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19624162-DS-21
| 19,624,162 | 24,767,947 |
DS
| 21 |
2169-10-15 00:00:00
|
2169-10-16 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with congenital aorta-right atrium
fistula status post repair and revision in ___ and ___ and
left sinus of Valsalva and left main coronary artery aneurysm
status post aneurysm repair and CABG x2 (LIMA-LAD and left
radial artery-OM) in ___ who presents with chest pressure. He
reports that he was in his usual state of health until the day
prior to admission, when he began to experience low-intensity
chest discomfort independent of activity involving his
subclavicular region bilaterally radiating to his neck without
clear precipitant. Low-intensity discomfort persisted until
approximately 2pm on the day of admission, when he developed
chest "pressure" and "burning" in the same region, up to ___
in intensity and occurring ___ hours after a large steak-meal,
prompting him to seek medical attention. He also notes a
sensation of focal "stretching" without frank pain at the left
upper sternal border. He denies associated fevers/chills/sweats,
diaphoresis, shortness of breath, pleuritic chest pain,
nausea/vomiting, abdominal pain, peripheral edema, or
PND/orthopnea and endorses exercise tolerance of at least many
blocks. He does not describe frank palpitations, but indicates
that he always can feel his heart beating in his chest.
Of note, he experienced similar symptoms for ___ days in early
___, at which time he contacted his outpatient cardiologist
Dr. ___ was started on metoprolol succinate 25mg daily. He
recalls taking this medication briefly, but self-discontinued,
noting minimal benefit, not wishing to become reliant on
medication, and speculating that his symptoms were perhaps
related to ongoing stressors. He was last admitted in ___ for
chest pressure occurring intermittently over a period of months.
Cardiac catheterization at that time demonstrated an irregular
(?beaded-appearing) lesion in the distal LCx and ?filling defect
causing separation of flow. Ultimately, his chest pain was felt
to be atypical in nature, not clearly related to coronary
lesions, but possibly related to ectopy, gastroenterologic
etiology, or ongoing stressors. Cardvedilol and isosorbide
mononitrate were initiated at that time, but he did not tolerate
isosorbide due to headaches.
In the ED, initial vital signs were as follows: 97.7 95 127/69
16 96% RA. Admission labs were notable for TnT <0.01 x1, and CXR
was negative for interval change. He received ibuprofen 600mg
only, having received aspirin 325mg and sublingual nitroglycerin
x3 from EMS. Vital signs at transfer were as follows: 98.0 81
127/74 18 100% RA.
On arrival to the floor, he reports essentially complete
resolution of chest discomfort. He is unable to comment on the
effect of sublingual nitroglycerin, wondering if chest
discomfort subsided on its own.
Past Medical History:
1. Aorta-right atrium fistula s/p repair and redo repair in ___
and ___
2. Left sinus of Valsalva and left main coronary artery aneurysm
s/p aneurysm repair and CABG x2 (LIMA-LAD and left radial
artery-OM) on ___
Social History:
___
Family History:
His mother is alive and well. His father died at ___ years old
of lymphoma. He is divorced and has 3 healthy children in
___.
Physical Exam:
On admission:
VS: 98.7, 117/94, 63, 16, 100% RA
General: Well-appearing in NAD
Neck: No JVD
CV: Hyperdynamic precordium, split S2
Lungs: CTAB
Abdomen: +BS, soft, NT/ND
Ext: WWP, no c/c/e
At discharge:
VS: 97.8, 114/70, 57, 18, 100% RA
General: Well-appearing in NAD
Neck: No JVD
CV: Hyperdynamic precordium, split S2
Lungs: CTAB
Abdomen: +BS, soft, NT/ND
Ext: WWP, no c/c/e
Pertinent Results:
On admission:
___ 04:35PM BLOOD WBC-8.6 RBC-4.94 Hgb-15.3 Hct-44.5 MCV-90
MCH-30.9 MCHC-34.3 RDW-13.3 Plt ___
___ 04:35PM BLOOD Neuts-55.9 ___ Monos-6.5 Eos-2.0
Baso-1.1
___ 05:42PM BLOOD ___ PTT-29.8 ___
___ 04:35PM BLOOD Glucose-88 UreaN-13 Creat-1.1 Na-139
K-4.5 Cl-102 HCO3-25 AnGap-17
___ 11:38PM BLOOD CK(CPK)-268
___ 04:35PM BLOOD cTropnT-<0.01
In the interim:
___ 11:38PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:25AM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:55PM BLOOD D-Dimer-347
At discharge:
___ 07:20AM BLOOD WBC-7.6 RBC-5.31 Hgb-16.6 Hct-48.4 MCV-91
MCH-31.2 MCHC-34.2 RDW-13.3 Plt ___
___ 07:20AM BLOOD Glucose-97 UreaN-16 Creat-1.2 Na-136
K-4.7 Cl-99 HCO3-30 AnGap-12
___ 07:20AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.3
Studies:
ECG (___):
Normal sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___
there is no significant change.
IntervalsAxes
___
___
CXR PA/lateral (___):
No significant interval change.
TTE (___):
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal. Quantitative (3D) LVEF = 62%. There is no left
ventricular outflow obstruction at rest or with Valsalva. The
aortic root is mildly dilated, with asymmetric enlargement of
the left sinus of Valsalva. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild, asymmetric enlargement of the left sinus of
Valsalva. Mild functional aortic regurgitation. Normal global
and regional biventricular systolic function.
Exercise MIBI (___):
1. Normal myocardial perfusion.
2. Increased left ventricular cavity size. Moderate systolic
dysfunction with global hypokinesis.
Brief Hospital Course:
Mr. ___ is a ___ with congenital aorta-right atrium
fistula status post repair and revision in ___ and ___ and
left sinus of Valsalva and left main coronary artery aneurysm
status post aneurysm repair and CABG x2 (LIMA-LAD and left
radial artery-OM) in ___ who presented with chest pressure.
Active Issues:
(1)Chest pressure: In the setting of chest pressure with known
complex coronary anatomy, acute coronary syndrome was excluded
on the basis of negative serial cardiac enzymes and EKGs without
acute ischemic changes. TTE was unchanged from prior, and
exercise MIBI demonstrated normal myocardial perfusion. Clinical
suspicion for pulmonary embolism was low in the absence of
shortness of breath, pleuritic chest pain, tachycardia, hypoxia,
EKG evidence of right heart strain, or risk factors for
thromboembolic event, and D dimer was negative. Home aspirin was
continued for cardioprotection and metoprolol succinate resumed
due to possible contribution from ectopy. Given seeming
exacerbation of symptoms following large meals, omeprazole was
trialed due to possible contribution from gastroesophageal
reflux.
Transitional Issues:
* Titration of metoprolol to heart rate is advised.
* Omeprazole may discontinued if ineffective.
* Pending studies: None.
* Code status: Full.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet extended
release 24 hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your admission to ___
___. As you know, you were admitted for
chest pain. Blood tests showed no evidence of heart attack, and
an ultrasound of your heart (echocardiogram) showed no new
structural abnormalities. A stress test of your heart
demonstrated no evidence of new damage.
Please see the attached sheet for specific medication changes.
Followup Instructions:
___
|
19624162-DS-23
| 19,624,162 | 22,690,450 |
DS
| 23 |
2175-12-14 00:00:00
|
2175-12-14 17:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure, dyspnea and pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male s/p Aortic root
aneurysm, aortic insufficiency, status post right atrial fistula
repair, and resection of left main aneurysm s/p Bentall and CABG
with complicated post op course with Anemia acute blood loss
Transaminitis Dysphagia tonic-clonic seizure post-op bilateral
watershed infarcts dysphonia with vocal cord paralysis
Ventilator
Associated pneumonia Hypercoagulable Acute respiratory failure
and deconditioned. He had made significant improvement after
long ICU course transitioned to post operative floor for
multiple
days and was discharged home ___. Since getting home he felt
well last night but had difficulty sleeping overnight and took
tylenol at 4 am for sternal discomfort. This am he was still
having discomfort but no further pain medications. He was
tolerating diet and verbalizing drinking fluids however noted
dizziness that was intermittent when standing or sitting.
States
that vision is unchanged from discharge. This afternoon he
became short of breath and came into emergency room for
evaluation. In emergency room he is tachypenic with respiratory
rate 30 but oxygen saturation 96% on room air, heart rate 104
sinus tachycardia with blood pressure 120/68. Notes chest pain
at
sternal incision that increases with palpation. Remains
hypophonic but able to complete sentences.
Past Medical History:
1. Aorta-right atrium fistula s/p repair and redo repair in ___
and ___
2. Left sinus of Valsalva and left main coronary artery aneurysm
s/p aneurysm repair and CABG x2 (LIMA-LAD and left radial
artery-OM) on ___
- Congenital Heart Disease
- Aortic Insufficiency
- Aortic root aneurysm
- History of Pulmonary Embolus(following first heart operation
in
___
- Hypertension
- Coronary Artery Disease
Social History:
___
Family History:
His mother is alive and well. His father died at ___ years old
of lymphoma. He is divorced and has 3 healthy children in
___.
Physical Exam:
Admission:
98.8 - 120/65- 106 ST -30- 98% RA
General: dyspenic
Skin: Dry intact well healed sternotomy, hypertrophic
scar tissue note
Neck: Supple Full ROM No JVD
Chest: Lungs clear except rales at left base decreased at right
base
Heart: RRR no murmur or rub
Abd: Soft non-distended non-tender bowel sounds +
Extremities: Warm well-perfused
Incisions Right groin incision healing
Left radial harvest incision well healed
Sternal incision healing no erythema or drainage
Right leg incision healing no erythema or drainage
Edema: None
Neuro: Alert and oriented x3 non focal deconditioned hypophonic
Pulses:
Femoral Right: P Left: P
DP Right: P Left: P
___ Right: P Left: P
Radial Right: P Left: absent
Ulnar Right: P Left: P
.
Discharge:
97.8
PO 100 / 63
R Sitting 78 18 96 Ra
.
General: NAD [x] Ambulating in hallways
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL []
Cardiovascular: RRR [x] mechanical heart valve sounds
Respiratory: CTA [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] No Edema
Left Upper extremity Warm [x] No Edema
Right Lower extremity Warm [x] No Edema
Left Lower extremity Warm [x] No Edema
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x]
Pertinent Results:
___ Chest CT
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval increase in size of circumferential ascending aortic
perigraft
fluid which demonstrates minimal complexity. No active
extravasation or rim
enhancement. Please note that superimposed infection cannot be
excluded on
the basis of this examination and clinical correlation is
needed.
3. Interval improvement in left lower lobe and right upper lobe
opacities
suggestive of improving infection.
4. Small volume, non organized fluid and fat stranding within
the
retroperitoneum which may reflect post endovascular procedural
changes.
Differential consideration includes acute pancreatitis and
correlation with
serum amylase and lipase levels suggested. No retroperitoneal
hematoma.
5. Interval decrease in size of left superior mediastinal
hematoma.
6. Interval decrease in size of a small fluid collection along
the superior
aspect of the sternum which now measures up to 1.4 cm.
7. Trace left pleural effusion.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___ electronically signed on ___ ___ 9:48
___
Imaging Lab
.
Echo ___
CONCLUSION:
The left atrium is normal in size. The right atrial pressure
could not be estimated. There is normal left
ventricular wall thickness with a normal cavity size. There is a
small area of regional left ventricular
systolic dysfunction with hypokinesis of the basal inferoseptum
(see schematic) and preserved/normal
contractility of the remaining segments. Quantitative 3D
volumetric left ventricular ejection fraction
is 54 % (normal 54-73%). Left ventricular cardiac index is low
normal (2.0-2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Transmitral and tissue
Doppler suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP less
than 12 mmHg). Normal right ventricular cavity size with mild
global free wall hypokinesis. Tricuspid
annular plane systolic excursion (TAPSE) is depressed. There is
post-thoracotomy interventricular septal
motion. The aortic sinus diameter is normal for gender with a
normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. There is a normal
diameter ascending aorta tube graft. A bileaflet mechanical
aortic valve prosthesis is present. The
prosthesis is well seated with normal gradient. The effective
orifice area index is normal (>=0.85 cm2/
m2). There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal. There is trivial
mitral regurgitation. Due to acoustic shadowing, the severity of
mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are normal. There is
mild pulmonic regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial pericardial effusion. A left
pleural effusion is present.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction most
consistent with single vessel coronary artery disease. Trivial
pericardial effusion. Well-seated
mechanical aortic valve and ascending aorta graft.
.
___ 06:30AM BLOOD WBC-8.8 RBC-3.10* Hgb-9.1* Hct-29.6*
MCV-96 MCH-29.4 MCHC-30.7* RDW-16.1* RDWSD-55.4* Plt ___
___ 12:45PM BLOOD ___
___ 05:50AM BLOOD ___ PTT-32.4 ___
___ 06:30AM BLOOD ___ PTT-104.5* ___
___ 04:25PM BLOOD ___
___ 09:02AM BLOOD ___
___ 05:20AM BLOOD ___
___ 06:30AM BLOOD ___ PTT-42.5* ___
___ 03:56AM BLOOD ___
___ 06:30AM BLOOD ALT-69* AST-27 LD(LDH)-361* AlkPhos-148*
Amylase-78 TotBili-0.4
___ 06:30AM BLOOD Mg-2.4
___ 06:30AM BLOOD Albumin-3.5 Calcium-9.4 Phos-5.1* Mg-2.2
Brief Hospital Course:
The patient was admitted for further management of pain and
dyspnea. Chest CT evaluated by Dr. ___ revealed
expected post-op changes. Echo revealed well seated mechanical
valve and aortic graft with trivial pericardial effusion. INR
became supratherapeutic over 5. Coumadin held and he trended to
therapeutic range. Goal INR is 2.5-3.5 for mechanical aortic
valve and h/o stroke and PE. Pain managed with low dose
oxycodone. Constipation successfully managed with bowel regimen.
INR stabilized. The patient was discharged home on hospital day
6. He will follow-up with ENT for hypophonia next week.
Cardiac Surgery will manage anti-coagulation until further
arrangements made. Will attempt to set up with ___
clinic through Dr. ___ patient's preference.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg NG DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. LevETIRAcetam 1500 mg PO BID
7. Lidocaine 5% Patch 2 PTCH TD QAM to back
8. Metoprolol Succinate XL 150 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. Warfarin ___ mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Ramelteon 8 mg PO QPM:PRN insomnia
RX *ramelteon 8 mg 1 tablet(s) by mouth qpm Disp #*20 Tablet
Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 ml by mouth twice a day Disp #*20 Tablet
Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg NG DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. LevETIRAcetam 1500 mg PO BID
11. Lidocaine 5% Patch 2 PTCH TD QAM to back
12. Metoprolol Succinate XL 150 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. Warfarin ___ mg PO DAILY
RX *warfarin 5 mg ___ tablet(s) by mouth daily as directed Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
coagulopathy
Secondary Diagnosis
Congenital Heart Disease
Hypertension
Coronary Artery Disease
Aortic root aneurysm, aortic insufficiency, status post right
atrial fistula repair, and resection of left main aneurysm s/p
Bentall and CABG
Dysphagia
tonic-clonic seizure post-op
bilateral watershed infarcts
dysphonia with vocal cord paralysis
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19624219-DS-9
| 19,624,219 | 23,871,904 |
DS
| 9 |
2119-07-27 00:00:00
|
2119-07-27 16:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Roxicet / Cipro
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
lap band and port removal
History of Present Illness:
___ year old female s/p lap band at OSH in ___, now
presenting with right-sided abdominal pain radiating to her
right
groin. The pain started suddenly yesterday morning. The
intensity
waxes and wanes, but is ___ at it's most severe. She reports
the
pain is worsened by movement, and feels similar to previous
attributed to her lap band. She states that her pain has never
radiated to her groin like this before, nor has it ever been
this
severe. She endorses occasional nausea and several episodes of
emesis yesterday and today. She has been able to retain most of
her oral intake. She denies fever, chills, dysuria, chest pain,
shortness of breath, changes in pain with eating, diarrhea or
constipation.
Past Medical History:
PMH:
HTN
migraines
heme?
All:
Cipro, roc
taken simultaneously, rash
PSH:
Lap band ___
relap ___
deflated ___
carpal tunnel
sinus surg x 2
Social History:
___
Family History:
Father has heart disease and DM
Physical Exam:
VS: 98.4 117/66 79 20 95RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, EOMI
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, diffuse tenderness, incision sites are c/d/i
covered with steri-strips
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
___ 11:50AM BLOOD WBC-13.3* RBC-4.78 Hgb-13.8 Hct-41.5
MCV-87 MCH-28.9 MCHC-33.3 RDW-12.7 RDWSD-40.0 Plt ___
___ 11:50AM BLOOD Neuts-70.4 ___ Monos-4.3* Eos-3.1
Baso-0.3 Im ___ AbsNeut-9.34* AbsLymp-2.85 AbsMono-0.57
AbsEos-0.41 AbsBaso-0.04
___ 11:50AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-139 K-4.0
Cl-105 HCO3-22 AnGap-16
___ 11:50AM BLOOD ALT-27 AST-20 AlkPhos-105 TotBili-0.6
___ 11:50AM BLOOD Albumin-4.5 Calcium-8.9 Phos-3.2 Mg-1.9
DISCHARGE LABS:
___ 06:23AM BLOOD WBC-14.8*# RBC-4.36 Hgb-12.6 Hct-38.3
MCV-88 MCH-28.9 MCHC-32.9 RDW-12.6 RDWSD-40.0 Plt ___
___ 07:51AM BLOOD Glucose-98 Creat-0.6 Na-138 K-3.7 Cl-102
HCO3-26 AnGap-14
___ 07:51AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
IMAGING:
___ CTU Abd/pelvis
1. Discontinuous/ fragmented gastric lap band catheter.
2. No secondary signs of appendicitis.
3. 2 mm nonobstructing renal stone on the right. No
hydronephrosis.
Brief Hospital Course:
The patient presented to the ED with abdominal pain and was
found to have a fragmented lap band tubing. She was admitted for
observation and pain management. Decision was made to remove the
lap band, port and catheter. She arrived to pre-op on ___.
Pt was evaluated by anaesthesia.
The patient was taken to the operating room for a laparoscopic
removal of the lap band and port. There were no adverse events
in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid.
Pain was very well controlled. The patient was then transitioned
to oral pain medication once tolerating a stage 3 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. The patient was
slowly advanced to stage 4 bariatric diet which the patient was
tolerating on day of discharge. Of note, patient was found to
have a 2mm kidney stone in her right kidney. Patient was told of
findings and encouraged to stay hydrated and to follow-up with
her PCP.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
bariatric stage 3 diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Meclizine 12.5 mg PO Frequency is Unknown
3. Amlodipine 10 mg PO DAILY
4. levonorgestrel 20 mcg/24 hr ___ years) injection ___ years
5. Naproxen 500 mg PO Q8H:PRN pain
6. Fluticasone Propionate NASAL 2 SPRY NU BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation X2
PRN wheezing
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
3. Amlodipine 10 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. levonorgestrel 20 mcg/24 hr ___ years) injection ___ years
7. Meclizine 12.5 mg PO Q6H:PRN dizziness
8. Naproxen 500 mg PO Q8H:PRN pain
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation X2
PRN wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Fractured lap band tubing
status post lap band and port removal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet: Regular
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
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:
___
|
19624253-DS-2
| 19,624,253 | 26,735,989 |
DS
| 2 |
2161-12-14 00:00:00
|
2161-12-15 08:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
headache, diplopia
Major Surgical or Invasive Procedure:
none (LP ___, on the day prior to admission)
History of Present Illness:
___ is a ___ year-old woman history of remote breast
CA who presents with headache x 5 days, nstagmus x 1 day,
staggering around house x 1 day, permanent double vision x 1
day. Of note, patient presented to the ED yesterday with rash on
arms/legs x 4 days, with generalized malaise, fever to 100.5,
constant HA with out neck pain and was discharge with
doxycycline for lyme meningitis.
Ms. ___ first became symptomatic 5 days prior to admission
with bilateral lower extremity rash. She presented to urgent
care and was given claritin.
4 days prior to admission, patient developed extreme fatigue.
She was unable to go to work because of her symptoms and saw her
PCP, who recommended "watchful waiting."
2 days prior to admission, patient woke up at 6AM with the worst
HA of her life. She describes the HA as occipital pain that
radiated forward, as if there were a "band" around her neck.
Headache was not positional, and only partially relieved with
tylenol. She also reports a fever on that day to ___.
Patient was seen in the ED on ___. In the ED, an LP was
performed that showed 4 WBC 146 RBC prot 41. The patient was
treated conservatively with Tylenol, zofran, and meclizine and
discharged home with doxycycline for presumed lyme meningitis.
However, the night prior to admission, patient started to have
severe neck stiffness, hurt when sitting up post-LP. She awoke
at 6 AM the morning of admission with worsening headache,
dizziness, and "quivering" horizontal eye movements that lasted
2 minutes. She laid down, and the movements subsided. However,
she had another similar episode when she sat back up. She
continued to feel dizziness, which she described as
lightheadedness. Patient also endorsed blurry vision throughout
visual field. Her horizontal diplopia persisted.
Of note, patient went on a trip to a ___ in ___
___ in ___. She did not recall any tick bites. Denies
any recent illness, including URI, and also denies any sick
contacts. No new medications.
In the ED initial vitals were: T 99.7 HR 100 BP 152/100 RR 17
98% RA.
- Labs were significant for AST 44. chemistry and CBC wnl.
Lactate 0.5. Gram stain of CSf was negative. Lyme titer is
still pending. Herpes Simplex Virus PCR, Borrelia burgdorferi
Antibody Index for CNS Infection, Varicella-Zoster Virus DNA,
PCR still pending.
- Patient was given Acyclovir 600 mg, ceftriaxone 2g IV (x 1),
and 1 L NS as well as tylenol for fever.
Vitals prior to transfer were: T 101 HR 119 BP 147/103 RR 18 98%
RA.
On the floor, patient continues to have double vision and
headache, but says overall she feels a little better.
Review of Systems:
(+) per HPI
(-) rhinorrhea, congestion, sore throat, cough, shortness of
breath, chest pain, abdominal pain, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
remote history of breast CA
insomnia
adjustment disorder
cervical radiculopathy
Social History:
___
Family History:
Non-contributory. Father died of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99.9, 118, 138/95, 20, 97% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, no oral lesions.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ midpeaking systolic murmur, no rubs or
gallops
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
SKIN: warm and well perfused, erythematous macular lesions
evenly distributed on bilateral ___
___:
- mental status: A&Ox3. Attentive. speech was not dysarthric.
- Cranial Nerves:
II: PERRL 4 to 2mm and brisk.
III, IV, VI: EOMI. +fasgt nystagmus to the right
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. Strength ___ in all proximal and distal muscle
groups.
-Sensory: No deficits to light touch proprioception throughout.
-DTRs: 2+ at biceps, triceps, patella, achilles bilaterally.
Downward babinski.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred.
DISCHARGE PHYSICAL EXAM:
VS: T 98-98.7, BP 108-139/72-90, HR 76-91, RR 18, ___
GENERAL: alert, oriented, interactive
HEENT: sclerae anicteric, MMM, PERLA
LUNGS: Clear to auscultation, 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: red macular rash appears to have resolved
Neuro: Alert, oriented. Gait not tested.
Pertinent Results:
FEVER CURVE:
___: AF
___: AF
___: AF
___: 101.8
___: 102.9
___: 101.5
___: 101.4
================================================================
LABS:
Transaminitis ___ resolving
WBC WNL ; Plts nadired at 137 on ___, now ___
BMP WNL except phos 2.2, LFTs WNL
================================================================
MICRO:
CSF (___):
4 WBC, 146 RBCs, Tprot 41, Gluc 67, ___ negative
VZV PCR neg
HSV PCR neg
Borrelia burgdorferi Ab negative
No cytology
SERUM:
BCx: ___ neg
HIV Ab: ___ - neg
RPR: ___ - neg
Lyme serology: ___ neg
___ Cx (serum): ___ - pending
**** ___ IgM, IgG: ___ - POSITIVE FOR ___ *****
Babesia IgG, IgM: ___ negative
Anaplasma IgG, IgM: ___ negative
Parasite smear: neg ___
Leptospira Ab: pending ___
Urine histo Ag: pending ___
RHEUM:
CRP: 40 (nl < 5)
ESR: ___
___: pending ___
ANCA: pending ___
Ferritin: 139 ___
================================================================
ABX:
Doxycycline: ___ @ 100q12h
Ceftriaxone: ___ (CNS Lyme; 2g 24h)
Acyclovir: ___ 600IV q8h
================================================================
STUDIES:
MRI Brain (+/-) (___): eptomeningeal enhancement within the
subarachnoid spaces of the cerebellum. This finding is felt
most likely to be secondary to an inflammatory or infectious
etiology. Hemorrhage is considered far less likely due to the
lack of susceptibility artifact on gradient images.
