ex fix in place
Plastic Surgery Instructions for outpatient dressing:
Please change every other day
Please wash the leg including wounds with soap and water
Please apply xeroform to the skin grafted areas, no xeroform on
incision sites
For drain sites, use betadine to clean and cover with dry gauze
For exfix pin sites, dress with dry gauze
wrap leg in kerlix and ace - not too tight
Follow up with Dr. ___ week after DC
Followup Instructions:
___
|
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