Brief Hospital Course:
___ F who p/w 5 days of rash, 2 days of headache, 1 day of
horizontal diplopia, and fever spikes to ___ 2 days PTA, found
to have ___ Fever.
# Horizontal diplopia / vertigo:
Patient presented with 5 days of red, macular rash on her
anterior thighs and upper arms, 2 days of fever, 2 days of HA,
and 1 day of diplopia. Of note, patient had presented on the
day PTA with those same symptoms (minus the diplopia). Headache
had worsened after the LP she had received 1 day prior to
current admission.
Presentation was concerning for a broad spectrum of etiologies,
so we consulted both the neurology and infectious disease teams.
CSF was notable for clear fluid, protein and glucose WNL (41 and
67, respectively), <WBCs, so bacterial meningitis was ruled out
in favor of an aseptic/viral etiology.
Patient's presentation of diplopia and HA that worsened post LP
is concerning for post LP complications, but given that not all
of her symptoms can be attributed to post LP, further workup was
initiated.
Patient also underwent brain MRI to rule out any acute
intracranial process. Imaging was notable only for
leptomeningeal enhancement, likely ___ lumbar puncture.
Patient was started on acyclovir (empiric for HSV), and
doxycycline/ceftriaxone (for other viral etiologies, including
insect borne) in order to cover broadly for infectious
etiologies. Patient's CSF and blood were sent for several tests
for a wide range of etiologies (most notably, viral/insect borne
illnesses) in order to determine the cause of her constellation
of symptoms. Throughout her hospital stay, from ___,
patient was spiking fevers to as high as 103, but fevers have
been resolved since ___. Pain was controlled with various
combinations of ibuprofen, morphine, tylenol, tylenol-caffiene,
and dilaudid. Patient received Zofran PRN for nausea. Over the
course of the week, patient stopped spiking fevers and both her
headache and diplopia improved.
On ___, the ___ Laboratory informed the team that Ms.
___ blood was positive for ___ antibody, which
lends itself to a diagnosis of ___ Fever. Given this,
patient was taken off all of her antibiotics prior to discharge.
# Transaminitis
Patient has baseline normal liver enzymes. Values rose to
AST/ALT 82/123 on ___, which was presumed to be an effect of
tylenol. Tylenol was withheld, and values downtrended (36/68 on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours as
needed for headache Disp #*42 Tablet Refills:*0
2. Lactulose 30 mL PO TID as needed for constipation
RX *lactulose 20 gram/30 mL 30 mL by mouth 3 times a day as
needed for constipation Disp #*630 Milliliter Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4
hours as needed for headache Disp #*42 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [___] 17 gram 1 powder(s) by
mouth twice a day Disp #*14 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- ___ Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for a progression of
symptoms over the past week that included rash, fatigue, fever,
headache, dizziness, and double vision.
We consulted both the neurology and infectious disease teams to
help us determine exactly what was causing your constellation of
symptoms. We immediately put you on antibiotics to cover for
viruses that would have required treatment, just in case you
were infected with these viruses. As the results of your tests
came back negative, we removed the medications that were not
needed.
You had a lumbar puncture on ___, when you presented to the
Emergency Department for the first time. This study involved
taking a sample of spinal fluid to look for infection. We
tested your spinal fluid for many different types of viruses,
but were unable to find a source of infection there.
You got an MRI of your brain, which showed no evidence of any
abnormalities that were likely to be the source of your
symptoms.
We sent your blood to the ___ Lab for further
testing, and it was discovered that you have ___ Fever.
This is a viral illness that is transmitted by mosquitos. Most
people (~80% of people) who are infected actually do not show
any symptoms at all. Currently, there are only a few confirmed
cases of this illness in ___, and you are one of them!
The illness resolves with time and does not require the use of
antibiotics. Therefore, we discontinued all of your
antibiotics.
There are two types of ___ Virus illnesses. One is ___ Fever," which is what you have. The other, more serious
illness, which you do NOT have, is called "neuroinvasive ___ and can involve the brain. Although we expect your ___ Fever to resolve on its own, you may continue to experience
residual symptoms that could persist for a few weeks (most
notably, your fatigue and headache). The good news is that
eventually, you should make a full recovery!
We have seen you improve over the past few days, with no more
fevers and better control of your headache. If your symptoms
get any worse, which we do not expect them to, you should follow
up with your PCP or come back to the Emergency Department.
You were a pleasure to take care of during your stay. We are as
relieved as you are to have an "official" diagnosis so that you
have some "closure" after a very rough week for you of feeling
miserable. We appreciate your patience in the process of us
figuring out the cause of your symptoms.
Please feel free to reach out to us with any questions, and best
of luck to you in your future health!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19624370-DS-2
| 19,624,370 | 23,704,916 |
DS
| 2 |
2170-05-27 00:00:00
|
2170-05-28 18:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematemesis, Melena
Major Surgical or Invasive Procedure:
Intubation ___
Upper endoscopy with esophageal variceal banding ___
History of Present Illness:
___ year old male with a past medical history of HCV s/p therapy
with possible cirrhosis, alcohol abuse, peptic ulcer disease
causing UGIB, who presented to ___ with melena and
hematemesis after recent increased NSAID use. According to the
patient, he has taken ibuprofen 800mg daily-BID for the past
couple of years, but switched to aleve BID two weeks ago for hip
pain. The day prior to admission he noted a "raw" abdominal pain
and black stool. Of note, the patient does recall a similar
episode ___ years prior when he was diagnosed with a peptic ulcer.
At ___, vitals were significant for tachycardia in the 110s, and
systolic blood pressure in the 120s-140s. While in the ED, he
vomited dark blood clots. Labs showed a hb of 12.9 and normal
liver enzymes and the patient was started on a PPI gtt and
transferred to ___ for further management.
In the ___ ED, initial vitals were 97.9 108 126/86 16 98%.
Rectal exam revealed guaiac positive stool. labs were
significant for wbc 13.4, hb 11.4, hct 35, platelets 111, INR
1.3, bicarb 21, BUN 52.
On arrival to the MICU, the patient reports no abdominal pain.
He states that prior to the last 2 days he did not have any
symptoms including abdominal pain, dark stools, nausea, or
vomiting. He currently reports no dizziness, chest pain,
palpitations, shortness of breath.
Review of systems: Per HPI
Past Medical History:
- HCV s/p treatment with interferon sofosbuvir (finished 3
months treatment about 6 weeks ago
- Possible cirrhosis (denies encephalopathy, varices, ascites)
- Peptic Ulcer Disease
- Alcohol Abuse, sober for past ___ years
- Diabetes
- Hypertension
- Gout
Social History:
___
Family History:
Brother with diabetes.
Physical Exam:
Admission Physical Exam:
Vitals- T:98.3 BP: 127/61 P: 113 R: 12 O2: 97% RA
___: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Normal respiratory effort, mild bibasilar crackles,
otherwise no adventitial sounds appreciated
CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, hypoactive bowel sounds no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No spider angiomata appreciated
NEURO:No asterixis, no focal motor or sensory deficit
Discharge Physical Exam:
VS: 98.9 98.9 120/74 78 20 100ra
___: bearded man, appearing older than stated age, several
tatoos
HEENT: sclerae anicteric, EOMI, PERRL
Neck: full ROM, no LAD
CV: RRR, no mrg
Lungs: CTAB
Abdomen: soft, nontender
GU: deferred. foley in place draining clear urine
Ext: warm and well perfused, no edema, pneumoboots on, L elbow
with warmth and limited range of motion ___ pain; not swollen
Neuro: grossly intact, no asterixis, aox3
Skin: tatoos on bilateral arms, no rashes, extensive
photodamage, not jaundiced
Pertinent Results:
Admission Labs:
___ 09:35PM ___ PTT-27.7 ___
___ 09:15PM GLUCOSE-131* UREA N-52* CREAT-0.9 SODIUM-145
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-21* ANION GAP-16
___ 09:15PM estGFR-Using this
___ 09:15PM ALT(SGPT)-18 AST(SGOT)-25 ALK PHOS-54 TOT
BILI-1.0
___ 09:15PM ALBUMIN-3.8
___ 09:15PM WBC-13.4* RBC-3.73* HGB-11.4* HCT-35.0*
MCV-94 MCH-30.5 MCHC-32.6 RDW-16.3*
___ 09:15PM NEUTS-79.1* LYMPHS-17.0* MONOS-3.4 EOS-0.2
BASOS-0.2
___ 09:15PM PLT COUNT-111*
Discharge Labs:
___ 06:50AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.7* Hct-25.9*
MCV-92 MCH-30.7 MCHC-33.4 RDW-18.1* Plt Ct-78*
___ 03:10AM BLOOD Neuts-73.4* ___ Monos-5.5 Eos-1.3
Baso-0.4
___ 06:50AM BLOOD Plt Ct-78*
___ 06:50AM BLOOD ___ PTT-28.0 ___
___ 06:50AM BLOOD Glucose-153* UreaN-14 Creat-0.7 Na-137
K-3.6 Cl-106 HCO3-23 AnGap-12
___ 06:50AM BLOOD ALT-19 AST-23 AlkPhos-62 TotBili-0.7
___ 06:50AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.7
Micro:
___ 12:25 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 8:30 pm SWAB Source: Rectal swab.
**FINAL REPORT ___
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
Imaging:
ELBOW, AP & LAT VIEWS LEFT Study Date of ___
Soft tissue prominence over olecranon. The differential
diagnosis includes olecranon bursitis or other causes of soft
tissue swelling/prominence. No bone erosion or osteolysis. The
presence or absence of infection associated with the soft tissue
prominence cannot be evaluated radiographically.
CHEST (PORTABLE AP) Study Date of ___
No acute cardiopulmonary abnormality ET tube in appropriate
position .
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
Coarsened hepatic echotexture and nodular contour, consistent
with cirrhosis. No ascites.
___ EGD report
4 cords of grade II varices were seen in the lower third of the
esophagus. The varices were oozing. 4 bands were successfully
placed.
Stomach: Contents: Melena was seen in the fundus. No obvious
gastric varices were noted. Unable to completely visualize the
fundus.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
(ligation)
Blood in the fundus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
BRIEF HOSPITAL COURSE: Mr. ___ is a ___ year old male with a
past medical history of HCV cirrhosis, PUD, and hip pain treated
with NSAIDs, who was transferred to ___ for management of
hematemesis and melena. He was taken urgently to ICU and an
upper endoscopy was performed. 4 cords of grade II varices were
seen in the lower third of the esophagus. The varices were
oozing. 4 bands were successfully placed. The patient was
treated with standard medical therapy after the procedure with
octreotide, pantoprazole, sucralafate and ceftriaxone. He
developed a mild gout flare which was treated with warm packs
and colchicine.
# Hematemesis and Melena: Patient was found to have 4 grade II
varices in the distal esophagus on EGD on ___ which were
banded w/o complication, as well as no duodenal ulcers, and
dried clotted blood in gastric fundus. Hepatology was consulted
from the ICU and contributed to the management of the
post-procedural care. He was extubated the morning of ___
without complication. He was monitored in the ICU for 24 hours
after the procedure and was called out to the floor on the
morning of ___ at which time he was hemodynamically stable
with Hct of 29 and was tolerating a clear diet, advanced to
regular prior to discharge. The patient was treated with
standard medical therapy after the procedure with octreotide,
pantoprazole, sucralafate and ceftriaxone.
# HCV with possible cirrhosis: The patient has a past history of
HCV s/p treatment with interferon and sofosbuvir. RUQ ___
performed on ___ showed coarsened echotexture consistent with
cirrhosis with no ascites. He will be seen in transplant
evaluation clinic should he ever require transplant in the
future.
# Alcohol Abuse: The patient has a past medical history of
alcohol use and reports sobriety for past ___ years. He presented
with no signs of withdrawal, and ongoing sobriety was encouraged
# Diabetes, type II: He was kept on ISS.
#Gout flare: Left elbow with warmth, erythema in this gentleman
with history of gout. NSAIDs and oral steroids avoided given
GIB, as above. Rheum consulted and wary of steroid injection
give risk of hemarthrosis in the patient with low plts. He was
treated with colchicine, home allopurinol was continued, and
warm packs/elbow cushioning, oxycodone and tylenol for pain.
Transitional issues:
-he was discharged on nadolol, sucralfate, and plans for repeat
EGD were initiated
-he will follow up in transplant clinic, should he need a liver
transplant in the future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Ferrous Sulfate 325 mg PO BID
3. Ibuprofen 800 mg PO Q6H:PRN hip pain
4. Omeprazole 20 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Naproxen 500 mg PO Q8H:PRN hip pain
8. Morphine SR (MS ___ 30 mg PO BID:PRN pain
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Acetaminophen 325 mg PO Q4H pain
RX *acetaminophen 325 mg 1 tablet(s) by mouth every 4 hours Disp
#*180 Tablet Refills:*0
3. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Sucralfate 1 gm PO QID Duration: 2 Weeks
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*24 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Esophageal varices
Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted for bleeding which was stopped
with an endoscopy and banding of esophageal varices. The varices
are the result of your liver disease (cirrhosis). Fortunately
the bleeding did not return after the procedure. You will need a
repeat endoscopy in 3 weeks. Please avoid NSAIDs (ibuprofen,
naproxen) which can worsen the bleeding. Your hepatitis C has
been treated so we hope that your liver disease does not
progress. We plan on evaluating you in the liver transplant
clinic, in case you are in need of a transplant in the future.
Please take your medications as prescribed and follow up with
the appointments listed below.
Followup Instructions:
___
|
19624478-DS-11
| 19,624,478 | 25,254,444 |
DS
| 11 |
2171-09-18 00:00:00
|
2171-09-19 08:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Right hip and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ resident at ___ with a
medical history of HTN, TIA, hypothyroidism, and RA on
prednisone who presents after a mechanical fall. The patient
states that she was returning from using the restroom, and
reaching for something overhead when lost her balance and fell.
She landed against a closet door on her way to the floor,
striking her right hip. No loss of consciousness or head strike.
She is able to recall all the details of the event. The patient
denies pain in her head or her neck. The patient denies chest
pain, shortness of breath, palpitations, prior to event. The
patient reports significant right hip pain and mid back pain.
In the ED, initial vs were: 97.9 60 100/67 18 96% RA O2 sat.
Labs were remarkable for Cr 1.3, WBC 12.5 (85% N). UA was
negative. FAST exam was negative. CT Head showed no acute
intracranial abnormalities. CT spine showed wedge compression of
T7 with approximately 25% loss of vertebral body height without
significant retropulsion into the spinal canal (felt to be
chronic), minimal loss of height in the inferior endplate of T8.
No fractures were noted at cervical or lumbar levels. CXR showed
possible small left pleural effusion. Patient was given tramadol
50 mg X 1 and acetaminophen 500 mg X 1. Patient was unable to
ambulate, and thus was admitted to medicine. Vitals on Transfer:
97.9 60 152/80 18 92%
On the floor, the patient reports significant R hip pain. She is
asking to eat a meal.
Past Medical History:
HTN, TIA on plavix, hypothyroidism, PMR on prednisone, insomnia,
depression/anxiety, GERD, B12 deficiency,CAD, diverticulitis,
h/o GI bleed
Social History:
___
Family History:
Brother and mother with leukemia
Physical Exam:
ADMISSION EXAM:
VS: T 99.1 BP 132/57 P 53 R 18 O2 95%RA
Gen: Alert, oriented, mild distress due to R hip pain
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally anteriorly
CV: Regular rate and rythm, normal S1, S2, systolic murmur at
___
Abd: soft, NTND, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: tenderness over R greater trochanter, no spinal tenderness,
no ___ edema
.
DISCHARGE EXAM:
VS: T 98.7 BP 133/55 P 59 R 18 O2 96%RA
GENERAL: Lying in bed, in NAD. Pleasant and conversant.
HEENT: Neck supple, no LAD, no thyromegaly noted
LUNGS: Clear bilaterally
CV: Regular rate and rhythm, II/VI systolic murmur strongest at
___
ABD: Soft, NTND,bowel sounds present.
EXT: ___ muscle strength bilaterally. Able to lift leg at knee
and hip without being limited by pain. No point tenderness.
SKIN: Ecchymosis on R mid-lower back and L upper-mid
NEURO: A&Ox3, Strength ___ bilaterally.
Pertinent Results:
ADMITTING LABS:
___ 10:35AM BLOOD WBC-12.5* RBC-4.07* Hgb-11.8* Hct-36.9
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.0 Plt ___
___ 10:35AM BLOOD Glucose-105* UreaN-16 Creat-1.3* Na-143
K-3.8 Cl-102 HCO3-33* AnGap-12
___ 06:25AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8
.
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-10.7 RBC-4.03* Hgb-11.6* Hct-36.7
MCV-91 MCH-28.8 MCHC-31.6 RDW-14.0 Plt ___
___ 06:25AM BLOOD Glucose-93 UreaN-15 Creat-1.1 Na-141
K-4.0 Cl-104 HCO3-29 AnGap-12
.
PERTINENT IMAGING:
#HIP UNILAT MIN 2 VIEWS RIGHT:No fracture of the right hip.
#CT L-SPINE W/O CONTRAST:No fracture of the lumbar spine.
#CT C-SPINE W/O CONTRAST: No acute fracture or subluxation.
#CT HEAD W/O CONTRAST:No acute intracranial abnormalities.
#PELVIS (AP ONLY):Limited study. No gross fracture or
dislocation.
#T-SPINE; L-SPINE (AP & LAT):
-No acute fracture or malalignment within the lumbar spine.
-Mild compression fracture of T7 vertebral body, which is age
indeterminate.
-Mild degenerative changes within the thoracic spine, and
moderate
degenerative changes within the lumbar spine, worse at L3-4.
#CHEST (SINGLE VIEW): Possible small left pleural effusion. No
displaced fractures are identified.
#KNEE (AP, LAT & OBLIQUE) RIGHT:No acute fracture or
dislocation.
#CT T-SPINE W/O CONTRAST:
-3 mm right upper lobe nodule. Follow up in 12 months is
recommended if the patient has risk factors for lung cancer,
otherwise, no follow up is
required.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ with a medical history of HTN, TIA on plavix, hypothyroidism
who presents with right hip and back pain after a mechanical
fall
.
ACTIVE DIAGNOSES:
#Right hip and back pain: Extensive imaging did not show any
acute fractures. She was able to move her leg at the hip and
the knee and did not have any point tenderness and her injury
likely musculoskeletal in origin. Pain was initially controlled
with tylenol and tramadol she was discharged home with tylenol
for pain.
.
#Dizziness/Weakness: The patient clearly denied any preceeding
symptoms leading up to her fall, which was thought to be purely
mechanical in nature. She did report dizziness when being
initially evaluated by physical therapy but symptoms improved
after eating. Her daughter notes that her mother seems
deconditioned since she has moved to ___. She was encouraged to
keep hydrated and will benefit from physical therapy to also
help with conditioning.
.
#Bradycardia: Her heart rate was in mid ___ during admission.
Her metoprolol was held for HR<60. On discharge, her metoprolol
was decreased to 12.5 mg daily.
.
#Hypertenison: Her blood pressure was well controlled but on the
morning of ___ she had elevated pressures in the morning
190/79, 177/84 (asymptomatic), possibly related to pain as it
returned to what was her baseline during this admission
(systolic 130s). She is currently on amlodipine 5mg and
metoprolol succinate 25mg (home meds). Because of her
bradycardia (see above), the metoprolol was held and will be
decreased to 12.5mg on discharge. She would benefit from blood
pressure monitoring to better adjust her antihypertensive
medication especially if she continues to have episodes of
hypertension after discharge.
.
#Leukocytosis: Mild at admission likely secondary to the stress
of injury and pain that normalized the next morning. No concern
for infection.
.
CHRONIC ISSUES:
#Sleep apnea- She wears CPAP at home but declined to use
hospital CPAP
#Insomnia- Maintained on current trazadone and clonopin. Of
note, daughter mentioned that patient sometimes takes extra
medication to help her sleep and this might contribute to her
unsteadiness at night. Pt was counseled on the dangers of doing
this, particularly with clonopin.
#Depression/anxiety: Maintained on paroxetine, trazadone,
clonopin (see above)
#Hypothyroid: Maintained on home dose of levothyroxine
#h/o TIA: Maintained on plavix
#PMR: Maintained on prednisone daily
#GERD: Maintained on pantoprozole
.
TRANSITIONAL ISSUES:
# Medication review: The medication list that we used was
provided from a note by ___, ___-BC, dated
___. This differed from the list of medications initially
provided to us by the patient's daughter, likely reflecting more
recent updates in medications. It may be beneficial to confirm
with the patient that this most recent list is what she is
taking once she is in the outpatient setting. Additionally,
during her hospital stay, the patient's heart rate was in the
___ and her metoprolol was held. Should her heart rate
consistently be in the ___ while not inpatient, she may benefit
from a different antihypertensive medication.
Similarly, she is on clonazepam. The patient feels that this
medication helps her sleep but other alternatives may be better
for her, considering her age and recent symptoms of dizziness
and falls. Her depression may also require further investigation
(please see below section on mental status) and she may benefit
from a different treatment regimen other than paroxetine.
.
#Mental Status: The patient generally was able to answer
questions. During evaluation by the geriatrics fellow, her
minicog was ___, with clock drawing time inaccurate (clock face
correct, hands at 10 and 11). This may require further workup in
the outpatient setting.
.
#Imaging incidental findings:
- Mild compression fracture, likely chronic.
- 3 mm right upper lobe nodule. Follow up in 12 months is
recommended if the patient has risk factors for cancer,
otherwise, no follow up is required.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Vesicare *NF* (solifenacin) 5 mg Oral daily
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 6 mg PO DAILY
6. Cyanocobalamin 100 mcg PO DAILY
7. ClonazePAM 0.5 mg PO DAILY
8. TraZODone 50 mg PO HS
9. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3)
unknown Oral daily
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. lactobacillus acidophilus *NF* unknown capsule Oral daily
13. Paroxetine 20 mg PO DAILY
14. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 6 mg PO DAILY
6. TraZODone 50 mg PO HS
7. ClonazePAM 0.5 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyanocobalamin 100 mcg PO DAILY
10. lactobacillus acidophilus *NF* 1 capsule ORAL DAILY
Use as directed
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Paroxetine 20 mg PO DAILY
13. Vesicare *NF* (solifenacin) 5 mg Oral daily
14. Acetaminophen 1000 mg PO Q12H:PRN pain
Please do not take more than 3000mg per day.
15. Calcium 500 + D (D3) *NF* (calcium carbonate-vitamin D3) 1
tablet ORAL DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Musculoskeletal injury secondary to mechanical fall
Discharge Condition:
Mental status: clear and coherent
Level of consciousness: Alert and interactive
Ambulatory status: Ambulate with assistance
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ after falling in your home and
injuring your hip. You had imaging of your head, back, hip and
knee that showed that you fortunately did not break any bones
when you fell. Your pain was likely from hurting the muscles and
soft tissue of your hip and back. You received tylenol and
tramadol for pain control.
You also felt dizzy and weak when being initially evaluated by
physical therapy. Your symptoms improved after you ate and
drank and they were able to assess your abilities the following
morning.
You may have some residual pain where you fell and you may also
get a bruise, both of which are normal. If you still have pain,
you can take tylenol (total daily dose must be less than
3000mg). You should also make sure to drink lots of fluids to
help you not have more episodes of feeling dizzy.
Please discuss your medications with your new PCP to ensure that
they are all safe to continue.
If you develop any fevers, chills, worsening back pain,
numbness, tingling, weakness, chest pain, palpitations, vision
changes, or any other concerning symptoms, please call your
doctor right away.
We wish you the best of luck!
Followup Instructions:
___
|
19624478-DS-14
| 19,624,478 | 23,223,272 |
DS
| 14 |
2172-11-24 00:00:00
|
2172-11-24 14:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
Mesenteric arteriogram by interventional radiology
History of Present Illness:
Ms. ___ is an ___ w/ Hx of GIB in ___ without identified
source, suspected ___ diverticulosis, Hx of diverticulitis, Hx
of esophagitis, CAD s/p DES in ___ on plavix, HTN, Hx of TIA,
Hx of C. diff x2 and other issues who presents with 4 episodes
of BRBPR. The BRBPR started this AM with four episodes of frank
blood. She has not had CP/SOB, dizziness/LH/syncope, abdominal
pain, fever/chills, or nausea/vomiting. She does report fatigue
for the past week or so. Of note she does also report 2 days of
watery diarrhea. She has not been hospitalized recently and has
not received antibiotics for any reason.
In the ED, initial vitals were: 61 125/65 21 96% RA. In the ED
she did have three medium-sized maroon stools with clots. Labs
were significant for WBC 9.8, Hgb/Hct were 10.7/34.7 (baseline
___, plts 281, INR 1.1, BUN/Cr ___, HCO3 29. CTA showed
active extravasation into the hepatic flexure. GI evaluated the
patient and recommended ___ evaluation. The patient received
Pantoprazole 40 mg IV, 3 PIVs were placed (16, 18, and 20G) and
was admitted. On transfer, vitals were: 59 121/69 19 96% RA.
On arrival to the MICU, the patient was comfortable and had no
complaints apart from continued BRBPR.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
HTN
Hx of TIA
hypothyroidism
PMR on prednisone
insomnia
depression/anxiety
GERD
B12 deficiency
CAD s/p DES to OM1 in ___, to be on plavix for ___ year
diverticulitis
h/o GI bleed
C. diff in ___
urinary frequency
Social History:
___
Family History:
Brother and mother had leukemia
Physical Exam:
On Admission:
VS: T 97.9 HR 83 BP 147/58 RR 18 SaO2 95% on RA
GENERAL: Alert, oriented, no acute distress, appears pale
HEENT: Sclera anicteric, pale conjunctiva, MM dry, oropharynx
clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, II/VI systolic murmur at RUSB,
normal S1 S2
ABD: soft, mild TTP of bilateral lower quadrants, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Rectal: Maroon blood with clots soiling pad
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Pale, no rash
NEURO: CN II-XI intact, moving all extremities
On Discharge:
Vital signs:
97.8 HR 79 BP 162/ 60 100% RA
General: Appears well, NAD
HEENT: Neck supple, no lymphadenopathy.
CV: No JVD. RRR. Holosystolic murmur LUSB, RUSB. Systolic murmur
at ___.
Lungs: CTAB.
Abdomen: Tender to palpation in R and LLQ. No rebound or
guarding. Bowel sounds present.
Ext: WWP, no edema.
Skin: Patch of erythema over R forearm.
Pertinent Results:
On Admission:
___ 06:00AM BLOOD WBC-9.8 RBC-3.61* Hgb-10.7* Hct-34.7*
MCV-96# MCH-29.7 MCHC-30.9* RDW-14.7 Plt ___
___ 06:00AM BLOOD Neuts-73.7* Lymphs-16.8* Monos-5.9
Eos-3.3 Baso-0.2
___ 06:00AM BLOOD ___ PTT-27.6 ___
___ 06:00AM BLOOD Glucose-102* UreaN-29* Creat-1.0 Na-142
K-4.3 Cl-103 HCO3-29 AnGap-14
___ 10:00AM BLOOD Albumin-3.1* Calcium-7.9* Phos-3.2
Mg-1.5*
___ 10:13AM BLOOD Lactate-1.4
Imaging/Studies:
___ CTA A/P
1. Active arterial extravasation, probably diverticular in
origin, just distal to the hepatic flexure, in the region of the
superior mesenteric artery. The superior mesenteric artery is
minimally narrowed from atherosclerosis.
2. Moderate atherosclerosis of the abdominal aorta with severe
celiac artery stenosis and occlusion of the inferior mesenteric
artery.
3. Vague fat stranding surrounding the descending colon may
reflect early
diverticulitis.
4. Stable left adnexal cyst from ___ for which a nonemergent
pelvic
ultrasound can be performed if clinically necessary, if not
already performed.
5. Progression of the compression deformity of L1 without
increased
retropulsion since ___.
___ Mesenteric Angiogram
Microbiology:
Stool culture: ___: C. Diff positive.
MRSA screen negative.
Discharge Labs:
___ 04:24AM BLOOD WBC-10.5 RBC-3.32* Hgb-10.0* Hct-31.4*
MCV-95 MCH-30.3 MCHC-31.9 RDW-15.7* Plt ___
___ 04:24AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-141 K-3.9
Cl-102 HCO3-28 AnGap-15
___ 04:24AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.5
Brief Hospital Course:
Ms. ___ is an ___ w/ Hx of GIB in ___ without identified
source, suspected ___ diverticulosis, Hx of diverticulitis s/p
partial colectomy, Hx of esophagitis, CAD s/p DES in ___ on
plavix, HTN, Hx of TIA, Hx of C. diff x2 (___) who presented
with 4 episodes of BRBPR and active extravasation from a vessel
in the hepatic flexure seen on CTA. Mesenteric angiography was
performed which revealed no ongoing contrast extravasation. She
spent < 1 day of observation in the MICU and after three blood
transfusions, her HCT was stable at 33. Given her ongoing
diarrhea and abdominal pain, a C. Diff PCR test was sent which
was positive. She was therefore started on a course of PO
vancomycin to complete as an outpatient.
Active Issues
# Acute blood loss anemia:
# Lower GI Bleeding:
She has a history of GIB without clear source identified,
possibly ___ diverticulosis given blood with clots visualized in
colon on last colonoscopy. Patient also with history of
esophagitis on EGD, though currently low suspicion for upper GI
contribution to bleed given no melena, and pt has been on PPI.
CTA in ED showed active extravasation into hepatic flexure of
colon. GI evaluated patient in ED and recommended ___ evaluation.
She was admitted to the MICU where she was hemodynamically
stable but had continued rectal bleeding and maroon stool. She
underwent mesenteric angiogram with ___ where no extravasation
was seen. After angiogram, she had no bleeding and GI offered
colonoscopy but she declined. She was transfused 3 u pRBC to
keep HCT>30. Her HCT remained stable around 33 after leaving the
MICU. She had no further episodes of bleeding from her rectum.
In discussion with her cardiologist, her plavix was held during
hospitalization and she was restarted on aspirin.
# Diarrhea: (C. Diff)
She presented with 2 days of diarrhea and crampy abdominal pain
preceding her GIB, no recent hospitalizatons and no recent
antibiotics. However, patient with history of C diff colitis x2
in ___, treated with flagyl both times. Had mesenteric
stranding in her colon on CT concerning for possible early
diverticulitis. She had no fevers. Diverticulits was considered
as a source for her symptoms, and she has a history of this
requiring a partial colectomy in the past, but it would be
unusual for diverticulitis to also present with a bleed. C. Diff
PCR assay from her stool was sent and came back positive. She
was therefore initiated on a three week course of Oral vancomyin
125 mg q6H for third recurrence of mild C. Diff infection. Her
PCP ___ be instructed to perform a vancomycin taper if loose
stools persist.
# Coronary Artery Disease
Currently no Signs or symptoms of ischemia, ECG with prolonged
QTc, which is new, and ST depressions in I and aVL, and biphasic
T waves in V3-V6, all of which are old. She had a DES in ___
and was supposed to be on ASA/clopidogrel but has only been
taking clopidogrel. Home metoprolol and atorvastatin were
initially held but subsequently restarted once stable. Per
discussion with her outpatient cardiologist, Dr. ___,
___ was stopped. She had received this medication for
almost a full year, since last ___, so this medication was
permanently stopped and she was discharged on a baby aspirin.
Chronic Issues
# Hypertension: Initially held home amlodipine in the setting of
active bleed. Restarted on floor.
# Depression/anxiety: Initially held home paroxetine, trazodone,
and clonazepam. Restarted on floor.
# Hypothyroidism: Held home Levothyroxine while NPO, restarted
once tolerating full diet.
# Osteoarthritis: cont'd home acetaminophen, oxycodone.
Transitional Issues:
-f/u abdominal pain and stool output on oral vancomycin.
-If diarrhea persists after three weeks of vancomycin, perform a
taper of oral vancomycin, (1 week of twice daily, 1 week once
daily, 1 week every other day, 1 week every three days).
***Incidental findings on ___ CTA that may require followup****
1) "Probably stable left adnexal cyst from ___ for which a
nonemergent pelvic ultrasound can be performed if clinically
necessary."
2) "Slight progression of L1 compression deformity."
Letter sent to patient and PCP, patient notified and aware of
finding
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Clopidogrel 75 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Paroxetine 40 mg PO DAILY
7. TraZODone 75 mg PO HS:PRN insomnia
8. Vitamin D 1000 UNIT PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Atorvastatin 80 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
12. Acetaminophen 325-650 mg PO BID:PRN pain
13. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO BID:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Paroxetine 40 mg PO DAILY
9. TraZODone 75 mg PO HS:PRN insomnia
10. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
11. Cyanocobalamin 500 mcg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*76 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
lower gastrointestinal bleed
clostridium dificille colitis
Secondary:
Diverticulosis
Coronary artery disease
Discharge Condition:
Alert and oriented, ambulating with assistance
Discharge Instructions:
Ms. ___, you were admitted to the hospital with bleeding from
your gastrointestinal tract. An area of bleeding in your colon
was identified on CAT scan but stopped bleeding on its own
during an angiogram procedure, so no intervention was performed.
Your blood count was stable after transfusion of three units of
red blood cells. We have held your plavix and are now giving you
one baby aspirin daily.
Of note, you were also found to have Clostridium Dificille
colitis, which you have had in the past. We are treating you
with three weeks of an oral antibiotic, vancomycin, which you
should complete as directed as an outpatient.
Followup Instructions:
___
|
19624478-DS-15
| 19,624,478 | 20,800,045 |
DS
| 15 |
2173-05-28 00:00:00
|
2173-05-28 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fosamax / Myrbetriq
Attending: ___.
Chief Complaint:
headache, nausea, fever
Major Surgical or Invasive Procedure:
Trach placed on ___
PEG placed on ___
History of Present Illness:
___ y/o F presenting with nausea, fevers, and headache x 2days.
Patient reports severe nausea starting yesterday associated with
a fever (unknown T max) and headache that has continued. She
reports poor PO. No neck pain or stiffness. No abdominal pain or
vomiting. Some intermittent diarrhea that may be at baseline.
Denies BRBPR or melena. No urinary symptoms. No chest pain,
cough, dyspnea, or congestion. No confusion or AMS. Did received
flu vaccine this year.
On arrival to the ED, VS 101.4 68 154/77 14 98% RA.
Labs notable for: +FluA PCR, normal lactate, normal WBC, and
normal Chem panel.
CXR showed bibasilar atelectasis.
Patient given: 2L NS, oseltamivir 75mg, acetaminophen, duonebs,
ketorolac
While in the ED she had an episode of hypoxia with sats in the
___. Given hypoxia, age, and positive flu swab, she was admitted
for further monitoring,
Vitals prior to transfer: 98.2 64 121/55 18 96% Nasal Cannula
On the floor, pt. was sleeping comfortably in NAD. She was
extremely tired and did not want to talk.
Review of Systems:
(+) per HPI
Past Medical History:
COMPRESSION FRACTURES
HYPERLIPIDEMIA
HYPERTENSION
CORONARY ARTERY DISEASE
s/p DES to OM1 in ___ to be on
plavix for ___ year
TRANSIENT ISCHEMIC ATTACK
HYPOTHYROIDISM
INSOMNIA
GASTROESOPHAGEAL REFLUX
VITAMIN B12 DEFICIENCY
DIVERTICULITIS
GASTROINTESTINAL BLEEDING
DEPRESSION
ANXIETY
Urinary frequency/ Incontinence
C.DIFF INFECTION
OSA
Social History:
___
Family History:
Brother and mother had leukemia
Physical Exam:
ADMISSION EXAM:
-------------------
Vitals - 97.8, 79, 145/48, 18, 94% on RA
GENERAL: NAD, sleeping, easily arousable but frequently falls
back asleep during interview
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMdry
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Largely clear with occasional wheeze; breathing
comfortably off oxygen
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
SKIN: warm and well perfused, dry
DISCHARGE EXAM:
-------------------
Vitals: 98.9; 130-140s/40-80s; 60-70s; 18; 98-100/trach
GENERAL: NAD, unable to speak, AO to hospital, person and ___
HEENT: AT/NC, trach in place
CARDIAC: RRR, S1/S2, holosystolic murmur. no gallops, or rubs
LUNG: scattered rhonchi throughout
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Right arm with significant ecchymoses, RUE swelling
that is outlined. Left upper extremity with picc in place
SKIN: warm and well perfused, dry
Pertinent Results:
ADMISSION LABS:
---------------
___ 05:00PM BLOOD WBC-7.5 RBC-3.79* Hgb-11.1* Hct-34.5*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.0 Plt ___
___ 05:00PM BLOOD Neuts-88.7* Lymphs-5.2* Monos-4.8 Eos-1.3
Baso-0
___:00PM BLOOD ___ PTT-27.3 ___
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-97 UreaN-19 Creat-1.0 Na-138
K-4.7 Cl-102 HCO3-26 AnGap-15
___ 05:00PM BLOOD ALT-18 AST-47* AlkPhos-79 TotBili-0.3
___ 05:00PM BLOOD Albumin-4.0
___ 05:12PM BLOOD Lactate-1.3
IMAGING:
----------------
___ CHEST CT W/O CONTRAST
IMPRESSION:
Preliminary Report1. Widespread peribronchial ground-glass
opacities in the upper and lower lobes are compatible with
multifocal pneumonia.
2. Increased fullness along the upper right hilus, adjacent to
the azygos
___ represent reactive lymphadenopathy, however repeat
Chest CT with IV contrast is recommended in ___ weeks after
adequate treatment for acute pneumonia to exclude underlying
malignancy.
3. Findings compatible with tracehobronchomalacia. Tracheal wall
thickening adjacent and superior to indwelling tracheostomy tube
may reflect granulation tissue. Correlation with recent
bronchoscopic findings is recommended.
4. Mild hydrostatic edema and trace right pleural effusion.
5. Interval progression of compression deformities of the T4
vertebral body and inferior endplate of the T10 vertebral body.
Other thoracic and lumbar compression deformities unchanged in
appearance.
6. Healed right lateral fifth through tenth rib fractures.
___ NECK CT W/O CONTRAST
IMPRESSION:
1. Limited study masses of intravenous contrast, but no evidence
of retropharyngeal or peritonsillar abscess.
2. 2.3 cm lesion posterior to the left clavicle. This could
represent hemorrhage if a subclavian line was attempted.
Consider further evaluation of this finding on ultrasound.
3. Pulmonary opacities and thoracic vertebral body compression
deformities are described in a separate report.
___ CXR
In comparison with the study of ___, there is an placement
of a left
subclavian PICC line that extends well into the jugular system.
Continued
enlargement of the cardiac silhouette with increasing pulmonary
edema. In the appropriate clinical setting, superimposed
pneumonia could be considered. Tracheostomy tube remains in
place.
___ upper extremity ultrasound
Nonocclusive thrombus within the right axillary vein.
Right upper arm complex intramuscular hematoma.
___ proximal trachea biopsy, granulation tissue
respiratory mucosa with squamous metaplasia, granulation tissue,
and acute and chronic inflammation. GMS and tissue gram stains
are negative for microorganisms.
___ renal ultrasound
Bilateral renal cysts are unchanged. Right greater than left
cortical
thinning. No evidence of stones or hydronephrosis bilaterally.
Chest X ray ___
Mild pulmonary vascular congestion and mild bibasilar
atelectasis. No focal consolidation, pleural effusion or
pneumothorax
is noted.
MICRO
___ 9:37 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. ~8OOO/ML.
Time Taken Not Noted Log-In Date/Time: ___ 10:24 am
FLUID,OTHER ESOPHAGEAL WASH.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
Reported to and read back by ___ ___ @ 1256.
SMEAR REVIEWED; RESULTS CONFIRMED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
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 BELOW, THEY ARE NOT
PRESENT in
this culture..
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL {YEAST}
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}
___ URINE URINE CULTURE-FINAL {YEAST}
___ FLUID,OTHER ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY {YEAST};
POTASSIUM HYDROXIDE PREPARATION-FINAL; GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {MIXED BACTERIAL FLORA}
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL
___ BRONCHIAL WASHINGS GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL {YEAST}
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ URINE URINE CULTURE-FINAL
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ SPUTUM POTASSIUM HYDROXIDE
PREPARATION-FINAL; FUNGAL CULTURE-FINAL
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL; VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS-FINAL
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ STOOL C. difficile DNA amplification
assay-FINAL {CLOSTRIDIUM DIFFICILE}
DISCHARGE LABS:
___ 05:46AM BLOOD WBC-13.0* RBC-2.69* Hgb-7.5* Hct-23.8*
MCV-88 MCH-27.9 MCHC-31.6 RDW-14.9 Plt ___
___ 05:46AM BLOOD ___ PTT-36.7* ___
___ 05:46AM BLOOD Glucose-154* UreaN-35* Creat-1.7* Na-141
K-4.4 Cl-98 HCO3-33* AnGap-14
___ 05:46AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5*
___ 05:47AM BLOOD Vanco-24.9*
Brief Hospital Course:
Ms. ___ is a ___ w/ PMHx notable for CVA and MI admitted with
influenza transferred to ICU for hypercarbic/hypoxic respiratory
failure and tracheobronchitis requiring intubation now s/p
trach/PEG.
ACUTE ISSUES
# acute hypercarbic/hypoxic respiratory failure: initially
thought to be secondary to Influenza +
tracheitis/tracheobronchitis. Received 5 days of tamiflu.
Initial bronch showed lesions concerning for possible HSV
tracheitis and was briefly on acyclovir for possible HSV
tracheitis, but discontinued on ___ due to ATN and negative BAL
HSV. Attempted extubation, but needed reintubation for flashed
pulmonary edema in setting of hypertension and again for
laryngeal edema. Repeat bronchoscopy on ___ showed ongoing
raised erythematous lesions thought to be secondary to viral
infection & mucus plugging in LLL. Trialed several days of
decadron for laryngeal edema. Given multiple failed extubations,
thick secretions, and weak cough, decision was made for trach.
Patient received trach/PEG on ___ and has been weaned to trach
mask. She was treated for ___ with vanc/zosyn for 7 days (day
1: ___ given thick secretions and CXR showing likely
retrocardiac opacity. She will need to follow up with IP as
outpatient for downsizing of trach. Patient transferred back to
floor on ___. She remained stable on the floor.
# Fever/ Leukocytosis: R PICC removed ___. Possible infection
in RUE hematoma/associated line, possible aspiration pna, in
addition to ___ esophagitis and c.diff. Empirically started
on cipro for ?UTI on ___ but discontinued on ___ when urine
culture grew yeast. CXR showed retrocardiac opacity concerning
for possible aspiration PNA. Started on vanc/zosyn for ___s per above. IV vanco also treating possible RUE
infection associated with hematoma. Blood, urine, and sputum
cultures only grew yeast.
# ___ esophagitis: noticed during placement of PEG. likely
secondary to antibiotics and steroids use while hospitalized.
She will complete 21 days of fluconazole (end date ___.
Atorvastatin discontinued as LFTs trended up while on
fluconazole.
# C. Diff colitis: on po vanc, cont for 2 weeks after last
antibiotics, plan for taper.
# R axillary vein clot: PICC associated with subcutaneous
spread. s/p removal of PICC on ___. Borders marked on ___. She
was started on warfarin and bridged with heparin gtt. Could
consider repeat ultrasound in 6 weeks to readdress need for
further anticoagulation.
# ATN: Renal U/S without obstruction. Creatinine trended down,
but may now be at new baseline. Diuresis held in setting of
worsening creatinine.
# Delirium / confusion: likely from prolonged hospitalization,
acute illness, and infectious process. Initially required
frequent seroquel but downtitrated to seroquel qHS:PRN. At
discharge, she was not requiring seroquel and this medication
was stopped. She also did not require trazadone for sleep and
this medication was also held.
# NSTEMI: pMIBI deferred given respiratory status as
pharmacological medications can cause bronchospasms. She was
started on baby aspirin. Did not tolerate low dose metoprolol.
Atorvastatin 80mg daily was started but discontinued due to
elevated CK. Plan for outpatient pMIBI.
# Anemia / RUE hematoma: Borders marked ___, improved.
Transfused 1 unit PRBCs without complications.
# Skin folliculitis: Resolved. s/p clobetasol ointment
TRANSITIONAL ISSUES
- please check vanc trough on ___.
- will need frequent INR checks as her INR increased quickly on
1.5mg (decreased to 1mg on ___ recommend first check 2 days
after discharge.
- f/u with IP as outpatient in 6 weeks for plan for downsizing
trach
- could potentially consider repeat ultrasound in 6 weeks to
readdress need for further anticoagulation.
- needs outpatient pMIBI and f/u with cardiology
- end date IV vanc/zosyn ___
- Continue po vancomycin until ___, then taper by reducing to
every 8 hour dosing for 1 week, then bid dosing for 1 week, then
once daily for 1 week.
- fluconazole end date ___
- consider restarting atorvastatin after CK trends down
- of note, her home clonazepam was held at the time of her
discharge and her trazodone dose was reduced.
- repeat Chest CT with IV contrast is recommended in ___ weeks
after adequate treatment for acute pneumonia to exclude
underlying malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Acidophilus (L.acidoph & ___
acidophilus) 175 mg oral DAILY
4. Psyllium 1 PKT PO TID:PRN loose stool
5. ClonazePAM 0.5 mg PO QHS:PRN insomnia
6. Acetaminophen 650 mg PO Q6H:PRN fever, pain
7. Amlodipine 5 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Paroxetine 40 mg PO DAILY
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Vitamin D 1000 UNIT PO DAILY
14. Cyanocobalamin 500 mcg PO DAILY
15. Cholestyramine Light (cholestyramine-aspartame) ___ gm oral
daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Paroxetine 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
9. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN sore throat
10. Ipratropium Bromide Neb 1 NEB IH Q6H
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Ondansetron ___ mg IV Q8H:PRN nausea
13. Piperacillin-Tazobactam 2.25 g IV Q6H
14. Vancomycin 1000 mg IV Q48H
15. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
DAILY
16. Atorvastatin 80 mg PO QPM
17. Cholestyramine Light (cholestyramine-aspartame) ___ gm oral
daily
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Psyllium 1 PKT PO TID:PRN loose stool
20. TraZODone 25 mg PO QHS:PRN insomnia
21. Fluconazole 200 mg PO Q24H
Please continue until ___. Vancomycin Oral Liquid ___ mg PO Q6H
Until ___, reduce to every 8 hours for 1 wk, then bid for 1 wk,
then once daily for 1 wk.
23. Warfarin 1 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Influenza A
Hypercarbic/hypoxic respiratory failure
SECONDARY DIAGNOSES:
___ esophagitis
C. diff
___ secondary to ATN
NSTEMI
R axillary vein clot
Toxic metabolic encephalopathy
Insomnia
Depression
Anxiety
Hypothyroidism
HTN
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure caring for you during your admission to
the ___ for flu. You came to the hospital with 2 days of
fever, headache, nausea and were found to have a positive flu
test. Your lungs had some congestion due to the flu infection,
and you were placed on oxygen. You were also treated with
Tamiflu. You then had trouble breathing and had to be sent to
the intensive care unit, where you required mechanical
ventillation and a trach and PEG tube placement. You were also
found to have a pneumonia, an infection of your esophagitis, C.
diff, which you were treated for. You should continue
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
19624478-DS-21
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DS
| 21 |
2175-07-07 00:00:00
|
2175-07-10 21:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fosamax / Myrbetriq
Attending: ___
___ Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of GIB (___), C diff colitis ___, 2015x2, now on
low-dose prophylactic vancomycin PO qOD), infectious colitis
(___), esophagitis, CAD (s/p DES ___, HTN, TIA, severe PNA
requiring tracheostomy who presents from urgent care with cough.
She reports ___ day history of nonproductive cough, ___ week
history of sore throat. She also report worsening hoarseness
(chronic for several years, seen by ENT in the past and
recommended for voice therapy). She denies any CP, SOB,
fever/chills. She reports occasional dyspnea on exertion. She
denies any recent weight gain, ___ edema, orthopnea. She
presented to urgent care and was found to be hypoxic to 88% on
RA, improved with 2L NC. Labs and CXR at ___ were unremarkable,
flu swab negative. She was treated with IV levaquin x 1 and
transferred for further management
She denies abd pain, n/v/d, dysuria. She does have chronic
dysphagia secondary to prior tracheostomy. She denies any sick
contacts, recent travel.
Past Medical History:
Compression fractures
Low back pain
Hyperlipidemia
Hypertension
Coronary artery disease (s/p ___ 2)
Pulmonary arterial hypertension (noted on ECHO ___
RBBB
Transient ischemic attack
Hypothyroidism
GERD
Esophagitis (EGD ___, thought ___ fosfomax)
Vitamin B12 deficiency
Diverticulitis (s/p colostomy with reversal)
GI bleeding
Urge incontinence
Depression
C. diff. colitis
S/p tracheostomy tube placement and PEG
placement (___) d/t hypoxemic respiratory failure, since
removed
Cholecystectomy
Tonsillectomy
Social History:
___
Family History:
Brother & mother - leukemia
Father - heart disease
Sister - diabetes
Physical ___:
ADMISSION PHYSICAL EXAM:
=======================
Vital Signs: 98.4 PO 160 / 78 100 20 97 2l
General: Alert, oriented, fatigued appearing
HEENT: Sclerae anicteric, MM dry, EOMI, PERRL.
Neck: Supple. JVP not elevated. 1 cm LN on left anterior
cervical chain, freely mobile, non tender
CV: Regular rate and rhythm. Normal S1+S2 no mrg
Lungs: CTAB except coarse breath sounds in left lower base, no
crackles, wheezes
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, MAE.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.4PO 135 / 65 62 18 95%RA
General: Alert, sitting up in bed, NAD
HEENT: atraumatic, normocephalic, MMM
CV: RRR, no murmurs, rubs, gallops
Lungs: coughing, some diffuse wheezes, but improved since ___
Ext: wwp, no evidence of peripheral edema or cyanosis
Neuro: AAOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
===============
White Blood Cells 5.3
Red Blood Cells 4.02
Hemoglobin 12.1
Hematocrit 38.7
MCV 96
MCH 30.1
MCHC 31.3*
RDW 13.4
RDW-SD 47.9*
IMAGING:
==========
___ CHEST (PORTABLE AP)
Stable cardiomegaly without pulmonary edema or consolidation.
DISCHARGE LABS:
===============
White Blood Cells 7.5
Red Blood Cells 3.69*
Hemoglobin 11.1*
Hematocrit 36.9
MCV 100*
MCH 30.1
MCHC 30.1*
RDW 13.7
RDW-SD 50.7*
Brief Hospital Course:
___ is an ___ with PMH of GIB (___), C diff colitis
___, 2015x2, now on low-dose prophylactic vancomycin PO qOD),
infectious colitis (___), esophagitis, CAD (s/p DES ___, HTN,
TIA, severe PNA requiring tracheostomy who presented from urgent
care with cough consistent with viral URI. She was admitted
overnight as she had a new O2 requirement. Her CXR did not show
any evidence of consolidation, and she did not have a
leukocytosis. She was treated symptomatically with benzonatate,
albuterol inhalers, guaifenisin. She was also given a 40mg
Prednisone burst x5d given the severity of her cough and concern
for hyper-reactive airways. Of note, her discharge Hgb was 11.1,
down from 12.1. As there were no signs of active bleeding and
she was hemodynamically stable this was deferred to outpatient
workup. She was able to be weaned off supplemental O2 and was
discharged with outpatient follow up.
CHRONIC ISSUES:
#HX C.DIFF: Continue prophylactic PO vancomycin qOD
#HTN: continue amlodipine 5 mg PO daily
#HYPOTHYROIDISM: continue levothyroxine 88 mcg PO daily
#DEPRESSION/ANXIETY: continue citalopram 20 mg PO daily,
trazodone 50 mg PO QHS prn insomnia
#CAD: continue aspirin 81 mg QD
#HYPERLIPIDEMIA: continue atorvastatin 80 mg PO QPM
#URINARY INCONTINENCE: hold tropsium as nonformulary
Transitional Issues:
[] Please check pulse oximetry at follow up appointment
[] Please check CBC at follow up appointment as she had a drop
in her Hgb, with no evidence of bleeding
# CODE: DNR/DNI
# CONTACT: ___ ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO DAILY PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Desonide 0.05% Cream 1 Appl TP BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Vancomycin Oral Liquid ___ mg PO EVERY OTHER DAY
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. trospium 20 mg oral BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, cough
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 PUFFS IH Q4H:PRN
Disp #*1 Inhaler Refills:*1
2. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth TID:PRN Disp #*30
Capsule Refills:*0
3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg 1 lozenge(s) by mouth Q2H:PRN Disp #*30 Lozenge
Refills:*0
4. Guaifenesin-Dextromethorphan ___ mL PO Q4H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL ___ mL by
mouth Q4H:PRN Refills:*0
5. Pantoprazole 40 mg PO Q12H
6. PredniSONE 40 mg PO DAILY Duration: 5 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth DAILY Disp #*4 Tablet
Refills:*0
7. Space Chamber Plus (inhalational spacing device) IH
Q4H:PRN
RX *inhalational spacing device [Space Chamber Plus] use with
inhaler Q4H:PRN Disp #*1 Canister Refills:*0
8. Acetaminophen 650 mg PO DAILY PRN pain
9. Amlodipine 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Citalopram 20 mg PO DAILY
13. Desonide 0.05% Cream 1 Appl TP BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Levothyroxine Sodium 88 mcg PO DAILY
16. Metoprolol Tartrate 25 mg PO BID
17. TraZODone 50 mg PO QHS:PRN insomnia
18. trospium 20 mg oral BID
19. Vancomycin Oral Liquid ___ mg PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral URI
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 because your oxygen levels
were low from a viral upper respiratory tract infection. You
were treated with steroids, nebulizer treatments, and
medications to help suppress your cough. You will be discharged
with steroids, cough medications, and an albuterol inhaler to
use when you are feeling short of breath.
New Medications:
Prednisone 40mg, the last day of this medication is ___
Benzonatate, to treat your cough symptoms
Albuterol inhaler, to treat your shortness of breath
Guaifenisin-dextromethorphan, to treat your cough symptoms
Cepacol lozenges, to treat your sore throat
Please attend your follow up appointments as listed below.
Thank you for choosing ___ for your healthcare needs. It was a
pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19624478-DS-24
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DS
| 24 |
2176-06-27 00:00:00
|
2176-06-27 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Fosamax / Myrbetriq / ciprofloxacin
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
ORIF R trimalleolar ankle fx ___, ___
History of Present Illness:
___ female w/ HTN, HLD, prior episode of pneumonia ___
who presents with the above fracture s/p mechanical fall. She
slipped while walking and sustained the above injury. She
normally uses a walker and walks minimally. She resides at a
retirement community in ___ for the past couple years.
Past Medical History:
Compression fractures
Low back pain
Hyperlipidemia
Hypertension
Coronary artery disease (s/p ___ 2)
Pulmonary arterial hypertension (noted on ECHO ___
RBBB
Transient ischemic attack
Hypothyroidism
GERD
Esophagitis (EGD ___, thought ___ fosfomax)
Vitamin B12 deficiency
Diverticulitis (s/p colostomy with reversal)
GI bleeding
Urge incontinence
Depression
C. diff. colitis
S/p tracheostomy tube placement and PEG placement (___) d/t
hypoxemic respiratory failure, since removed
Cholecystectomy
Tonsillectomy
Social History:
___
Family History:
Brother & mother - leukemia
Father - heart disease
Sister - diabetes
Physical ___:
General: Well-appearing female in no acute distress.
Right lower extremity:
- Skin intact
- short leg splint in place
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 07:30AM BLOOD WBC-9.8 RBC-3.21* Hgb-9.3* Hct-30.1*
MCV-94 MCH-29.0 MCHC-30.9* RDW-14.9 RDWSD-50.1* Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R ankle fx, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Enoxaparin Sodium 30 mg SC Q24H
RX *enoxaparin 30 mg/0.3 mL 1 syringe subcutaneous nightly Disp
#*28 Syringe Refills:*0
3. Senna 8.6 mg PO BID
4. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every four to six
hours Disp #*25 Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
6. Anastrozole 1 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Citalopram 20 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 300 mg PO TID
11. Oxybutynin 2.5 mg PO BID
12. Calcium Carbonate 500 mg PO QID:PRN abdominal pain
13. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non weight bearing 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 aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
THIS PATIENT IS EXPECTED TO REQUIRE <30 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 and any new
medications/refills.
Physical Therapy:
- non weight bearing right lower extremity
Treatments Frequency:
- short leg splint to stay on until follow up
Followup Instructions:
___
|
19624898-DS-21
| 19,624,898 | 28,364,195 |
DS
| 21 |
2122-09-16 00:00:00
|
2122-09-17 21:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Whole brain radiation: ___
History of Present Illness:
___ woman with metastatic breast cancer with known brain
and lung metastatses presenting with a first-time seizure, CT
showing L ICH with midline shift. The patient has had 2 days
of diffuse headache and worsening confusion. Headache has been
worse in the evening and associated with nausea. She was with
her niece this morning who was in another room when she heard
the
patient fall. The patient had brief right arm shaking, with
urinary incontinence. EMS was activated, glucose of ___nd the patient was brought in by ambulance. At the time
of initial evaluation seizure has subsided however patient was
confused. Her family members report she was speaking
incoherently and was AOx0. Patient was moving all extremities
however she is inattentive and unable to follow commands.
In the ED, vital signs T96.3 HR120 BP101/70 RR18 99% RA. CT
scan showed left ICH with 3mm midline shift. The area of
hemorrhage corresponds to a metastatic lesion last visualized on
MRI in ___. She was given 1g of Keppra and 10 mg of
Decadron. She was still confused and poorly following commands
although therewas no obvious focality to the exam.
Past Medical History:
-Breast CA: T4bN1M0, ER+, PR-, HER2+++ per records,
CNS mets treated with whole brain radiation, completed on ___ and subsequently she has been receiving T-DM1 5x
cycles to date. CT scan of the chest, abdomen and pelvis
revealed the majority of the nodules in the lungs were smaller
since ___.
- Possible history of latent TB. Per OMR notes, ___ years ago
patient reports history of lung problem diagnosed by X-ray for
which she was treated for at least 6 months.
-Thyromegaly
-s/p total hysterectomy (she thinks with salpingo-oophorectomy)
for fibroids
Social History:
___
Family History:
Parents healthy (mother ___, father ___). 1 cousin with cancer.
Otherwise, no known family history of malignancy, heart disease
Physical Exam:
=============================
ADMISSION PHYSICAL EXAM
=============================
Vitals: 96.3 120 101/70 18 99% RA
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no tongue biting
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: AAO xO. confused, disoriented. Unable to follow
commands
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF
III, IV, VI: EOMI, does not track.
VII: No facial droop
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone No adventitious movements. No
asterixis
noted. Strength is grossly full and symmetric except L triceps
___
-Sensory: Intact to light touch.
-DTRs: ___ mute.
-Coordination: Did not assess
-Gait: Did not assess
.
.
=============================
DISCHARGE PHYSICAL EXAM
=============================
VS: 98.7 ___ 57-63 18 100/RA
BG: ___ 255
GENERAL: NAD, awake and alert. A&O to name, place, season,
president.
HEENT: AT/NC, EOMI, PERRLA, dry mucous membranes
NECK: nontender and supple, no LAD, no JVD
CARDIAC: Regular rate and rhythm
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: Strength upper and lower extremities ___. No asterixis
SKIN: warm and well perfused, excoriation on nose
.
Pertinent Results:
=============================
ADMISSION LABS:
=============================
___ 08:00AM BLOOD WBC-5.2 RBC-4.72 Hgb-14.3 Hct-41.9 MCV-89
MCH-30.3 MCHC-34.2 RDW-13.6 Plt Ct-88*
___ 08:00AM BLOOD Neuts-62.7 ___ Monos-7.6 Eos-1.5
Baso-0.5
___ 08:00AM BLOOD ___ PTT-31.9 ___
___ 08:00AM BLOOD Glucose-185* UreaN-7 Creat-0.8 Na-140
K-3.8 Cl-101 HCO3-19* AnGap-24*
___ 08:00AM BLOOD ALT-52* AST-81* AlkPhos-70 TotBili-0.6
___ 08:00AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.4 Mg-2.1
___ 08:08AM BLOOD Lactate-7.4*
___ 09:12AM BLOOD Lactate-2.8*
.
.
=============================
DISCHARGE LABS:
=============================
___ 06:49AM BLOOD WBC-10.0 RBC-4.59 Hgb-13.4 Hct-41.1
MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt ___
___ 06:49AM BLOOD ___ PTT-29.9 ___
___ 06:49AM BLOOD Glucose-172* UreaN-14 Creat-0.6 Na-136
K-3.8 Cl-101 HCO3-28 AnGap-11
___ 06:49AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.2
.
.
=============================
IMAGING:
=============================
___ CT head without contrast
Metastatic disease with large parenchymal hemorrhage in the left
posterior frontal lobe. Mass effect and left cerebral vasogenic
edema noted with 5-mm rightward shift of midline structures.
.
___ CXR
IMPRESSION: No acute cardiopulmonary process.
.
___ MRI head with and without contrast
FINDINGS:
Again seen are multiple enhancing hemorrhagic lesions throughout
the
gray-white matter junction in both cerebral hemispheres, as well
as in the
posterior fossa and left midbrain extending into the pons.
Overall these
lesions have increased in size since the prior study. The
dominant lesion in the left temporal lobe now measures 4.4 x 2.8
cm, compared to 2.1 x 1.9 cm on the prior study (10:56).
Another lesion in the left frontal lobe now measures 10 x 9 mm,
previously measuring 7 x 4 mm (2:59). Surrounding vasogenic
edema has also significantly increased, especially in the left
cerebral hemisphere. No new definite lesion is identified. 6 mm
of midline shift to the right is stable since the recent head
CT.
No extra-axial blood or fluid collection is present. There is
no diffusion abnormality or evidence of acute infarct. The
principal intracranial vascular flow voids are preserved.
Ventricles and sulci are normal in size and configuration. The
basal cisterns remain patent.
IMPRESSION:
Overall increase in size of multiple hemorrhagic metastatic
lesions in the brain.
.
.
=============================
URINE
=============================
___ 09:45AM URINE Color-Straw Appear-Clear Sp ___
___ 09:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:45AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 09:45AM URINE CastHy-9*
___ 09:45AM URINE Mucous-RARE
___ 9:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
=============================
PRIMARY REASON FOR ADMISSION
=============================
___ with metastatic ER positive, PR negative HER2/Neu amplified
breast cancer (mets to bone,liver, lung, brain) s/p whole brain
radiation, on c9 of T-DM1, presenting with seizures and found to
have hemorrhagic brain lesions and midline shift of 5mm
.
.
# Metastatic Breast Cancer, hemorrhagic brain lesions: The
patient was on C9 of T-DM1 and s/p whole brain radiation who
presented after seizure likely caused by progressive brain
metastases. Imaging showed multiple hemorrhagic lesions and
vasogenic edema causing a 5mm midline shift. The patient had
cognitive deficits with language and communication but no other
focal deficits. She was started on high dose dexamethasone and
keppra with cognitive but no other focal deficits or seizure
activity. Neurosurgery did not feel any surgical would be
beneficial. Her outpatient Heme/Onc team recommended possibly
enrolling in a clinical trial of naratonib but her daughter
(HCP) felt her mother would not want to participate in a trial.
Radiation Oncology evaluated and initiated whole brain radiation
on ___ to be continued as an outpatient. Her mental status
improved with steroids and radiation treatment and she will
follow-up with her outpatient providers with the goal of
returning to ___
.
# GERD: Stable. Continued home omeprazole.
.
=============================
TRANSITIONAL ISSUES
=============================
- She will benefit from discussion re: continuing systemic
cancer tx with outpatient onc team. Family was directed to
contact ___ NP for earlier appointmen
- Dexamethasone taper: to be managed by ___ Onc. Will be
discharged on dex 4mg q8hr
- Should have keppra level monitored
- Full Code
Medications on Admission:
___ s/p 5x cycles, whole brain radiation
omeprazole 20 mg daily
Calcium 600 + D(3) 600 mg (1,500 mg)-400 mg BID
Discharge Medications:
1. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Metastatic breast cancer
Discharge Condition:
Mental Status: Confused
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having a seizure at home.
Imaging of your brain unfortunately showed progression of your
metastatic breast cancer as the tumors in your brain had grown
much larger. There was also dangerous swelling around these
lesions so you were started on a medication, dexamethasone, to
help decrease the swelling and a medication, levitiracetem, to
prevent seizures.
Your imaging was evaluated by Neurosurgery who did not feel
there was any surgical intervention; however, the Radiation
Oncologists felt you might benefit from whole brain radiation
again. You had your first session on ___ and will continue as
an outpatient. By the time of discharge, your speech and
thinking had improved.
Again it was our pleasure participating in your care.
We wish you the very best,
-- Your ___ Medicine Team
Followup Instructions:
___
|
19624947-DS-12
| 19,624,947 | 24,536,817 |
DS
| 12 |
2162-10-20 00:00:00
|
2162-10-20 11:31:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
urinary retention/fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ with transfusion dependent MDS now
C1D13 azacytadine, CAD s/p multiple stents, aortic stenosis s/p
porcine valve, previous intracerebral hemorrhage, post-op atrial
fib/flutter, HTN, HLD, and early dementia who presents with
urinary retention and neutropenic fever.
.
He was in his usual state of health through yesterday evening
when he noted difficulty urinating, voiding only a few drops. He
noted frequency with the urge to urinate but could not
significantly void. He noted no dysuria or abdominal pain. He
had constipation as well over the past few days- each of these
symptoms are atypical. While vicodin is noted on his med list,
he has not taken it in 2+ weeks. His medication is administered
by health aides. He has no other new medication changes. This AM
he had a fever to 100.1, which prompted ED referral.
.
Initial ED vitals were T100.3 Pulse: 73, RR: 18, BP: 110/63,
O2Sat: 96, O2Flow: ra. Foley catheter was placed with 500cc
clear urine passed, producing normal urinalysis. Labs revealing
neutropenia with ANC of 880. Otherwise pancytopenic with HCT
20.9 and plt 17. He was treated with vancomycin/cefepime. CXR
wnl, and his blood an urine were cultured prior to admission.
Received APAP.
.
On arrival to the floor, initial vitals were T97.3, P53 RR16
Sat100RA. He is comfortable and has no complaints. He denies any
focal weakness of the extremities. He denies recent bowel or
bladder incontinence. He denies saddle anesthesia. He does
suffer from mild dementia, so his history is at times
incomplete. His caretaker is present, and states that he was
somewhat weak and required assistance with stairs last night,
which is atypical. He denies chest pain or pressure, coughing,
sore throat, congestion, headaches, neck stiffness, photo or
phonophobia, nausea, vomiting, diarrhea, dysuria, hematuria,
BRBPR. No chills, rigors, recent weight changes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ - Found to have a macrocytic anemia when admitted for
fevers. No source of infection identified, but workup of anemia
and mild intermittent thrombocytopenia, led to the diagnosis of
MDS ___ - ___ cytopenia with multilineage dysplasia
with
ringed sideroblasts). Cytogenetics showed no aberration. Patient
received 3 units of PRBC at that admission.
___ - Patient called in with gradually worsening dyspnea
on
exertion. CBC revealed Hb of 7.6 and patient received 2 units of
PRBC.
___ - 2 units of PRBC transfused for symptomatic anemia.
Concomitantly, patient initiated on 300 mcg sc of darbopoetin
alpha.
___ - Darbopoetin alpho dose increased to 600 mcg sc
___ - 2 units of PRBC transfused for symptomatic anemia
___ - 2 units of PRBC transfused
___ - 2 units of PRBC
___ - 2 units of PRBC transfused
___ - cycle 1 d ___ azacytadine
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS:
-CAD s/p stenting to RCA (___) cypher stent to distal RCA;
___: BMS to RCA
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
-H/O post-op Atrial Fibrillation
-Aortic stenosis s/p porcine AVR (___)
-IPH of R parieto-occipital region (___) question amyloidosis
angiopathy ___ with some memory and cognitive deficits.
-Gout
-Upper GI bleed
-Minor cognitive impairment
PAST SURGICAL HISTORY:
-b/l inguinal hernia repair
-deviated septum repair
-tonsillectomy
-b/l saphenous vein stripping
-perforated duodenal ulcer s/p resection ___
-Superficial squamous cell carcinoma f/u w/ dermatology
Social History:
___
Family History:
No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
___.
Physical Exam:
Vitals -T97.3, P53 RR16 Sat100RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD. Pupils 2mm and reactive.
CARDIAC: RRR, S1/S2, ___ SEM at the second RICS, no radiation.
CAnon A waves noted. No JVD.
LUNG: crackles located at the bases bilaterally
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Strength ___ throughout. Sensation
intact in all extremities and groin. Normal RAM. No neck
stiffness.
Discharge PE
less abdominal distention and tenderness in suprapubic area
Pertinent Results:
___ 05:35PM URINE HOURS-RANDOM CREAT-120 SODIUM-88
POTASSIUM-65 CHLORIDE-81
___ 05:35PM URINE OSMOLAL-685
___ 05:35PM URINE opiates-NEG
___ 10:05AM ___ PTT-30.2 ___
___ 10:00AM LACTATE-1.4
___ 10:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:00AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:00AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:00AM URINE MUCOUS-RARE
___ 09:45AM GLUCOSE-136* UREA N-34* CREAT-1.4* SODIUM-137
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 09:45AM estGFR-Using this
___ 09:45AM ALT(SGPT)-23 AST(SGOT)-28 ALK PHOS-67 TOT
BILI-1.1
___ 09:45AM WBC-2.0* RBC-2.29* HGB-7.3* HCT-20.9* MCV-91
MCH-31.8 MCHC-34.8 RDW-18.8*
___ 09:45AM NEUTS-39* BANDS-5 ___ MONOS-25* EOS-0
BASOS-0 ATYPS-3* ___ MYELOS-0 NUC RBCS-1*
___ 09:45AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ACANTHOCY-1+
___ 09:45AM PLT SMR-RARE PLT COUNT-17*
___ BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND MCH-PND
MCHC-PND RDW-PND Plt Ct-PND
___ BLOOD WBC-2.3* RBC-2.82* Hgb-9.1* Hct-26.7* MCV-95
MCH-32.3* MCHC-34.1 RDW-18.1* Plt Ct-27*
___ BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-137 K-3.8
Cl-106 HCO3-23 AnGap-12
Imaging
CXR ___: IMPRESSION: Mild interstitial edema. No focal
consolidation.
Brief Hospital Course:
Mr. ___ is an ___ with transfusion dependent MDS now
C1D13 azacytadine, CAD s/p multiple stents, aortic stenosis s/p
porcine valve, previous intracerebral hemorrhage, post-op atrial
fib/flutter, HTN, HLD, and early dementia who was admitted to
___ for workup of urinary retention and neutropenic fever.
Several studies were completed. A CXR did not show any acute
cardiothoracic process. A UA was not consistent with a UTI.
Blood and urine cultures showed no growth.
The patient was initially given vanc and cefepime. This was
narrowed to cefepime while in the hospital. The patient was
afebrile during his hospitalization. He was found to have a hct
of 20.9 for which he received a unit of PRBCs. His PLTs were
stable during his stay.
The patient had a foley placed for urinary retention. It was
d/c'ed the morning after admission and the patient voided, but
was retaining up to 500cc in his bladder. After discussing
options extensively between the team members and urology
resident and attending Dr. ___ seemed reasonable to place a
foley for a week, send the patient home on
augmentin/ciprofloxacin for 10 days, start flomax, and arrange
for urology followup in one week for a void trial. This plan was
also discussed with his PCP, ___ agreed with the
plan.
It is likely the patient has BPH given his age and presenting
symptoms. We were unable to do a DRE given he is neutropenic.
Keeping the patient in the hospital longer would predispose him
to hospital acquired infections. Given that he is neutropenic
the team was hesitant to send the patient out with a foley. We
decided that sending him out with antibiotics for prophylaxis
would be a good option, and since he already has extensive home
services this would be a safe option.
At the time of discharge, the patient was doing much better and
ready to leave the hospital.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
AMOXICILLIN - 500 mg Capsule - 4 Capsule(s) by mouth once 1 hour
before dental procedure
HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) -
Dosage uncertain
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day replaces omeprazole
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
ACETAMINOPHEN - (Prescribed by Other Provider; ___) - Dosage
uncertain
CANE - Device - use as directed daily dx: spinal stenosis &
compression fracture of spine
HYDROCOLLOID DRESSING [DUODERM CGF EXTRA THIN] - 4" X 4" Bandage
- change dressing every 48-72 hours
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. Hospital bed
Semi-electric hospital bed with gel overlay.
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: last day ___.
Disp:*20 Tablet(s)* Refills:*0*
7. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days: last day ___.
Disp:*20 Tablet(s)* Refills:*0*
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime): Please monitor
for orthostatic hypotension and check blood pressure regularly.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
urinary retention
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 ___ on ___ for workup of your urinary
retention and low grade fever. You were started on IV
antibiotics to cover infection. You had several studies
completed, but no obvious source of infection was detected.
Given that you are neutropenic, it is appropriate to continue a
full course of antibiotics.
Your hematocrit was low, and you recieved a unit of packed red
blood cells. Your hematocrit responded appropriately after the
transfusion. Your blood counts were closely monitored during
your stay.
After removing your foley catheter, you were able to void, but
it was found that you were retaining a significant amount of
urine in your bladder. The foley catheter was placed again and
you will go home with the foley. It will remain in until your
appointment with Dr. ___, in which a void trial will be
attempted.
We believe you have a condition called benign prostate
hypertrophy, more commonly known as BPH. This is usually
confirmed with a digital rectal exam, but since you are
neutropenic, this exam is not safe. You were started on a
medication for BPH called flomax.
The following medications were added to your med list upon
discharge:
augmentin
ciprofloxacin
flomax 0.4mg qhs
Please attend the appointments listed below.
Thank you for allowing us at ___ participate in your care.
Followup Instructions:
___
|
19624947-DS-13
| 19,624,947 | 24,177,276 |
DS
| 13 |
2162-11-07 00:00:00
|
2162-11-08 20:18:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
OMED ADMIT NOTE ___ 22:30
___ y/o M with MDS, CAD s/p stent in ___ and dementia who came
in to clinic this am for scheduled chemotherapy but this was
held due to hypotension and reported left sided chest pain. Pt
is demented and not able to answer questions appropiately but
per chart, he had BP at home this AM 70/50 with some dizziness
and about 10 minutes of left-sided chest pain. No sob or
diaphoresis associated with the chest pain. Pt received IVFs in
clinic and BP improved to SBPs 100s, pt was sent to ED for eval
due to changes in EKG.
In ED, BP 112/81, EKG showed atrial flutter and TW inversions in
V1 and III, which are similar to EKG from ___. Cardiac
enzymes negative x 1. Pt received 2 units in ED.
Currently, pt denies any complaints, just wants to go home.
Denies HAs, dizziness, lightheadedness, chest pain, cough,
urinary problems, diarrhea, constipation.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ - Found to have a macrocytic anemia when admitted for
fevers. No source of infection identified, but workup of anemia
and mild intermittent thrombocytopenia, led to the diagnosis of
MDS ___ - ___ cytopenia with multilineage dysplasia
with
ringed sideroblasts). Cytogenetics showed no aberration. Patient
received 3 units of PRBC at that admission.
___ - Patient called in with gradually worsening dyspnea
on
exertion. CBC revealed Hb of 7.6 and patient received 2 units of
PRBC.
___ - 2 units of PRBC transfused for symptomatic anemia.
Concomitantly, patient initiated on 300 mcg sc of darbopoetin
alpha.
___ - Darbopoetin alpho dose increased to 600 mcg sc
___ - 2 units of PRBC transfused for symptomatic anemia
___ - 2 units of PRBC transfused
___ - 2 units of PRBC
___ - 2 units of PRBC transfused
___ - cycle 1 d ___ azacytadine
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS:
-CAD s/p stenting to RCA (___) cypher stent to distal RCA;
___: BMS to RCA
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
-H/O post-op Atrial Fibrillation
-Aortic stenosis s/p porcine AVR (___)
-IPH of R parieto-occipital region (___) question amyloidosis
angiopathy ___ with some memory and cognitive deficits.
-Gout
-Upper GI bleed
-Minor cognitive impairment
PAST SURGICAL HISTORY:
-b/l inguinal hernia repair
-deviated septum repair
-tonsillectomy
-b/l saphenous vein stripping
-perforated duodenal ulcer s/p resection ___
-Superficial squamous cell carcinoma f/u w/ dermatology
Social History:
___
Family History:
No coagulopathy, aneurysms, stroke. No known cardiopulmonary
disease. His parents lived until they reached ages greater than
___.
Physical Exam:
Exam
VS T current 96.7 BP 118/60 HR 56 RR 18 O2sat
97%RA
Gen: In NAD, confused, Ox1 (person).
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: irregularly irregular, + murmur, no rubs, gallops.
Abdomen: soft, NT, slightly distended, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 1, CN II-XII intact,
strenght ___ throughout.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
.
DISCHARGE EXAM
96.6, 123/86, 90-105, 20, 98RA
Gen: In NAD, mildly demented, Ox2 (person+place).
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: irregularly irregular, ___ SEM, no rubs, gallops.
Abdomen: soft, NT, slightly distended, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 1, CN II-XII intact,
strength ___ throughout.
Skin: No rashes or ulcers.
GU: no foley
Pertinent Results:
___ 02:03PM BLOOD WBC-2.1* RBC-2.61* Hgb-8.0* Hct-22.9*
MCV-88 MCH-30.8 MCHC-35.1* RDW-17.1* Plt Ct-53*
___ 03:30PM BLOOD WBC-2.1* RBC-2.74* Hgb-8.3* Hct-24.2*
MCV-88 MCH-30.4 MCHC-34.4 RDW-18.0* Plt Ct-58*
___ 07:35AM BLOOD WBC-2.2* RBC-3.35* Hgb-10.4*# Hct-29.1*
MCV-87 MCH-31.0 MCHC-35.8* RDW-16.6* Plt Ct-55*
___ 06:25AM BLOOD WBC-2.5* RBC-3.42* Hgb-10.8* Hct-29.6*
MCV-86 MCH-31.5 MCHC-36.5* RDW-16.7* Plt Ct-53*
___ 03:30PM BLOOD Neuts-25* Bands-0 Lymphs-61* Monos-12*
Eos-0 Baso-0 ___ Metas-2* Myelos-0
___ 07:35AM BLOOD Neuts-26* Bands-5 Lymphs-57* Monos-2
Eos-1 Baso-1 Atyps-8* ___ Myelos-0
___ 06:25AM BLOOD Neuts-26* Bands-0 Lymphs-67* Monos-6
Eos-0 Baso-1 ___ Myelos-0
___ 06:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Burr-1+ Acantho-OCCASIONAL
___ 03:30PM BLOOD ___ PTT-33.3 ___
___ 03:30PM BLOOD Glucose-106* UreaN-21* Creat-1.2 Na-134
K-4.7 Cl-102 HCO3-25 AnGap-12
___ 07:35AM BLOOD Glucose-92 UreaN-21* Creat-1.2 Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
___ 06:25AM BLOOD Glucose-95 UreaN-19 Creat-1.1 Na-139
K-4.3 Cl-106 HCO3-25 AnGap-12
___ 01:00AM BLOOD CK(CPK)-32*
___ 07:35AM BLOOD ALT-49* AST-30 CK(CPK)-35* AlkPhos-71
TotBili-1.1
___ 03:30PM BLOOD CK-MB-2
___ 03:30PM BLOOD cTropnT-<0.01
___ 01:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:35AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
___ 07:35AM BLOOD VitB12-___*
___ 07:35AM BLOOD TSH-2.6
___ 03:43PM BLOOD Lactate-0.9
.
EKG:
Baselne artifact. Atrial flutter with 4:1 conduction. RSR'
pattern
in lead V1 may be due to flutter waves. Mild non-specific ST
segment
flattening in the limb leads. Compared to the previous tracing
of ___,
A-V conduction is more regular at 4:1 with a slower overall
ventricular rate. Right precordial electrode placement is now
correct. T wave amplitude in leads V4-V5 is lower, proportional
to reduction in QRS amplitude. Repolarization abnormalities are
unchanged.
-Decreased pre-cordial voltage resolved on repeat EKG obtained
on the medical floor when the patient was normotensive.
.
CXR:
The lungs are hyperinflated, consistent with COPD. There is
moderate
cardiomegaly. The aorta is calcified and tortuous. There is no
CHF, focal
infiltrate, or gross effusion. Again seen isdense biapical
pleural thickening.
.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
.
UA negative
Brief Hospital Course:
.
Dr. ___ is an ___ year-old gentleman with MDS, dementia, and
CAD s/p PTCI with BMS in ___ and ___. He was admitted with
anemia, hypotension, and chest pain, all of which resolved
status post transfusion of 2 units of packed red cells.
.
# Hypotension: Pt responded to IVFs and blood transfusion
(2uPRBC) and has remained hemodynamically stable. Infectious
screen negative with bland UA and blood cultures negative to
date. CXR unremarkable. Etiology remains somewhat unclear as has
not had hypotension with anemia in the past, but hypotension did
not recur over the 36 hours he was observed after transfusion
and fluid resuscitation.
.
# MDS: He has been receiving azacitadine and is now on cycle #2
(day 3). Plans for furhter treatment are on hold as there is
some suspicion by oncology that the azacitadine in conjunction
with high-dose zofran could be worsening his symptoms. He was
kept on neutopenic precautions during this admission.
.
# Chest pain / CAD s/p PTCI: His statin was continued. He is
neither on a beta-blocker or an anti-platelet agent as an
outpatient (thrombocytopenia). Cardiac enzymes were negative.
There were no ischemic EKG changes compared to priors. If CP was
cardiac, then it may have been related to demand in setting of
anemia. He denies ever having had exertional chest pain. He
will follow-up with his cardiologist within the next week.
.
# Atrial Flutter: Rate-controlled. Not anti-coagulated.
.
# Dementia: Has 24 hour care at baseline and does quite well in
his current living situation.
.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - one Tablet(s) by
mouth four times a day as needed for nausea
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day replaces omeprazole
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by
mouth twice a day
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider; OTC) - Dosage
uncertain
CANE - Device - use as directed daily dx: spinal stenosis &
compression fracture of spine
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day as needed for
constipation
GUAR GUM [BENEFIBER (GUAR GUM)] - (Prescribed by Other
Provider)
- Packet - 1 Packet(s) by mouth twice daily
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - (Prescribed by Other
Provider) - 400 mg/5 mL Suspension - 2 tablespoons by mouth once
nightly
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
2. amoxicillin 500 mg Tablet Sig: Four (4) Tablet PO once as
needed for before dental procedures.
3. Zofran 4 mg Tablet Sig: One (1) Tablet PO four times a day as
needed for nausea.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO twice a day.
7. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
9. Benefiber (guar gum) Packet Sig: One (1) PACKET PO twice
a day.
10. Milk of Magnesia 400 mg/5 mL Suspension Sig: Two (2)
TABLESPOONS PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Myelodysplastic Syndrome / Anemia / Neutropenia
Hypotension (etiology unclear)
Atrial Flutter, rate controlled
CAD s/p PTCI
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to the hospital after an episode of low blood
pressure and chest pain. ___ were given 2 units of blood and
your symptoms resolved. EKGs and blood tests showed that there
was no damage to your heart.
___ were observed for over 24 hours and did not have any fevers
or recurrence of low blood pressure.
We discussed your care with Dr. ___ thinks it is best to
hold off on the remainder of this cycle of azacitadine. He will
address further treatment with ___ at the appointment below.
None of your medications have been changed.
If ___ develop chest pain at rest or a worsening pattern with
ambulation, then ___ should present to the emergency department
immediately. If ___ notice fevers or chills, please call the
office of Dr. ___ present to the emergency department for
further evaluation.
Followup Instructions:
___
|
19625205-DS-15
| 19,625,205 | 25,771,702 |
DS
| 15 |
2154-08-26 00:00:00
|
2154-08-26 15:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
3 day hx of headache, blurry vision, malaise
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a pleasant ___ year old female who presents to
___ ED after suffering a posterior headache since ___. Although the patient has a remote history of migraines,
they have not been an issue in years. Mrs. ___ states
that three weeks ago, she had a headache affecting the left side
of her head. It was sudden but was short lasting. She did not
take any medications to treat the headache.
Three days ago, the patient says she began to have a posterior
headache (bilaterally), intermittent in nature. She had no
associated nausea, vomiting, photophobia, or neck pain. Again,
she did not take any oral medications to relieve the pain.
Because she has had an overall feeling of malaise and lack of
energy, she came to the ED for evaluation. At the time of my
evaluation, she had a very minor, dull headache of ___.
Past Medical History:
HTN, HLD, DM, GERD
Social History:
___
Family History:
NC
Physical Exam:
O: T 99.2 HR 109 SBP 177/59 RR 16 O2 Sat 96% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation not tested.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch, proprioception, bilaterally.
Toes downgoing bilaterally
Pertinent Results:
___ CT Head:
1. Hyperdense collection consistent with acute hemorrhage in the
suprasellar cistern, with extension into the right ambient
cistern. No appreciable mass effect or evidence of
hydrocephalus.
2. Please note that MR is more sensitive in the detection of
intracranial
masses.
NOTE ON ATTENDING REVIEW:
The above mentioned slightly heterogeneous hyperdense focus, in
the suprasellar location predominantly in the hypothalamus, with
extension towards the right side, can represent a mass lesion
(primary or metastatic) with heterogeneous cellular component or
some hemorrhage within or cyst with dense contents rather than
pure hemorrhage itself.
The optic chiasm is not well seen on the present study with
likely mass effect by the focus.
Correlate with ophthalmologic examination.
There is displacement of the adjacent vessels, better seen on
the subsequent CT angiogram study. Further workup with MRI of
the head without and with IV contrast if not contraindicated and
further systemic workup as needed.
___ CTA Head:
No flow-limiting stenosis, occlusion, or aneurysm greater than 3
mm in the cerebral vasculature.
___ MRI Brain:
Suprasellar and hypo thalamic mass J-tube a signed area
measuring approximately 1.5 cm in size. The appearance is most
likely due to a craniopharyngioma.
___ CT ABD/Pelvis:
No evidence of malignancy in the abdomen or pelvis.
Brief Hospital Course:
Patient presented to ___ with complaints of headache, blurry
vision, and malaise and was admitted to ___ ICU for workup of
concern for pre-pontine hemorrhage. CTA was negative and an MRI
was ordered. the MRI was obtained and showed a
suprasellar/hypothalmic mass likely representing a
cranipharyngioma.
On ___ she was started on dexamethasone. She was transferred
from the ICU to the floor. CT torso was negative for malignancy.
On ___ she underwent formal ophthalmologic examination. She was
noted to have a subtle visual field cut (L lateral visual
field), decreased visual acuity in R eye but can detect motion.
Her reflexes were brisk, R toe up, but she was otherwise neuro
intact otherwise neuro-intact. Visual field testing was
consistent with chiasmal compression representing significant
vision loss.
On ___, the patient remained neurologically stable on
examination. The ___ Clinic was consulted for management; she
was restarted on Metformin.
On ___, the patient remained neurologically stable. ___
Diabetes came to counsel the patient on changes to her home
insulin and metformin doses. Endocrine was consulted to
determine endocrine stability and to establish outpatient follow
up. They felt that she was hightly unlikely to have any adrenal
insufficiency. A panel of labs were ordered to assess her
endocrine function which were added onto her labs prior to the
start of decardron. An appointment was set up for the the
patient the following day with Dr. ___. An endocrine follow up
appointment was also established.
Medications on Admission:
Pravachol 40mg', alendronate 70mg weekly, cholecalciferol 2,000
units (two capsules daily), ergocalciferol 50,000 units capsule
weekly, lisinopril 30mg daily, metformin ER 500'', omeprazole
20mg daily.
Discharge Medications:
1. Lisinopril 30 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
Please make sure to take this while you are taking the
dexamethasone.
3. Pravastatin 40 mg PO QPM
4. Vitamin D ___ UNIT PO DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
6. Alendronate Sodium 70 mg PO QSUN
7. MetFORMIN XR (Glucophage XR) 500 mg PO BID
RX *metformin 500 mg 2 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
RX *metformin 500 mg 2 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
8. Dexamethasone 4 mg PO Q8H Duration: 3 Doses
RX *dexamethasone 4 mg per taper tablet(s) by mouth per taper
Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Suprasellar mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you had a headache and changes
in your vision. After you received an MRI we found that you had
an area concerning for a mass near your optic chiasm, the tract
through which your visual pathways travel. Because this is the
first time this mass has been observed, it is unclear how long
it has been there or how quickly it is changing. We recommend
survelliance to determine whether surgery would be appropriate
or not. For this reason we are discharging you home, with
follow-up in neurosurgery with Dr. ___.
You were started on dexamethasone, a steroid medication to
reduce swelling. We are reducing this slowly to prevent rebound.
You should take the full taper. This medication can increase
your blood sugars. You should follow up with your primary care
provider. Your Metformin was increased from 500mg twice a day to
1000mg twice a day.
Followup Instructions:
___
|
19625372-DS-12
| 19,625,372 | 24,970,847 |
DS
| 12 |
2146-03-11 00:00:00
|
2146-03-11 17:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral hip pain
Major Surgical or Invasive Procedure:
Left Eye Laceration Repair
History of Present Illness:
___ pedestrian struck by motor vehicle today, ___. Pt was
transferred to ___. Upon presentation pt had GCS 15. Endorses
HS but denies LOC. Pt reports she did not attempt to ambulate
following the accident. Denies Numbness/weakness/parasthesias.
Describes pain in her right shoulder and in her bilateral hips.
Past Medical History:
PMH: HTN
PSH: None
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Admission Physical Exam:
HR: 80 BP: 125/80 Resp: 17 O(2)Sat: 93 Normal
Constitutional: Constitutional: Lying in stretcher,
protecting airway
Head / Eyes: NC, laceration to the L lateral aspect of the
lower lid, able to open and close eyelid. PERRL
Back: +midline TTP over the L spine. no midline TTP over the
c & t spine, no step-off or deformity.
ENT: OP WNL
Resp: CTAB
Cards: RRR
Abd: S/NT/ND
Pelvis stable
Skin: abrasions over the anterior knees, L hip, medial
aspect of the L great toe, L hand
Ext: Grossly moving all extremities, abrasions as noted. No
gross deformity or open wounds. Distal CMS intact.
Neuro: speech fluent
Psych: normal mood
Discharge Physical Exam:
Gen: Awake, alert, sitting up in bed.
CV: RRR
Pulm: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended. Active bowel sounds
Ext: Warm and dry. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 10:31AM BLOOD WBC-8.0 RBC-3.97 Hgb-12.3 Hct-37.9 MCV-96
MCH-31.0 MCHC-32.5 RDW-11.9 RDWSD-41.6 Plt ___
___ 11:39AM BLOOD WBC-8.5 RBC-3.87* Hgb-12.5 Hct-36.7
MCV-95 MCH-32.3* MCHC-34.1 RDW-12.5 RDWSD-43.1 Plt ___
___ 06:40AM BLOOD WBC-8.8 RBC-3.72* Hgb-11.3 Hct-35.3
MCV-95 MCH-30.4 MCHC-32.0 RDW-12.5 RDWSD-43.4 Plt ___
___ 06:40PM BLOOD WBC-9.8 RBC-4.20 Hgb-13.0 Hct-39.4 MCV-94
MCH-31.0 MCHC-33.0 RDW-12.2 RDWSD-42.1 Plt ___
___ 10:31AM BLOOD Glucose-86 UreaN-9 Creat-0.8 Na-133 K-4.2
Cl-94* HCO3-27 AnGap-16
___ 11:39AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-102 HCO3-26 AnGap-14
___ 06:40AM BLOOD Glucose-90 UreaN-16 Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
___ 10:31AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
___ 11:39AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
___ 06:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9
___ 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:52PM BLOOD pO2-36* pCO2-45 pH-7.37 calTCO2-27 Base
XS-0
___ 06:52PM BLOOD Glucose-99 Lactate-1.2 Na-139 K-3.4
Cl-103
___ 06:52PM BLOOD Hgb-13.7 calcHCT-41 O2 Sat-65 COHgb-2
MetHgb-0
___ CXR:
1. No acute cardiopulmonary abnormality
2. Mildly displaced right acetabular and right inferior pubic
rami fractures,
and left sacral fracture. Left inferior pubic rami fracture is
better
evaluated on CT performed on same day.
___ CT Head:
1. Mild left periorbital soft tissue swelling, with no
underlying fracture.
2. No acute intracranial process.
3. Paranasal sinus disease as described.
___ CT C-Spine:
No fracture or traumatic malalignment.
___ CT Ch/ab/pelvis
1. Multiple acute pelvic fractures, including minimally
displaced fractures of the left sacrum, right anterior
acetabulum, and bilateral inferior pubic rami.
2. There is a tiny ossific density posterior to the right
humeral head, with no clear donor site, may be due to calcific
tendinitis. No right shoulder dislocation or gross fracture.
3. Fibroid uterus.
4. Multiple simple hepatic cysts and simple right renal cyst.
5. Subcentimeter cystic lesions in the pancreas, potentially
IPMNs.
___ Pelvis/femur:
Acute fractures through the right superior pubic ramus,
bilateral inferior
pubic rami and left sacral ala are as seen on prior CT scan.
Pubic symphysis and SI joints are preserved. No new fracture
identified. The left femur is intact. The femoroacetabular
joint is anatomically aligned. Excreted contrast is seen within
the bladder.
___ Shoulder/Humorus:
No fracture or dislocation.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Trauma
Surgery service on ___ after being struck by a car in a
parking lot. Imaging revealed bilateral superior and inferior
pubic rami fractures and a left sacral fracture consistent with
an LC1 type pelvic ring fracture. She was evaluated by
orthopedic surgery who determined her injuries to be
non-operative. She sustained a laceration to the left eye which
was sutured by plastic surgery. She was admitted to the floor
hemodynamically stable for pain control and further management.
On HD1 she was given IV and oral pain medication with good
effect. She was seen by physical therapy who recommended
discharge to rehab and the patient was in agreement with the
plan. Tertiary survey was preformed and did not reveal any
further injuries.
The patient was alert and oriented throughout hospitalization.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored.
The patient remained stable from a pulmonary standpoint. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient tolerated a
regular diet; intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible. On HD6 her facial sutures
were removed by the plastic surgery team.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged to
___ rehab.
Medications on Admission:
Lisinopril 20mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4 grams/ 24 hours
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
take lowest effective dose.
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral Pubic Rami Fractures
Right Acetabular Fracture
Left Sacral Fracture
Left Eye Laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after being struck by a car. You were found to have multiple
fractures in your pelvis. You were evaluated by the orthopedic
surgery team and your injuries were determined to be
non-operative. Continue to ambulate as tolerated and follow up
in the ___ clinic at your scheduled appointment.
You sustained a laceration on your face that was sutured by
plastic surgery. The sutures were removed in the hospital. You
can continue to shower and leave the area open to air.
You were seen by the physical therapist who recommend discharge
to a rehabilitation facility to regain your strength.
You are now doing better, pain is better controlled, and you are
ready to be discharged to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions.
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o Your pain medicine will work better if you take it before
your pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19625440-DS-15
| 19,625,440 | 20,550,624 |
DS
| 15 |
2127-06-07 00:00:00
|
2127-06-09 14:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, lysis of adhesions
History of Present Illness:
___ with h/o MI, s/p PTCA on ASA/Plavix, lymphoma s/p chemo
finished 2 months ago who presented to ___ this AM with severe
diffuse abdominal pain. CT scan at ___ showing dilated small
bowel concerning for a closed loop bowel obstruction. He
currently denies any pain. no N/V. +BM/Flatus this AM. No
fevers/chills. No chest pain/SOB.
Past Medical History:
PMH: HL, MI, CHF EF 50%, lymphoma s/p chemotherapy last session
___
PSH: PTCA/S RCA ___, port placement, port removal,
mediastinoscopy
Social History:
___
Family History:
Father died at age ___ from an MI
Physical Exam:
Upon admission:
Vitals:98.0 98 120/71 16 98%
Gen: NAD
CV: RRR
Abd: Soft, minimally tender b/l LQ. No distension, no
peritoneal
signs.
Ext: no c/c/e
Discharge PE:
Gen: NAD
HEENT: NT/NC
CV: RRR
Lungs: CTA
Abd: soft, ND, mild tenderness x4quads
ext: no c/c/e
Pertinent Results:
___ 05:45PM BLOOD WBC-12.7*# RBC-4.47* Hgb-12.8* Hct-38.8*
MCV-87 MCH-28.5 MCHC-32.9 RDW-15.8* Plt ___
___ 07:25AM BLOOD WBC-9.9 RBC-3.90* Hgb-11.1* Hct-33.7*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.6* Plt ___
___ 10:10PM BLOOD WBC-6.7 RBC-3.99* Hgb-11.5* Hct-34.3*
MCV-86 MCH-28.8 MCHC-33.5 RDW-15.6* Plt ___
___ 05:16AM BLOOD WBC-10.3# RBC-3.75* Hgb-10.6* Hct-32.4*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.6* Plt ___
___ 06:25AM BLOOD WBC-6.5 RBC-3.64* Hgb-10.5* Hct-31.4*
MCV-86 MCH-28.8 MCHC-33.4 RDW-15.6* Plt ___
___ 05:45PM BLOOD Glucose-102* UreaN-21* Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-25 AnGap-15
___ 05:58AM BLOOD Glucose-131* UreaN-21* Creat-0.8 Na-135
K-4.5 Cl-103 HCO3-23 AnGap-14
___ 07:25AM BLOOD Glucose-131* UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-11
___ 10:10PM BLOOD Glucose-132* UreaN-10 Creat-0.7 Na-139
K-3.1* Cl-101 HCO3-27 AnGap-14
___ 05:16AM BLOOD Glucose-105* UreaN-10 Creat-0.7 Na-137
K-3.7 Cl-102 HCO3-30 AnGap-9
___ 10:08AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
___ 06:25AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-140
K-3.2* Cl-105 HCO3-29 AnGap-9
___ 05:45PM BLOOD ALT-16 AST-21 AlkPhos-76 TotBili-0.3
___ 10:10PM BLOOD CK(CPK)-232
___ 05:16AM BLOOD CK(CPK)-171
___ 02:50PM BLOOD CK(CPK)-160
___ 05:45PM BLOOD Lipase-18
___ 10:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:16AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:50PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:25AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1
___ 06:25AM BLOOD %HbA1c-5.3 eAG-105
___ 11:54PM BLOOD Type-ART pO2-236* pCO2-36 pH-7.48*
calTCO2-28 Base XS-4 Intubat-NOT INTUBA Comment-NON-REBREA
Imaging:
___ CT torso
IMPRESSION:
1. Negative for pulmonary embolism.
2. Mild bibasilar atelectasis and small pleural effusions.
Emphysema.
3. Pneumoperitoneum and small amount of free fluid, likely
post-operative.
4. No evidence of bowel obstruction or ischemia.
5. Bladder wall thickening. Correlate for history of UTI or
outlet
obstruction.
___ ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45 %) secondary to inferior posterior
hypokinesis. The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal with depressed
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Pt was admitted on ___ under the acute care surgery service
for management of his small bowel obstruction. He was taken to
the operating room and underwent a Exploratory laparotomy with
lysis of adhesions. Please see operative report for details of
this procedure. He tolerated the procedure well and was
extubated upon completion. He was subsequently taken to the PACU
for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of ___
to regular, which he tolerated without abdominal pain, nausea,
or vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic.
Pt BC from ___ was positive for GRAM POSITIVE COCCI IN CLUSTERS
on ___. Pt was placed on IV abx and transitioned to PO abx
before discharge.
Pt had an episode of CP on ___ and had serial ekgs and
cardiac enzymes which did not show any signs of ischemia. Pt
also had an echo performed.
Medications on Admission:
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Valsartan 80 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*20 Tablet
Refills:*0
7. Levofloxacin 750 mg PO Q24H Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with abdominal pain and had a CT scan
which showed a small bowel obstruction. You were taken to the
operating room for exploratory laparotomy and lysis of
adhesions. Your bowel function has returned and you have resumed
a regular diet.
Please follow up in ___ clinic at the appointment sdcheduled for
you below.
You also had a blood culture that was positive for bacteria. You
will be placed on medication for this. Please complete the full
course of medication.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. 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 from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. 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 folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
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:
___
|
19625808-DS-10
| 19,625,808 | 23,180,703 |
DS
| 10 |
2180-05-30 00:00:00
|
2180-06-01 13:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ondansetron / Linzess / codeine / Percocet /
Reglan
Attending: ___.
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of IDDM and stage 5 CKD on PD
as of ___ who presents with cough and fevers.
Pt was admitted for one on ___ with abdominal pain. CT A/P as
well as peritoneal fluid all negative for intra-abdominal
infection. She was treated with oral clindamycin and topical
gentamicin for superficial infection of the PD catheter site.
Pt reports experiencing cough, fever, and chills x2 days. Fevers
up to 101.4. She also reports hoarse voice but denies dyspnea or
chest discomfort. Her abdominal pain has improved but she
expresses concern that her PD catheter is draining very slowly.
Her husband has had a recent viral illness. She denies N/V or
changes in BM. Endorses poor appetite since starting PD.
In the ED, initial vitals were: 100.4 88 133/53 17 100% RA.
- Labs were significant for WBC 3.9, H&H 11.7/36.1 at baseline,
normal lactate.
- Imaging revealed: CXR with RLL PNA.
- The patient was given vancomycin, cefepime, and azithromycin.
Vitals prior to transfer were: 98.2 71 122/59 15 95% RA.
Pt was seen by renal who recommended peritoneal fluid analysis.
Upon arrival to the floor, VS are: 98.3 124/47 77 16 95% on RA.
She has undergone 3 PD sessions today. She usually does 4. She
does not do PD overnight and requests if it can be done in am.
Pt reports cough but denies pain or dyspnea or abd pain.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
- IDDM
- Peripheral Neuropathy
- Chronic Kidney Disease Stage IV (GFR ___
- Gastroparesis
- OSA
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- h/o Bulemia
Past surgical history: L BC AVF ___ (___), L breast
lumpectomy ___, R breast lumpectomy ___, appendectomy
Social History:
___
Family History:
No history of diabetes or kidney disease
Physical Exam:
ADMISSION EXAM:
--------------
Vitals: 98.3 124/47 77 16 95% on RA
General: Alert, oriented, no acute distress. no conversational
dyspnea
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
along left sternum
Lungs: decreased breath sound in the right LL with mild crackles
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.
Skin: PD catheter with dressing c/d/i, no surrounding erythema
c/f infection. mildly tender in that area.
DISCHARGE EXAM:
--------------
Vitals: Tm/Tc 97.8 119/49 64 18 95%RA
General: Alert, oriented, no acute distress. no conversational
dyspnea
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
along left sternum
Lungs: decreased breath sounds in the bases b/l with diffuse
rales
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.
Skin: PD catheter with dressing c/d/i, no surrounding erythema
c/f infection. mildly tender in that area.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:30PM PLT COUNT-287
___ 12:30PM NEUTS-75.5* LYMPHS-16.6* MONOS-5.0 EOS-2.2
BASOS-0.7
___ 12:30PM WBC-3.9* RBC-3.73* HGB-11.7* HCT-36.1 MCV-97
MCH-31.5 MCHC-32.5 RDW-13.0
___ 12:30PM ALBUMIN-3.6 CALCIUM-8.2* PHOSPHATE-3.9
MAGNESIUM-2.1
___ 12:30PM LIPASE-37
___ 12:30PM ALT(SGPT)-26 AST(SGOT)-32 ALK PHOS-140* TOT
BILI-0.1
___ 12:30PM GLUCOSE-169* UREA N-32* CREAT-3.6* SODIUM-135
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14
___ 12:36PM LACTATE-0.9
___ 02:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:00PM URINE MUCOUS-RARE
___ 04:00PM URINE RBC-1 WBC-2 BACTERIA-MANY YEAST-NONE
EPI-5 TRANS EPI-<1
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:00PM URINE UCG-NEGATIVE
___ 04:00PM URINE HOURS-RANDOM
___ 04:10PM ASCITES WBC-3* RBC-5* POLYS-2* LYMPHS-3*
MONOS-84* EOS-4* MESOTHELI-7*
___ 04:10PM ASCITES TOT PROT-0.3 GLUCOSE-401
MICRO:
=====
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
___ 1:59 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ URINE URINE CULTURE-PENDING INPATIENT
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ 6:11 pm PERITONEAL FLUID PERITONEALFLUID.
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.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY EMERGENCY WARD
___ 4:10 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
URINE CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ SWAB WOUND CULTURE-FINAL EMERGENCY WARD
WOUND CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
IMAGING/STUDIES:
===============
___ Imaging ABDOMEN (SUPINE & ERECT
IMPRESSION:
Prominent air distended loops of small bowel on the left abdomen
on the supine view, not well seen on the upright view, may
relate to peristalsis or focal ileus. Small air-fluid levels
scattered in the colon are nonspecific and could be normal
versus related to the mild gastroenteritis. No evidence of high
grade bowel obstruction.
___ Imaging CHEST (PA & LAT)
FINDINGS:
Right lower lobe consolidation is seen, consistent with
pneumonia. The left lung is clear. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are unremarkable.
IMPRESSION:
Right lower lobe pneumonia.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
New heterogeneity in the right lower lobe consolidation could be
some
improvement since ___ or development of cavitation. There
is no definite pleural effusion or consolidation elsewhere.
Heart size is normal. No definite hilar adenopathy.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Lower lung volumes. No change in appearance of the known right
basal pneumonia and the known left basilar atelectasis. Mild
cardiomegaly without pulmonary edema. No larger pleural
effusions.
DISCHARGE LABS:
==============
___ 08:25AM BLOOD WBC-2.9* RBC-3.54* Hgb-11.2* Hct-33.3*
MCV-94 MCH-31.7 MCHC-33.7 RDW-13.1 Plt ___
___ 08:25AM BLOOD Glucose-125* UreaN-18 Creat-3.3* Na-134
K-3.9 Cl-96 HCO3-29 AnGap-13
___ 08:25AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ with history of IDDM and stage 5 CKD on PD
as of ___ who presents with cough and fevers.
# PNA: The patient presented with cough and fevers and was found
to have a RLL infiltrate on CXR. She was started on
vanc/cefepime/azithromycin in the ED (___) due to concern for
HCAP. On ___ vanc/cefepime/azithro were stopped and she was
switched to levofloxacin; however later that day she developed a
fever and felt worse and so vanc/cefepime were added back to
levofloxacin. She remained afebrile for the next ___ hours and so
then vanc/cefepime were stopped and she continued on
levofloxacin, finishing a 7-day course of antibiotics by day of
discharge. Her urine and blood cultures remained negative. For
cough, she was continued on guaifenisin and benzonatate PRN.
# ESRD on PD: Pt was started on PD in ___. She was recently
(___) admitted for superficial infection of catheter site. Exam
during this hospitalization was reassuring for infection.
Peritoneal fluid was sent off for culture twice during
hospitalization and analysis is reassuring for infection. She
had been started on clindamycin for a superficial cellulitis
around the PD catheter site prior to this admission. This
stopped given that the patient was taking other antibiotics for
pneuomonia; it also caused her to have diarrhea. She was
continued on gentamycin topical and was also started on
mupiricin topical ointment for a two week course. She was
continued on PD and followed by the nephrology service.
# Diarrhea: The patient reported diarrhea at home in the setting
of taking clindamycin. C. diff this admission was negative.
Clindamycin was changed to topical mupiricin for a 2 week course
(in addition to gentamicin).
# Yeast infection: The patient complained of a yeast infection
and received 150 mg fluconazole PO.
# IDDM: The patient has a history of IDDM c/b gastroparesis and
neuropathy. She was continued on home ISS and glargine 6U qHS.
CHRONIC ISSUES
#Psych: The patient was continued on home ClonazePAM,
Dextroamphetamine, Fluoxetine, LaMOTrigine 200 mg PO BID,
modafinil
#Hypothyroidism: The patient was continued on home
levothyroxine.
#GERD: The patient was continued on home pantoprazole.
#Migraines: The patient was continued on topiramate. She was
given sumatriptan once for a headache.
#Chronic pain/neuropathy: The patient was continued on home
gabapentin.
# CODE STATUS: full code
# CONTACT: husband ___ ___
TRANSITIONAL ISSUES:
- Mupiricin ointment was added to gentamycin to apply to PD
catheter site for two weeks, instead of clindamycin, as this
caused diarrhea.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Fluoxetine 60 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Gabapentin 600 mg PO QHS
6. LaMOTrigine 200 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lubiprostone 24 mcg PO BID
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. Sumatriptan Succinate ___ mg PO ONCE
12. Topiramate (Topamax) 25 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. modafinil 300 oral AM
15. modafinil 200 mg ORAL AS DIRECTED
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Gentamicin 0.1% Cream 1 Appl TP DAILY
18. Clindamycin 300 mg PO Q8H
19. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
20. Polyethylene Glycol 17 g PO DAILY
21. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. ClonazePAM 1 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 60 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Gabapentin 600 mg PO QHS
7. Gentamicin 0.1% Cream 1 Appl TP DAILY
8. LaMOTrigine 200 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Lubiprostone 24 mcg PO BID
11. modafinil 300 oral AM
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Topiramate (Topamax) 25 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID:PRN Disp #*60
Capsule Refills:*0
19. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q4H:PRN
cough
RX *dextromethorphan-guaifenesin ___ DM Diabetic] 100
mg-10 mg/5 mL 5 mL by mouth Q4H:PRN Refills:*0
20. Multiple Vitamins Liq. 5 mL PO DAILY
RX *therapeutic multivitamin 5 mL by mouth Daily Disp #*1 Pint
Refills:*0
21. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % 1 Appl twice a day Refills:*0
22. modafinil 200 mg ORAL AS DIRECTED
23. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pneumonia
Secondary diagnoses:
ESRD on PD
Diabetes
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
because you were having fevers and a cough. You were found to
have a pneumonia and you were treated with a course of
antibiotics. You stopped having fevers and you were showing some
improvement and so you were determined safe to go home. You were
having diarrhea but you were found not to have an infection in
your GI tract called C.diff.
You have the following appiontments listed below.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team.
Followup Instructions:
___
|
19625808-DS-11
| 19,625,808 | 23,981,245 |
DS
| 11 |
2180-06-06 00:00:00
|
2180-06-06 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ondansetron / Linzess / codeine / Percocet /
Reglan
Attending: ___.
Chief Complaint:
Weakness, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ y/o female with PMH notable for IDDM and
Stage 5 CKD on PD as of ___ who presents from home with
cough, weakness, and poor PO intake.
Of note, she has had frequent recent admissions, including admit
from ___ to ___ for pneumonia treated initially with
vanc/cefepime/levofloxacin completing regimen of levoflox for 7
days. Pt. was having diarrhea attributed to clinda on that
admission (had been on clinda for ? infection at PD catheter
site) and as such was changed to mupirocin topical in addition
to gentamycin topical (to complete total ___nding
___. On day of admission, ___ found patient at home in bed,
unable to get out of bed. Per report, PO / fluid intake has been
very minimal. She was referred back to the ED for further
evaluation.
Currently, she endorses similar symptoms that led to her prior
admission including mild headache, cough with no sputum
production, dyspnea with coughing, dysuria. She believes she
currently has a yeast infection. Otherwise, pt. states that
during her hospitalization, she felt that her symptoms improved
initially, but stayed stable or even worsened closer to time of
her discharge. She has not kept up with her usual PD schedule.
In the ED, initial vitals were: 97.5 70 138/60 20 100% 4L NC
- Labs were significant for WBC 3.1 6.3% eos, stable H/H
11.4/33.9, initially contaminated U/A, stable creatinine at 3.3
and otherwise normal chemistries, lactate 0.8,
- CXR revealed unchanged right basilar pneumonia and opacity at
the left lung base c/w atelectasis vs pneumonia
- The patient was given 150 mg fluc x 1, levoflox 750 mg x 1,
1gm vanco x 1, cefe1L NS
Vitals prior to transfer were: 97.9 67 122/87 16 95% RA
Upon arrival to the floor, Ms. ___ is sleeping comfortable.
She endorses the above history and states simply that she felt
too weak to be at home. No subjective or objective fevers,
chills, nausea, chest pain.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
- IDDM
- Peripheral Neuropathy
- Chronic Kidney Disease Stage IV (GFR ___
- Gastroparesis
- OSA
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- h/o Bulemia
Past surgical history: L BC AVF ___ (___), L breast
lumpectomy ___, R breast lumpectomy ___, appendectomy
Social History:
___
Family History:
No history of diabetes or kidney disease
Physical Exam:
ADMISSION EXAM:
==============
Vitals: 97.2 132/60 67 80 18 95% RA
General: sleepy, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur heard throughout precordium
Lungs: coughing, diffusely wheezy, ronchi at bilateral bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PD catheter site
bandaged and not painful to palpation
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:moving all extremities with purpose
DISCHARGE EXAM:
==============
VS - Tm 98.3 120s/40s-60s ___ 18 96%RA
General: NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur heard throughout precordium
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PD catheter site non
erythematous, no purulent discharge, nontender
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
==============
___ 01:58AM URINE MUCOUS-RARE
___ 01:58AM URINE HYALINE-2*
___ 01:58AM URINE RBC-1 WBC-12* BACTERIA-FEW YEAST-NONE
EPI-7 TRANS EPI-<1
___ 01:58AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 01:58AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:25AM PLT COUNT-295
___ 08:25AM WBC-2.9* RBC-3.54* HGB-11.2* HCT-33.3* MCV-94
MCH-31.7 MCHC-33.7 RDW-13.1
___ 08:25AM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.0
___ 08:25AM GLUCOSE-125* UREA N-18 CREAT-3.3* SODIUM-134
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13
___ 08:10PM PLT COUNT-324
___ 08:10PM NEUTS-47.5* ___ MONOS-6.3 EOS-6.3*
BASOS-0.6
___ 08:10PM WBC-3.1* RBC-3.66* HGB-11.4* HCT-33.9* MCV-93
MCH-31.2 MCHC-33.7 RDW-13.1
___ 08:10PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.8
___ 08:10PM GLUCOSE-92 UREA N-15 CREAT-3.3* SODIUM-134
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-30 ANION GAP-11
___ 08:14PM LACTATE-0.8
___ 10:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-7 TRANS EPI-<1
___ 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:30PM URINE GR HOLD-HOLD
___ 10:30PM URINE HOURS-RANDOM
MICRO:
=====
___ URINE URINE CULTURE-PENDING INPATIENT
___ 04:16AM ASCITES WBC-101* RBC-1* Polys-49* Lymphs-11*
Monos-2* Eos-4* Basos-1* Macroph-33*
___ DIALYSIS FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY INPATIENT
GRAM STAIN (Final ___:
2+ ___ 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 (Preliminary):
___ URINE Legionella Urinary Antigen -FINAL
EMERGENCY WARD
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ 12:36 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending):
FLUID CULTURE (Pending):
ANAEROBIC CULTURE (Pending):
___ 12:36 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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.
___ 12:36PM ASCITES WBC-3* RBC-0 Polys-6* Lymphs-60*
Monos-26* Eos-1* Mesothe-2* Macroph-5*
IMAGING/STUDIES:
===============
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Essentially unchanged right basilar pneumonia. Opacity at the
left lung base could represent atelectasis although developing
pneumonia is also possible.
DISCHARGE LABS:
==============
___ 07:45AM BLOOD WBC-5.6 RBC-3.77* Hgb-11.6* Hct-35.9*
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.4 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-177* UreaN-29* Creat-3.3* Na-138
K-3.5 Cl-100 HCO3-33* AnGap-9
___ 07:45AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ y/o female with PMH notable for IDDM and
Stage 5 CKD on PD as of ___ who presents from home with
weakness and poor PO intake after a recent discharge on ___,
where she completed a 7-day course of antibiotics for pneumonia
(treated with vanc/cefepime/levofloxacin). Please see previous
discharge summary for that admission for full details.
# Weakness: The patient re-presented to the ED with weakness and
poor PO intake. She was afebrile on presentation and throughout
admission, with no SIRS criteria except for WBC of 3.6. Her CXR
showed a stable RLL infiltrate seen on previous imaging. Her
blood, urine, and peritoneal dialysis cultures were negative,
urine Legionella antigen negative. She worked with physical
therapy and occupation therapy during hospital stay.
# Cough: The patient presented with a cough similar to prior
hospitalization, without sputum production. Infectious workup
was negative, as above. Cough may be secondary to bronchitis or
reactive airway disease in the setting of recent pneumonia. She
was treated symptomatically with benzonatate and guaifenisin.
# ESRD on HD: The patient was unable to perform her daily PD due
to weakness. She was followed by the nephrology dialysis team
who managed her PD during hospitalization. She had a peritoneal
fluid sample with 101 WBCs but no physical signs of peritonitis.
# PD site superficial infection: The patient was diagnosed with
a superficial infection around her PD site prior to this
admission where she was started on topical gentamicin as well as
PO clindamycin which was switched to topical mupiricin due to
diarrhea. She continued on topical gentamicin and mupiricin
ointments and completed a two week course and had no signs of
infection by day of discharge.
#IDDM: The patient was continued on home Glargine 6U daily and
ISS.
#Psych: Continued home ClonazePAM, Fluoxetine, LaMOTrigine 200
mg PO BID. Modafinil should also be continued upon discharge.
#Hypothyroidism: Continued home 50 mcg levothyroxine daily.
#GERD: Continued pantoprazole.
#Migraines: Continued home topiramate, sumatriptan discontinued
at past admission.
#Chronic pain/neuropathy: Continued home
Hydrocodone-Acetaminophen, gabapentin.
#Constipation: Patient was on senna and docusate sodium.
# CODE STATUS: full
# CONTACT: husband ___
TRANSITIONAL ISSUES:
- Will need to continue peritoneal dialysis daily, please
contact outpatient nephrologist Dr. ___ at ___
___, ___
Peritoneal dialysis: Last inpatient cycler prescription:
0800 - 1.5% - 1500 mL - 4 hours
1200 - 1.5% - 1500 mL - 3 hours
1500 - 1.5% - 1500 mL - 4 hours
___ - 1.5% - 1500 mL - 3 hours
___ - 1.5% - 1500 mL - Leave overnight
- Target weight 64 kg
- Above Rx includes fill time, drain time, and dwell time.
- Record clarity, presence of fibrin, and any problems with
drainage.
- Please take daily weight with dry abdomen
- Please ensure patient has at least 1 bowel movement daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough
3. Multiple Vitamins Liq. 5 mL PO DAILY
4. Mupirocin Ointment 2% 1 Appl TP BID
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. ClonazePAM 0.5 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Fluoxetine 60 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Gabapentin 600 mg PO QHS
11. Gentamicin 0.1% Cream 1 Appl TP DAILY
12. LaMOTrigine 200 mg PO BID
13. Lubiprostone 24 mcg PO BID
14. modafinil 300 mg oral QAM
15. modafinil 200 mg oral ASDIR
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Pantoprazole 40 mg PO Q12H
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 8.6 mg PO BID:PRN constipation
20. Topiramate (Topamax) 25 mg PO BID
21. Vitamin D 1000 UNIT PO DAILY
22. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
23. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. ClonazePAM 0.5 mg PO BID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Fluoxetine 60 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 600 mg PO QHS
8. Gentamicin 0.1% Cream 1 Appl TP DAILY
9. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. LaMOTrigine 200 mg PO BID
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lubiprostone 24 mcg PO BID
13. Multiple Vitamins Liq. 5 mL PO DAILY
14. Mupirocin Ointment 2% 1 Appl TP BID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Pantoprazole 40 mg PO Q12H
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. Topiramate (Topamax) 25 mg PO BID
20. Vitamin D 1000 UNIT PO DAILY
21. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough
22. modafinil 300 mg oral QAM
23. modafinil 200 mg ORAL ASDIR
24. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Deconditioning
Secondary diagnoses:
ESRD on PD
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
because of weakness and cough after your recent hospitalization.
You were given a dose of broad-spectrum antibiotics in the
emergency room. You had no fevers during hospital stay and
showed no signs of a worsening pneumonia. Your cough may be a
bronchitis or reactive airway disease in the setting of your
recent pneumonia. Your weakness may be due to deconditioning.
While you were here, you were seen by our physical therapists
and they recommended that you go to a rehabilitation facility.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19625808-DS-12
| 19,625,808 | 27,792,482 |
DS
| 12 |
2180-07-22 00:00:00
|
2180-07-22 15:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ondansetron / Linzess / codeine / Percocet /
Reglan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Underwent peritoneal dialysis ___
History of Present Illness:
___ w/ hx of ESRD on PD, DM c/b gastroparesis, constipation who
p/w abdominal pain.
Patient reports that she began experiencing a gradual, dull,
non-radiating, ___, LLQ abdominal pain at the site of her
peritoneal dialysis drain yesterday morning. She states that the
pain was worse after meals. No alleviating factors. The pain
progressed over the course of the day and eventually spread
across her entire lower abdomen. Of note, she has a history of
gastroparesis and constipation, which has previously required
enemas to resolve. Denies any associated nausea, vomiting,
fevers, chills, recent weight loss. Last BM was a couple of days
ago, required enema to elicit. She had instilled 1800cc of
dialysate into her abdomen yesterday morning. Patient has a
history of decreased PO intake for the past several months, and
was recently admitted ___ for weakness and poor PO
intake. She was diagnosed with a superficial infection around
her PD site at that time, and completed a 2 week course of
topical gent and mupiricin.
In the ED, T 97.9, P 72, BP 102/46, RR 18, O2 100% RA. Patient
was noticed to have poor mentation and confusion, and a fasting
blood glucose returned at 23. She was given OJ and an amp of
D50, with repeat ___ of 207 and improvement in mentation. Rectal
exam was with no impaction and guiac negative. Labs demonstrated
Na 130, K 2.8, BUN 44, Cr 2.9, Glucose 16, WBC 6.3, lactate 1.7,
lipase 35, ALT 30, AST 42, AP 113, tbili 0.2, lip 35, lactate
1.7. Peritoneal fluid returned 1 WBC, 3 RBC. CT abdomen without
evidence of acute intraabdominal process and moderate ascites
with intraperitoneal air likely related to peritoneal dialysis.
She was given K replacement, dextrose 25g, morphine 5mg x1, D5NS
@ 125cc/hr for 1L, prochlorperazine 10mg IV x1, 2 units of
insulin, NS at 10cc/hr, 200mg lamotrigine. Renal was consulted
and recommended sending peritoneal fluid studies. They felt
symptoms likely related to constipation. Their plan is to start
PD in the am. Vitals prior to transfer were: T 97.5, HR 70, BP
115/61, RR 16, O2 98% RA.
On the floor, the patient feels better. This morning, she
reports improvement in her pain, which is now ___. States that
she believes she may be constipated but wanted to come in make
sure it wasn't anything more serious. Mentating well, A+Ox3.
Denies nausea, vomiting, fevers, chills, dyspnea, chest pain.
Past Medical History:
- IDDM
- Peripheral Neuropathy
- Chronic Kidney Disease Stage IV (GFR ___
- Gastroparesis
- OSA
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- h/o Bulemia
Past surgical history: L BC AVF ___ (Raven), L breast
lumpectomy ___, R breast lumpectomy ___, appendectomy
Social History:
___
Family History:
No history of diabetes or kidney disease
Physical Exam:
ADMISSION EXAM
Vitals: Tm=Tc: 97.6, P 66-70, BP 106-108/47-67, RR 18, O2 100%
RA
General: comfortable, NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: III/VI holosystolic murmur heard best at apex, normal S1 +
S2
Lungs: CTAB, no wheezes/crackles/rhonchi
Abdomen: Soft, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PD catheter site non
erythematous, no purulent discharge, mildly tender to deep
palpation across lower abdomen
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNs grossly intact, moving all extremities with
purpose
DISCHARGE EXAM
Vitals: Tm 97.8 Tc: 97.4, P 70 (67-75), BP 114/63
(114-126/56-63), RR 18, O2 99% RA
General: comfortable, NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: III/VI holosystolic murmur heard best at apex, normal S1 +
S2
Lungs: CTAB, no wheezes/crackles/rhonchi
Abdomen: Soft, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PD catheter site non
erythematous, no purulent discharge, diffusely mildly tender to
deep palpation
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNs grossly intact, moving all extremities with
purpose
Pertinent Results:
ADMISSION LABS
___ 03:10PM BLOOD WBC-5.3 RBC-4.07 Hgb-12.4 Hct-37.2 MCV-91
MCH-30.5 MCHC-33.3 RDW-12.6 RDWSD-41.9 Plt ___
___ 03:10PM BLOOD Glucose-16* UreaN-44* Creat-2.9* Na-130*
K-2.8* Cl-90* HCO3-29 AnGap-14
___ 03:10PM BLOOD Albumin-3.4*
___ 03:59PM BLOOD Lactate-1.7
DISCHARGE LABS
___ 04:50AM BLOOD Glucose-102* UreaN-28* Creat-2.7* Na-135
K-3.4 Cl-99 HCO3-25 AnGap-___bdomen and Pelvis w/o Contrast (___)
1. No evidence of acute intra-abdominal process.
2. Moderate ascites with intraperitoneal air likely related to
peritoneal
dialysis. Evaluation for peritonitis is limited in the absence
of IV contrast.
MICRO
BCX x 2 (___): NGTD
Peritoneal Fluid (___): gram stain unremarkable, culture NGTD
Brief Hospital Course:
___ w/ hx of ESRD (stage 5) on PD (as of ___, IDDM c/b
gastroparesis, constipation who p/w abdominal pain.
#Constipation: Patient presented with abdominal pain and altered
mental status raising concern for peritonitis. Mental status
cleared with dextrose, and peritoneal fluid revealed 1 WBC
making this unlikely. Peritoneal catheter site was clean, dry
and intact. Other causes of pain included constipation, which
the patient has suffered from in the past vs gastroparesis.
There was low concern for an acute abdominal process
(diverticulitis, appendicitis, colitis, pancreatitis) given
benign CT, stable labs. Most likely cause was constipation.
Transplant did not believe PD catheter was misplaced. Tap water
enemas failed to relieve obstruction. Patient was already on an
aggressive home bowel regimen, and so was offered moviprep,
which relieved her constipation. Her abdominal pain continued,
however. Pain could be from IBS vs abdominal wall pain from
nerve impingement vs functional abdominal pain. Patient will
follow up with GI outpatient.
#Hypokalemia: Likely in the setting of poor PO intake. Patient
denied vomiting or diarrhea. There was low concern for a
hypoaldo state given bicarb of 29.
#Hyponatremia: Given decreased PO, and soft blood pressures in
the ED, likely due to hypovolemic hyponatremia from poor PO
intake. Patient denied vomiting, not on diuretics.
#Hypoglycemia: Likely due to continued insulin use in the
setting of poor PO intake. Patient also had not had PD since the
morning prior to presentation, which may also have contributed
to increased body insulin.
# ESRD on HD: Continued on PD per renal.
CHRONIC ISSUES
# Psych: continued home ClonazePAM, Fluoxetine, LaMOTrigine 200
mg PO BID, Modafanil
# Hypothyroidism: continued home 50 mcg levothyroxine daily.
# GERD: continued pantoprazole
# Migraines: continued home topiramate
# Chronic pain/neuropathy: continued home gabapentin.
TRANSITIONAL ISSUES:
-f/u constipation
-needs GI referral
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. ClonazePAM 0.5 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fluoxetine 60 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 600 mg PO QHS
8. LaMOTrigine 200 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Lubiprostone 24 mcg PO BID
11. Multiple Vitamins Liq. 5 mL PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Topiramate (Topamax) 25 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. modafinil 300 mg oral QAM
19. modafinil 200 mg ORAL ASDIR
20. Lidocaine 5% Patch 1 PTCH TD QPM
21. Glargine 6 Units Bedtime
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. ClonazePAM 0.5 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 60 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Gabapentin 600 mg PO QHS
7. Glargine 6 Units Bedtime
8. LaMOTrigine 200 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QPM
11. Lubiprostone 24 mcg PO BID
12. modafinil 300 mg oral QAM
13. Multiple Vitamins Liq. 5 mL PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Senna 8.6 mg PO BID:PRN constipation
16. Topiramate (Topamax) 25 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Lactulose 45 mL PO TID
Please take ___ once a day as needed for constipation.
19. modafinil 200 mg ORAL ASDIR
20. Benzonatate 100 mg PO TID:PRN cough
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-constipation
Secondary
-ESRD on PD
-DM
-gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during you recent admission
to the ___. You were admitted for abdominal pain, and were
ultimately found to have constipation. Your constipation was
relieved after undergoing a colon prep. You continued to have
some residual abdominal pain after the colon prep. Please follow
up with your regular GI physician (appointment information
below).
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
19625808-DS-16
| 19,625,808 | 23,157,744 |
DS
| 16 |
2181-06-04 00:00:00
|
2181-06-05 12:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ondansetron / Linzess / codeine / Percocet /
Reglan
Attending: ___.
Chief Complaint:
lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with medical history of DM1, ESRD on PD, OSA, HTN, HLD,
depression, migraine headaches, presenting with lower abdominal
pain. Pt reports that pain has been around for "a while" but
worse over the past ___ days. Pain is diffuse but more intense
in the LLQ. Pt last performed PD yesterday ___ AM but states
that she was unable to drain all fluid off (was able to drain
~375 cc per pt). Pt also reports that she has stopped taking her
antibiotic prophylaxis for SBP about 1 week ago due to ?
allergic reaction. No associated nausea, vomiting, diarrhea,
fevers, chills, no CP, dyspnea, additional complaints.
In the ED, initial vital signs were: 98.1 89 160/77 16 100% RA.
- Exam was notable for: epigastric or upper abdominal
tenderness.
- Labs were notable for: wv=bc 8.8, chemistries notable for BUN
35, Cr 2.7 (ESRD), lipase 185, lactate 1.4, UA negative for
infection, peritoneal fluid: 305 wbcs, 15 polys, 5 RBCs. Blood,
urine and peritoneal fluid cultures sent.
- Imaging: RUQ US: The hepatic parenchyma is coarsened. No
evidence of cholelithiasis or cholecystitis. KUB: A peritoneal
dialysis catheter projects over the mid pelvis. Otherwise,
unremarkable radiograph of the abdomen and pelvis. CXR: normal.
- The patient was given: IV vancomycin and cefepime.
- Consults: Renal/ HD, who recommended abx for peritonitis and
no acute indication for dialysis overnight.
- Pt was admitted to medicine for: management of peritonitis.
Vitals prior to transfer were: 97.6 87 168/74 17 99% RA.
Upon arrival to the floor, the patient endorses the story
above. She states that she has been feeling bloated and
distended for several days. She has had abdominal pain,
especially at the site of her catheter. Over the last couple of
days the pain has become very sharp and she has felt like
"doubling over." She also endorses chronic nausea but no emesis
or diarrhea.
REVIEW OF SYSTEMS: a complete ROS was negative except as noted
in HPI.
Past Medical History:
- Type I Diabetes Mellitus
- Peripheral Neuropathy secondary to diabetes
- ESRD on Peritoneal Dialysis
- Gastroparesis secondary to diabetes
- OSA, not on home CPAP
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- Migraines
- h/o Bulemia
- h/o bacterial peritonitis ___
- L BC AVF ___ (___), L breast lumpectomy ___, R breast
lumpectomy ___, appendectomy
Social History:
___
Family History:
No history of diabetes or kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp 97.6, BP 169/68, HR 82, RR 18, O2 100% RA.
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly. Catheter insertion site is c/d/i
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
VITALS: 97.4 131/73 83 17 100RA
GENERAL: laying in bed, calm, in no acute distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, mildly tender diffusely, no
rebound. PD catheter with dressing c/d/i
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
==========================================
___ 03:24PM BLOOD WBC-8.8 RBC-3.98 Hgb-11.6 Hct-37.7 MCV-95
MCH-29.1 MCHC-30.8* RDW-13.2 RDWSD-46.3 Plt ___
___ 03:24PM BLOOD Neuts-69.0 Lymphs-18.7* Monos-6.6 Eos-5.0
Baso-0.5 Im ___ AbsNeut-6.08 AbsLymp-1.65 AbsMono-0.58
AbsEos-0.44 AbsBaso-0.04
___ 06:20AM BLOOD ___ PTT-31.3 ___
___ 03:24PM BLOOD Glucose-51* UreaN-35* Creat-2.7* Na-141
K-4.3 Cl-104 HCO3-30 AnGap-11
___ 03:24PM BLOOD ALT-37 AST-36 AlkPhos-126* TotBili-0.1
___ 03:24PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.3 Mg-2.0
___ 03:24PM BLOOD PTH-115*
___ 02:35PM BLOOD Vanco-14.0
___ 01:25AM BLOOD Lactate-1.4
___ 04:33PM URINE Color-Straw Appear-Hazy Sp ___
___ 04:33PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:33PM URINE RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE Epi-9
___ 04:33PM URINE Mucous-RARE
___ 10:55PM OTHER BODY FLUID WBC-305* RBC-5* Polys-15*
Lymphs-6* Monos-60* Eos-15* Mesothe-4*
OTHER PERTINENT LABORATORY STUDIES
==========================================
___ 11:52AM ASCITES WBC-3* RBC-0 Polys-0 ___ Monos-0
Eos-14* Macroph-86*
___ 10:55PM OTHER BODY FLUID WBC-305* RBC-5* Polys-15*
Lymphs-6* Monos-60* Eos-15* Mesothe-4*
___ 02:35PM BLOOD Vanco-14.0
___ 05:18AM BLOOD Vanco-12.9
___ 05:15AM BLOOD Vanco-14.6
___ 03:24PM BLOOD PTH-115*
___ 01:25AM BLOOD Lactate-1.4
LABORATORY STUDIES ON DISCHARGE
==========================================
___ 08:42AM BLOOD WBC-4.6 RBC-3.99 Hgb-11.6 Hct-38.2 MCV-96
MCH-29.1 MCHC-30.4* RDW-13.2 RDWSD-46.5* Plt ___
___ 05:15AM BLOOD Glucose-252* UreaN-35* Creat-3.2* Na-135
K-5.1 Cl-96 HCO3-25 AnGap-19
___ 05:15AM BLOOD Calcium-9.0 Phos-5.9* Mg-2.1
MICROBIOLOGY
==========================================
___ 11:52 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
___ 11:52 am PERITONEAL FLUID PERITONEAL FLUID.
RECEIVED IN EDTA TUBE.. ONLY GRAM STAIN TEST WILL BE
PERFORMED.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
___ 10:55 pm DIALYSIS FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD CULTURES: NGTD
___ 4:33 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING/REPORTS
==========================================
++ ___ RUQ US:
The hepatic parenchyma is coarsened. No evidence of
cholelithiasis or cholecystitis.
++ ___ KUB:
A peritoneal dialysis catheter projects over the mid pelvis.
Otherwise, unremarkable radiograph of the abdomen and pelvis.
++ ___ CXR:
Normal.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a with history of ESRD
on PD, DM1, HTN, HLD who presented with lower abdominal pain and
found to have PD peritonitis.
#) PD PERITONITIS:
Pt presented with abdominal pain with PD fluid studies
concerning for peritonitis (WBC > 100 although only 15% polys).
Gram stain from the dialysis fluid was negative and the culture
has shown no growth to date. Pt remained afebrile without
leukocytosis during admission. Pt received IV Vancomycin and IV
Cefepime in the ED on admission, and then was transitioned to IP
Vancomycin and ceftazidime, with improvement in abdominal pain.
Pt was discharged with a plan to complete a 14-day course of IP
Vancomycin and Ceftazidime (last day ___.
#) ESRD on PD:
During admission, pt was seen by renal dialysis consult team. Pt
was continued on peritoneal dialysis. Pt was continued on home
nephrocaps.
CHRONIC ISSUES
==============
# T1DM: continued home insulin regimen
# Gastroparesis: continued home reglan
# Hypothyroid: continued home synthroid
# Depression/ anxiety: continued home fluoxetine, lamotrigine,
and clonazepam
# Pruritus: continued home hydroxyzine
TRANSITIONAL ISSUES
================================================
1. Pt needs to complete a 14-day course of IP Vancomycin and
Ceftazidime (last day ___ for treatment of PD peritonitis.
When going home and resuming CCPD
- add additional manual 6h Dwell after her CCPD ends
Dextrose 1.5% - ___ mL with following Abx and dwell for 6
hours:
1.Vanco 1000 mg IP daily, hold for trough > 25 to be checked on
TTS
2.CefTAZidime 1000 mg IP DAILY
# CONTACT:Husband/HCP ___ ___
# CODE STATUS: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID
2. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU Q6H
3. Dextroamphetamine 10 mg PO QAM
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. HydrOXYzine 50 mg PO Q6H:PRN itch
6. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. LamoTRIgine 100 mg PO BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lubiprostone 24 mcg PO BID
10. Modafinil 300 mg PO DAILY
11. Modafinil 200 mg PO QPM
12. Pantoprazole 40 mg PO Q24H
13. Prochlorperazine 5 mg PO Q6H:PRN nausea
14. rizatriptan 10 mg oral DAILY
15. Tizanidine 2 mg PO QHS
16. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Fish Oil (Omega 3) 1000 mg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. pramoxine 1 % topical Q8H:PRN itch
22. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. ClonazePAM 1 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. HydrOXYzine 50 mg PO Q6H:PRN itch
6. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. LamoTRIgine 100 mg PO BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lubiprostone 24 mcg PO BID
10. Modafinil 300 mg PO DAILY
11. Modafinil 200 mg PO QPM
12. Pantoprazole 40 mg PO Q24H
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Prochlorperazine 5 mg PO Q6H:PRN nausea
15. Senna 8.6 mg PO BID:PRN constipation
16. Tizanidine 2 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
18. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU Q6H
19. Dextroamphetamine 10 mg PO QAM
20. pramoxine 1 % topical Q8H:PRN itch
21. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
22. rizatriptan 10 mg oral DAILY
23. Lactulose 15 mL PO Q8H:PRN constipation
24. Vancomycin 1000 mg IP DAILY Duration: 12 Days
Intraperitoneal only
(last day ___
RX *vancomycin 500 mg 1000 mg IP daily Disp #*12 Vial Refills:*0
25. CefTAZidime 1000 mg IP DAILY Duration: 12 Days
Intraperitoneal only.
(last day ___.
RX *ceftazidime 1 gram 1000 mg daily daily Disp #*12 Vial
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- PD peritonitis
SECONDARY:
- type 1 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
because of your abdominal pain. You were found to have an
infection of the fluid in your belly (called "peritonitis").
You were treated with antibiotics called Vancomycin and
ceftazidime, which were given through your peritoneal dialysis
catheter. You will continue on these antibiotics to complete a
14-day course (last day ___.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19625808-DS-20
| 19,625,808 | 21,132,472 |
DS
| 20 |
2182-02-04 00:00:00
|
2182-02-04 21:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Linzess / codeine / Percocet / Reglan
Attending: ___.
Chief Complaint:
nausea, pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with a history of T1DM complicated by
moderate to severe gastroparesis, ESRD on PD (on list for
kidney/pancreas transplant), fibromyalgia, anxiety, and
depression, who presented with 3 days of reduced appetite and
feeling poorly, as well as neuropathic ("burning" and
"stabbing") pains in all her extremities leading her to be
unable to sleep.
For the 3 days prior to admission, she had been feeling well.
She had not been eating. She did not do her PD the night prior
to admission. She also reported "nerve pain everywhere" and
inability to sleep, but denied any fever, chills, chest pain,
dyspnea, or diarrhea. Her last bowel movement was day before
admission, and no dark or blood stools, and no bloody emesis.
Her only abdominal surgery was an appendectomy many years ago.
Of note, she was recently admitted with abdominal pain,
attributed to a gastroparesis flare. At that time, she received
PO erythromycin to promote motility, and received Zofran and
Ativan prn just prior to meals to help reduce nausea. She did
not receive inpatient narcotics on that admission, was not
discharged on narcotics, and has a narcotics contract in OMR.
- In the ED, initial vitals were: 97.8 78 140/80 18 98% RA
- Exam notable for: Abdomen soft, nontender, nondistended, PD
site well appearing
- Labs showed: Na 120, lactate 0.8
- Imaging showed CXR without evidence of pneumonia.
Received:
-___ 10:43 IV Ondansetron 4 mg ___
-___ 10:43 IVF NS ___ Started
-___ 11:31 IV Ondansetron 4 mg ___
-___ 11:52 IVF NS 1 mL ___ Stopped (1h
___
-___ 12:45 IV Lorazepam ___ Not Given
-___ 12:58 IV HYDROmorphone (Dilaudid) .5 mg
-___ 14:07 IV HYDROmorphone (Dilaudid) .5 mg
-___ 16:10 IV Lorazepam 1 mg
- Transfer VS were 97.8 81 107/45 16 99% RA
- Nephrology dialysis were consulted, and determined she had no
urgent PD needs overnight. Plan for CCPD or CAPD on ___.
- Patient refused Gabapentin and Tizanidine, was adamantly
requesting Dilaudid.
- Decision was made to admit to medicine for further
management.
On arrival to the floor, patient reported horrible nerve pain
in her arms, hands, and legs. She felt that her nerve pain was
bothering her more than the abdominal pain. This had been
getting worse over the week before admission. She continues to
have nausea, and was unable to keep food or medications down.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria.
Past Medical History:
- Type I Diabetes Mellitus
- Peripheral Neuropathy secondary to diabetes
- ESRD on Peritoneal Dialysis, listed for transplant
- Gastroparesis secondary to diabetes
- OSA, not on home CPAP
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- Migraines
- h/o Bulemia
- h/o bacterial peritonitis ___
- L BC AVF ___ (___), L breast lumpectomy ___, R breast
lumpectomy ___, appendectomy
Social History:
___
Family History:
No family history of diabetes or kidney disease
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 97.7 PO 151 / 73 76 18 98 ra
Gen: anxious woman, lying in bed
HEENT: no scleral icterus, mmm
CV: rrr, no m/r/g
PULM: lungs clear bilaterally, no wheezes or crackles
ABD: soft, NT/ND, +bs, +PD cath c/d/I
GU: no foley
EXT: warm, 2+ DP pulses, no edema
MSK: no erythema or effusions over any joints in UE or ___. MCPs
ttp diffusely
NEURO: CN II-XII grossly intact, ___ strength but poor effort
DISCHARGE EXXAM
===============
VITALS: 97.5 | 138/85 (low: 90/46)| 88 | 20 | 98%RA
GEN: Sleeping. Rouses to voice and then is alert and oriented.
No acute distress.
HEENT: No scleral icterus. Tacky mucous membranes.
CV: RRR, no m/r/g appreciated
PULM: Lungs clear bilaterally, no wheezes, rhonci or crackles
ABD: Soft, NT to deep palpation, +bs. PD catheter site clean,
dry, and intact
NEURO: moving all limbs with purpose against gravity, no
dysarthria. Face grossly symmetric. Walked up to nursing station
with normal gait and no gross instability.
Pertinent Results:
--ADMISSION LABS--
==================
___ 10:25AM BLOOD WBC-4.4 RBC-3.80* Hgb-11.0* Hct-34.8
MCV-92 MCH-28.9 MCHC-31.6* RDW-12.3 RDWSD-41.3 Plt ___
___ 10:25AM BLOOD Neuts-74.7* Lymphs-14.0* Monos-5.7
Eos-4.5 Baso-0.9 Im ___ AbsNeut-3.30 AbsLymp-0.62*
AbsMono-0.25 AbsEos-0.20 AbsBaso-0.04
___ 10:25AM BLOOD Glucose-119* UreaN-33* Creat-5.6*#
Na-130* K-3.8 Cl-90* HCO3-24 AnGap-20
___ 10:25AM BLOOD ALT-13 AST-22 AlkPhos-171* TotBili-<0.2
___ 10:25AM BLOOD Albumin-3.6
___ 10:38AM BLOOD Lactate-0.8
--MICRO--
=========
___ URINE CULTURE - negative
___ PERITONEAL CULTURE - negative
___ & ___ BLOOD CULTURES - no growth to date
--IMAGING--
===========
___ CXR IMPRESSION: No evidence of pneumonia.
___ GASTRIC EMPTYING STUDY FINDINGS: Residual tracer
activity in the stomach is as follows:
At 45 mins 79% of the ingested activity remains in the stomach
At 2 hours 45% of the ingested activity remains in the stomach
At 3 hours 43% of the ingested activity remains in the stomach
At 4 hours 38% of the ingested activity remains in the stomach
IMPRESSION: 38% of ingested activity remains within the stomach
at 4 hours, consistent with moderate/severe gastroparesis.
--OTHER LABS & DISCHARGE LABS --
==================================
___ 03:37PM PERITONEAL FLUID WBC-23* RBC-2* Polys-6*
Lymphs-8* Monos-56* Eos-22* Macro-8*
___ 07:54AM BLOOD WBC-5.7 RBC-4.02 Hgb-11.5 Hct-37.6 MCV-94
MCH-28.6 MCHC-30.6* RDW-12.5 RDWSD-42.8 Plt ___
___ 07:54AM BLOOD Glucose-127* UreaN-44* Creat-4.6* Na-130*
K-3.8 Cl-91* HCO3-23 AnGap-20
___ 07:54AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.4
Brief Hospital Course:
Ms ___ is a ___ woman with a history of T1DM complicated by
moderate to severe gastroparesis, ESRD on PD (on list for
kidney/pancreas transplant), anxiety, and depression, who
presented with 3 days of nausea, vomiting, and decreased
appetite, as well as worsened neuropathic pain.
#NEUROPATHY and
#FIBROMYALGIA: Presented with burning of all extremities and no
tolerance for blankets to touch her, consistent with previous
flares of neuropathy. She additionally had diffuse joint pain
but no focal joint effusions or erythema, consistent with
fibromyalgia. Per patient, the neuropathy in particular was
causing acute distress, "Greater than ___ Per patient, no
dose of gabapentin worked previously. Had been trialed on
duloxetine briefly and with reasonable effect, but not a
long-term solution given her kidney dysfunction and risk of harm
from metabolites, which per pharmacy are broad-ranging but could
include life-threatening reactions such as ___
Syndrome. She was started on Pregabalin ___ with good effect
on her pain; gabapentin stopped in conjunction. She was also
started on nortryptaline, which was eventually reduced from 25
to 10mg QHS given some exhaustion in the morning. She was also
on her home Tizanidine 12mg QHS. No narcotics were given.
#GASTROPARESIS: Presented with nausea, vomiting, abdominal pain
and constipation, consistent with a flare of her moderate to
severe gastroparesis. Her abdominal exam was benign, and she had
no vitals or labs to suggestion infection, including normal LFTs
and lipase ruling out pancreatitis or hepatitis, ad normal
diagnostic paracentesis without evidence of SBP. She did
intermittently require IV antiemetics but these stopped ___
and she was continued on ___ ondansetron ODT PRN, which she
received 2x/day. She was also on erythromycin for promotility
while inpatient, discontinued the morning of discharge. She had
no emesis >48h before discharge. Her constipation also improved
by day of discharge. She was otherwise maintained on home
medications including lubiprostone and domperidone. Of note, she
was tried on promethazine the night of ___ and was
hypotensive to SBP of 70 two hours later, so this was
discontinued. She was also not given lorazepam per renal due to
her ESRD.
# ESRD ON PD: Continued while inpatient per renal
recommendatios.
# DEPRESSION/ANXIETY: Home medicines including ClonazePAM 1 mg
PO/NG BID, Dextroamphetamine 10 mg PO DAILY, FLUoxetine 60 mg
PO/NG DAILY and Modafinil 300 mg PO/NG QAM AND Modafinil 200 mg
PO/NG DAILY
# T1DM: Last discharged on glargine 5qAM/10 QHS and standing
___ humalog. She was maintained on the same glargine but ___
humalog with meals, in addition to sliding scale, but reduced
while poor PO/NPO per protocol.
CHRONIC STABLE ISSUES:
# HLD: home Atorvastatin 40 mg PO/NG QPM
# GERD: home Pantoprazole 40 mg PO Q12H
# CONSTIPATION: home regimen (Bisacodyl 10 mg PO QHS, Docusate
Sodium 100 mg PO/NG BID, Senna 34.4 mg PO/NG BID) with some
additional PRNs
# HYPOTHYROID: home Levothyroxine Sodium 88 mcg PO/NG DAILY
# ALLERGIES: home Loratadine 10 mg PO EVERY OTHER DAY
# CODE: presumed full
# CONTACT: ___ (Husband): ___ ||
___
TRANSITIONAL ISSUES
==================
-New medications: Pregabalin 75mg daily; Nortryptiline 10mg QHS
-Stopped medications: Gabapentin 100mg QHS
-Patient is also taking domperidone 10 mg PO TID W/MEALS, which
cannot go into her pre-admission or discharge medication list as
it is a ___ medicine. She continued it in-house from her
personal supply.
-Gastric emptying study performed ___ showing moderate to
severe gastroparesis. She will need outpatient follow up with
plans for GI to perform EGD with botox injection.
-Sent home with ___ evaluation and services per ___
recommendations.
-She should have regular EKG monitoring given the significant
number of QTC-prolonging medications she is prescribed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Bisacodyl 10 mg PO QHS
3. ClonazePAM 1 mg PO BID
4. Dextroamphetamine 10 mg ORAL DAILY
5. Docusate Sodium 100 mg PO BID
6. FLUoxetine 60 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. HydrOXYzine 50 mg PO Q6H:PRN itchiness
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Modafinil 300 mg PO QAM
12. Modafinil 200 mg PO DAILY
13. Nephrocaps 1 CAP PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Senna 34.4 mg PO BID
16. Tizanidine 12 mg PO QHS
17. Fish Oil (Omega 3) 1000 mg PO DAILY
18. Saccharomyces boulardii 250 mg oral daily
19. Sumatriptan Succinate ___ mg PO PRN for headaches
20. Vitamin D 1000 UNIT PO DAILY
21. Ondansetron ODT 4 mg PO Q8H:PRN nausea
22. Lubiprostone 24 mcg PO BID
23. trimethobenzamide 300 mg oral QHS
24. Glargine 5 Units Breakfast
Glargine 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Nortriptyline 10 mg PO Q8PM abdominal pain
RX *nortriptyline 10 mg 1 by mouth at bedtime Disp #*30 Capsule
Refills:*0
2. Pregabalin 75 mg PO DAILY
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
3. Glargine 5 Units Breakfast
Glargine 10 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO QHS
6. ClonazePAM 1 mg PO BID
7. Dextroamphetamine 10 mg ORAL DAILY
8. Docusate Sodium 100 mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. FLUoxetine 60 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. HydrOXYzine 50 mg PO Q6H:PRN itchiness
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Loratadine 10 mg PO DAILY
15. Lubiprostone 24 mcg PO BID
16. Modafinil 300 mg PO QAM
17. Modafinil 200 mg PO DAILY
___ hours after morning dose
18. Nephrocaps 1 CAP PO DAILY
19. Ondansetron ODT 4 mg PO Q8H:PRN nausea
20. Pantoprazole 40 mg PO Q12H
21. Saccharomyces boulardii 250 mg oral daily
22. Senna 34.4 mg PO BID
23. Sumatriptan Succinate ___ mg PO PRN for headaches
24. Tizanidine 12 mg PO QHS
25. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Gastroparesis
Secondary
Fibromyalgia
ESRD on peritoneal dialysis
Type 1 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
vomiting and worsening total body pain. You were treated for a
gastroparesis flare with medications to help your bowels move,
and the pain service was consulted to help adjust your pain
medications. You improved and are being discharged home. You
should follow up with your usual doctors.
___ was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
19625808-DS-32
| 19,625,808 | 23,834,188 |
DS
| 32 |
2183-04-22 00:00:00
|
2183-04-22 20:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Linzess / codeine / Percocet / Reglan / latex /
cefpodoxime
Attending: ___.
Chief Complaint:
weakness, N/V, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with PMH of T1DM (c/b neuropathy, gastroparesis),
ESRD (on PD c/b recurrent culture-negative peritonitis),
fibromyalgia, and migraines who is presenting with
nausea/vomiting and intermittent hypoxia.
The patient states that she has been feeling unwell for the past
1 week. She has been nauseous and vomiting during this time and
this has worsened over the past few days to the point that this
morning, she was unable to tolerate any of her morning
medications. She notes that this feels like her prior episodes
of
gastroparesis. She denies any bilious or bloody emesis. She has
had mild, diffuse abdominal pain. She completed her PD session
yesterday with some pain associated with it. The patient denies
diarrhea but did have a "loose" BM this AM. She notes that she
her loose stools alternate with periods of constipation. She
denies any new foods, recent travel or sick contacts.
The patient also complains of dyspnea, particularly with
exertion. She states that this is a chronic issue for her and
has
been a "problem for years." She denies any chest pain on the
left
side of her chest but does have pain at her right clavicle,
extending into her neck and upper back. This pain radiates down
the right arm as well. No evidence of rib or clavicle fractures
on recent imaging studies.
She is currently suffering one of her migraines (for the past
few
days) which is currently characterized by a "blinding pain" on
the top of her head "like a cap." She endorses photophobia and
states that sounds also make the pain worse. Denies shimmering
lights or floaters.
Of note, patient recently admitted ___ to ___ following an
episode of loss of consciousness in the setting of hypoglycemia.
She notes that she has had difficulty taking in deep breaths
since this last hospitalization due to pain on her right side.
She is unable to recall the mechanics of the fall including
whether or not she fell on her chest.
In the ED:
- VS: AF 124/71 85 16 100%NC, FGS 190
- Exam: notable for PD site is bandaged and patient refused to
take down dressing due to "cleanliness" of ED; mild diffuse TTP;
1+ pitting edema to knees bilaterally
- Labs notable for BUN/Cr 63/10, LFTs notable for AP 152, CBC
notable for plt 537; lactate 1.3. Peritoneal fluid showed ___
PMNs.
- EKG: rate 83, NSR, nl axis, nl R wave progression, no ST-T
wave
changes, QTc 435
- CXR: RML, RLL, LLL atelectasis/scarring corresponding with
recent CT; no definite consolidations
- Received: fiorcet, morphine 4mg IV, Zofran 4mg IV x 2, 500cc
NS
- Patient noted to be hypoxic in ED with worsening DOE. She had
ambulatory saturation of 85-87%.
- Renal consulted, recommended ruling out peritonitis
- Ascitic fluid analysis notable for TNC 146, RBC 36, polys 6,
lymphs 3, monos 88, Eos 2, and mesothe 1.
Review of Systems:
She denies any URI symptoms, UTI symptoms, rashes, neuro
deficits, or difficulty ambulating from baseline.
On arrival to the floor, patient is in NAD, resting comfortably
in bed with lights off due to persistent headache. She notes
that
her nausea/vomiting have improved to the point that she was able
to tolerate some ice chips. T 97.7, BP 131/77, HR 74, RR 14, Sa
98% on RA.
Past Medical History:
1. Type I Diabetes Mellitus
2. Peripheral Neuropathy secondary to diabetes
3. ESRD on Peritoneal Dialysis, listed for transplant
4. Gastroparesis secondary to diabetes
5. OSA, not on home CPAP
6. HLD
7. HTN
8. Chronic Fatigue
9. Depression
10. Anxiety
11. Migraines
12. History of bulemia
13. Recurrent culture-negative peritonitis
14. Left brachicephalic fistula (___)
15. Left breast lumpectomy (___)
Social History:
___
Family History:
No family history of diabetes or kidney disease.
Physical Exam:
ADMISSION Physical Exam:
==============
VITALS: T 97.7, BP 131/77, HR 74, RR 14, Sa 98% on RA.
GENERAL: Alert and interactive. In no acute distress though does
report headache as well as right sided chest wall pain.
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: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
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.
CHEST/BACK: TTP along right anterior chest wall as well as
cervical spine. No CVA tenderness.
ABDOMEN: Mildly tender throughout. PD catheter in place c/d/i.
Normal bowels sounds, non distended. No organomegaly.
EXTREMITIES: Trace ___ edema. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Alert and oriented. CN2-12 intact. ___ strength
throughout with the exception of her right grip strength which
is
___. Normal sensation.
DISCHARGE PHYSICAL EXAM
Physical Exam:
==============
VITALS:
___ 0245 BP: 145/82 R Lying RR: 14 O2 sat: 93-95% O2
delivery: RA Dyspnea: 9 RASS: 0
GENERAL: Alert and interactive.
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: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
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.
CHEST/BACK: TTP along right anterior chest wall as well as
cervical spine. No CVA tenderness.
ABDOMEN: Mildly tender throughout. PD catheter in place c/d/i.
Normal bowels sounds, non distended. No organomegaly.
EXTREMITIES: Trace ___ edema. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Alert and oriented. CN2-12 intact. ___ strength
throughout. Normal sensation.
Pertinent Results:
ADMISSION
___ 02:05PM BLOOD Glucose-200* UreaN-63* Creat-10.0* Na-135
K-4.8 Cl-88* HCO3-23 AnGap-24*
___ 02:05PM BLOOD ALT-14 AST-22 AlkPhos-152* TotBili-0.3
___ 02:05PM BLOOD cTropnT-0.14*
___ 02:05PM BLOOD Albumin-3.2* Calcium-9.1 Phos-6.2* Mg-2.0
CXR ___
FINDINGS:
PA and lateral views of the chest provided. Overlying EKG leads
are present.
Linear densities in the right perihilar region likely represent
platelike
atelectasis, less likely scarring. A similar small linear
density in the left
lower lung abutting the left heart border also likely represent
linear
atelectasis versus scarring. No convincing evidence for
pneumonia or edema.
No large effusion or pneumothorax. Cardiomediastinal silhouette
is stable.
Imaged bony structures are intact.
IMPRESSION:
Linear atelectasis versus scarring as detailed. No signs of
pneumonia.
MICRO:
___ 5:58 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ONE COLONY OF A GRAM POSITIVE COCCUS OF UNCERTAIN CLINICAL
SIGNIFICANCE.
Reported to and read back by ___. (___) AT 1515 ON
___.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
DISCHARGE
___ 05:50AM BLOOD Glucose-264* UreaN-60* Creat-10.2*
Na-132* K-5.5* Cl-87* HCO3-27 AnGap-18
___ 02:53AM BLOOD CK-MB-4 cTropnT-0.13*
___ 05:50AM BLOOD Calcium-9.0 Phos-6.0*
Brief Hospital Course:
====================
This is a ___ F with PMH of T1DM (c/b neuropathy, gastroparesis),
ESRD (on PD c/b recurrent culture-negative peritonitis),
fibromyalgia, and migraines who is presenting with
nausea/vomiting c/f hypoxemia, now resolved. Patient improved
significantly with supportive care.
ACTIVE ISSUES:
# Abdominal Pain
Suspect mild abdominal pain and nausea are related to the
patient's migraine, which is resolving, with some component of
gastroparesis or constipation. Unlikely to be perotinitis given
perotineal fluid. Narcotic withdrawl cannot be excluded. She was
treated with IV ondansetron and continued on her home aggressive
bowel regimen.
# Hypoxia
# Dyspnea on Exertion
Patient noted to be hypoxic in ED with worsening DOE. She had
ambulatory saturation of 85-87%. Pt remained comfortable and
normoxemic on room air throughout her stay. Troponins were 0.14
-> 0.12 in the absence of symptoms or ischemic EKG changes.
Suspect her presentation was secondary to splinting in the
setting of pain from recent fall. Incentive spirometry was
encouraged.
# Pain from recent fall
Patient with right sided clavicular pain that is pleuritic in
nature. S/p recent unwitnessed fall with possible mechanical
injury to right side of chest. Pt should follow up with ___ on
discharge.
CHRONIC ISSUES
# T1 DM
- Continued home insulin at 8 U glargine and mealtime coverage
with Novalog
# ESRD on PD
Pt had peritoneal dialysis overnight from ___ -> ___. Her home
torsemide was continued.
# Orthostatic hypotension
- Hold home midodrine given stable BPs
# Chronic pain
# Fibromyalgia
# Chronic fatigue
# Peripheral neuropathy
- continued home dilaudid with IV as needed if unable to
tolerate PO
pregabalin, modafinil, tizanidine, Nortriptyline 10mg daily
# Hypothyroidism: Continued home levothyroxine
# Depression/anxiety: Continued home clonazepam, fluoxetine,
nortriptyline as above
# GERD: Continued home pantoprazole
# Asthma: Continued home albuterol prn
# HLD: Continued home atorvastatin
# Other home meds
- cont Fish Oil (Omega 3) 1200 mg PO DAILY
- cont HydrOXYzine ___ mg PO QHS:PRN itchiness
===================
TRANSITIONAL ISSUES
===================
[] Pt c/o vaginal itchiness and discharge c/w prior yeast
infections and was discharged with a prescription for 150 mg
fluconazole ONCE per previous prescriptions from PCP
[] Pt continues to complain of R arm pain after fall and should
be evaluated for physical therapy
# CODE: Full Code. Patient further specified that she must
remain
Full Code so long as she is a candidate for transplant. She
explains, however, that she has had life-long religious beliefs
which run counter to aggressive medical interventions. Should
she
no longer be a candidate for renal transplant, she would like to
be made DNAR/DNI.
# HCP: ___, Phone number: ___, Cell phone:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/inhalatin inhalation Q4H-Q6H PRN
dyspnea
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl 10 mg PO BID
4. Calcitriol 0.5 mcg PO DAILY
5. ClonazePAM 1 mg PO BID
6. ClonazePAM 1 mg PO DAILY:PRN anxiety
7. dextrose 40 % oral PRN
8. Docusate Sodium 100 mg PO BID
9. Fish Oil (Omega 3) 1200 mg PO DAILY
10. FLUoxetine 60 mg PO DAILY
11. HYDROmorphone (Dilaudid) 4 mg PO QHS:PRN BREAKTHROUGH PAIN
12. HydrOXYzine ___ mg PO QHS:PRN itchiness
13. Lanthanum 1000 mg PO BREAKFAST
14. Lanthanum 1000 mg PO LUNCH
15. Lanthanum 1500 mg PO DINNER
16. Levothyroxine Sodium 88 mcg PO DAILY
17. Lubiprostone 24 mcg PO BID
18. Midodrine 5 mg PO BID:PRN only if SBP<100
19. Modafinil 300 mg PO QAM
20. Modafinil 200 mg PO DAILY
21. Nortriptyline 10 mg PO QHS
22. Ondansetron 4 mg PO TID:PRN nausea
23. Pantoprazole 40 mg PO Q12H
24. Pregabalin 100 mg PO DAILY
25. Senna 34.4 mg PO BID
26. Sodium Bicarbonate 1300 mg PO BID
27. Tizanidine 4 mg PO BID:PRN spasms
28. Vitamin D 1000 UNIT PO DAILY
29. isomethepten-caf-acetaminophen 65-20-325 mg oral ONCE MR1
30. Nephronex (B complex with C#10-folic acid) 900 mcg/5 mL oral
DAILY
31. 70/30 10 Units Bedtime
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
32. Torsemide 100 mg PO DAILY
Discharge Medications:
1. Fluconazole 150 mg PO ONCE Duration: 1 Dose
RX *fluconazole 150 mg 1 tablet(s) by mouth once Disp #*1 Tablet
Refills:*0
2. 70/30 10 Units Bedtime
Glargine 10 Units Bedtime
3. albuterol sulfate 90 mcg/inhalatin inhalation Q4H-Q6H PRN
dyspnea
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO BID
6. Calcitriol 0.5 mcg PO DAILY
7. ClonazePAM 1 mg PO BID
8. ClonazePAM 1 mg PO DAILY:PRN anxiety
9. dextrose 40 % oral PRN
10. Docusate Sodium 100 mg PO BID
11. Fish Oil (Omega 3) 1200 mg PO DAILY
12. FLUoxetine 60 mg PO DAILY
13. HYDROmorphone (Dilaudid) 4 mg PO QHS:PRN BREAKTHROUGH PAIN
14. HydrOXYzine ___ mg PO QHS:PRN itchiness
15. isomethepten-caf-acetaminophen 65-20-325 mg oral ONCE MR1
16. Lanthanum 1000 mg PO BREAKFAST
17. Lanthanum 1000 mg PO LUNCH
18. Lanthanum 1500 mg PO DINNER
19. Levothyroxine Sodium 88 mcg PO DAILY
20. Lubiprostone 24 mcg PO BID
21. Midodrine 5 mg PO BID:PRN only if SBP<100
22. Modafinil 300 mg PO QAM
23. Modafinil 200 mg PO DAILY
24. Nephronex (B complex with C#10-folic acid) 900 mcg/5 mL
oral DAILY
25. Nortriptyline 10 mg PO QHS
26. Ondansetron 4 mg PO TID:PRN nausea
27. Pantoprazole 40 mg PO Q12H
28. Pregabalin 100 mg PO DAILY
29. Senna 34.4 mg PO BID
30. Sodium Bicarbonate 1300 mg PO BID
31. Tizanidine 4 mg PO BID:PRN spasms
32. Torsemide 100 mg PO DAILY
33. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Migraine
Gastroparesis
SECONDARY DIAGNOSES
Type I Diabetes
End stage renal disease
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
WHY DID YOU COME TO THE HOSPITAL?
You came to ___ because you were nauseous and had a migraine.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
We gave you medications to treat your nausea, abdominal pain,
and migraine. You had dialysis overnight. You improved
considerably and were able to eat. You were ready to leave the
hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please resume your home insulin regimen
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see
below).
- Seek medical attention if you are so nauseous you cane eat or
have other symptoms that concern you.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19625808-DS-33
| 19,625,808 | 28,912,145 |
DS
| 33 |
2183-05-01 00:00:00
|
2183-05-01 18:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Linzess / codeine / Percocet / Reglan / latex /
cefpodoxime
Attending: ___.
Chief Complaint:
dyspnea and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ patient with a history of type 1 diabetes,
gastroparesis, chronic migraines, fibromyalgia, end-stage renal
disease on peritoneal dialysis, recent fall with clavicular
bruising presenting with multiple complaints. Patient was seen
by her primary care physician at ___ ___ who noted the
patient to be
hypoglycemic with symptoms of increasing fatigue, diffuse
musculoskeletal pain with ___ sternal pain, and poor PO intake
due to nausea.
Patient has an underlying history of chronic pain especially in
her shoulders, neck due to her fibromyalgia. She had a fall
several weeks ago with trauma to the chest and resulting rib
bruising. This pain has been particularly worse and she rates
___. The pain is worsened with lying down and with deep
breaths.
She also had profound fatigue and poor PO intake for the past 2
days and has not taken her pain meds due to concern about side
effects. Patient receives peritoneal dialysis every night at
home with the assistance of her husband. She presented to ___ on
day of admission for an urgent care visit and was noted to have
asymptomatic hypoglycemia with increased somnolence and was
referred to the ED for further evaluation.
Of note, patient was recently admitted from ___ to ___
with similar complaints of nausea, vomiting, pain and
intermittent hypoxia. Her GI symptoms were attributed to
gastroparesis and her hypoxia was thought to be due to splinting
from her rib contusions. She was continued on her home
medications on discharge in addition to fluconazole for reported
vaginal itchiness and discharge c/w yeast infection.
In the ED:
- Initial vital signs were: 98.4 103 133/72 18 98% RA96
- Exam notable for:
+towel over eyes ___ photophobia from migraines
+chest wall TTP
normal cardiac exam
lungs CTA
abd ntnd
- Labs were notable for: WBC 11.2, Hgb 11.2 (last 12.5), plts
400s, BUN/Cr 43/8.9, alk phos 130s (baseline), albumin 2.3
- Studies performed include: none
- Patient was given:
___ 19:18IVHYDROmorphone (Dilaudid) 1 mg
___ 19:18IVOndansetron 4 mg
___ 19:18POAcetaminophen-Caff-Butalbital
___ ( 1000 mL ordered)
___ 20:44PO/NGClonazePAM 1 mg
___ 20:44PO/NGHYDROmorphone (Dilaudid) 2 mg
___ 21:40POPantoprazole 40 mg
- Consults: Dialysis was consulted for PD orders
- Vitals on transfer: 98.2 103 111/55 18 94% RA
Upon arrival to the floor, patient reported persistent pain in
the R clavicle and back of neck. Reported headaches from her
migraine. Denied any abdominal pain.
Past Medical History:
1. Type I Diabetes Mellitus
2. Peripheral Neuropathy secondary to diabetes
3. ESRD on Peritoneal Dialysis, listed for transplant
4. Gastroparesis secondary to diabetes
5. OSA, not on home CPAP
6. HLD
7. HTN
8. Chronic Fatigue
9. Depression
10. Anxiety
11. Migraines
12. History of bulemia
13. Recurrent culture-negative peritonitis
14. Left brachicephalic fistula (RAVEN)
15. Left breast lumpectomy (___)
Social History:
___
Family History:
No family history of diabetes or kidney disease.
Physical Exam:
Phyiscal Exam on Admission ___:
============================
VITALS: 98.7
PO 131 / 73
R Sitting ___ Ra
GEN: AAOx3, uncomfortable appearing
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: no JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
No murmurs/rubs/gallops.
LUNGS: Decreased BS at the bases bilaterally
CHEST/BACK: TTP along right anterior chest wall as well as
cervical spine. No CVA tenderness.
ABDOMEN: Nontender. PD catheter in place c/d/i. Normal bowels
sounds, non distended. No organomegaly.
EXTREMITIES: Trace ___ edema. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
NEUROLOGIC: Alert and oriented. CN2-12 intact. ___ strength
throughout. Normal sensation.
=============================================
Phyiscal Exam on Discharge ___:
=============================
24 HR Data Temp: 97.4 (Tm 98.3), BP: 93/58 (93-134/58-85), HR:
77
(77-99), RR: 17 (___), O2 sat: 95% (92-98), O2 delivery: Ra,
Wt: 153.1 lb/69.45 kg
GEN: AAOx3, NAD, ill apperaing
HEENT: NC/AT. PERRLA, EOMI. Anicteric sclera. Moist mucous
membranes, good dentition. OP clear.
NECK: no JVD.
CARDIAC: RRR. Audible rub at right and left upper sternal
border.
LUNGS: Difficult to hear due as patient not taking deep breaths
CHEST/BACK: TTP along anterior upper chest wall as well as
clavicle.
ABDOMEN: Nondistended. Normal bowels sounds. Nontender to
palpation. No organomegaly.
EXTREMITIES: Warm and well perfused. No edema, clubbing, or
cyanosis.
NEUROLOGIC: Alert and oriented. CNII-XII grossly intact.
Spontaneously moves all limbs against gravity. Normal sensation.
Pertinent Results:
LABS on ADMISSION ___:
==========================
___ 06:58PM BLOOD WBC-11.2* RBC-3.90 Hgb-11.1* Hct-36.2
MCV-93 MCH-28.5 MCHC-30.7* RDW-14.8 RDWSD-51.4* Plt ___
___ 06:58PM BLOOD Neuts-71.2* Lymphs-13.1* Monos-8.9
Eos-5.7 Baso-0.7 Im ___ AbsNeut-8.00* AbsLymp-1.47
AbsMono-1.00* AbsEos-0.64* AbsBaso-0.08
___ 06:58PM BLOOD Glucose-51* UreaN-45* Creat-9.3* Na-138
K-5.7* Cl-93* HCO3-25 AnGap-20*
___ 08:30PM BLOOD Glucose-163* UreaN-43* Creat-8.9* Na-136
K-5.0 Cl-95* HCO3-21* AnGap-20*
___ 06:58PM BLOOD ALT-8 AST-13 AlkPhos-148* TotBili-0.2
___ 08:30PM BLOOD ALT-7 AST-10 AlkPhos-131* TotBili-0.2
___ 06:58PM BLOOD Lipase-14
___ 06:58PM BLOOD Albumin-2.9*
___ 05:30PM BLOOD D-Dimer-1604*
___ 06:15AM BLOOD TSH-4.4*
___ 06:15AM BLOOD T4-4.2*
___ 06:15AM BLOOD CRP-228.8*
___ 03:12PM BLOOD ___
MICROBIOLOGY RESULTS:
===============================
MRSA SCREEN (Final ___: No MRSA isolated
___ 12:10 pm DIALYSIS FLUID: No microorganisms on Gram
stain. No growth on culture.
IMAGING:
================================
CXR ___
Compared to chest radiographs since ___ most recently
___. Mild cardiomegaly is exaggerated by AP orientation.
Pulmonary vasculature is mildly engorged, but there is no
pulmonary edema. Bilateral infrahilar opacification could be
atelectasis or pneumonia. Linear atelectasis, right midlung
unchanged. No pneumothorax or appreciable pleural effusion.
CTA CHEST ___
1. New moderate pericardial effusion and small bilateral pleural
effusions.
2. No evidence of acute pulmonary embolism or right ventricular
strain.
ECHO ___
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 68 %). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are mildly thickened. There is
no valvular aortic stenosis. The increased transaortic velocity
is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
moderate sized pericardial effusion. The effusion appears
circumferential. No right ventricular diastolic collapse is
seen. There is brief right atrial diastolic collapse. Compared
with the prior study (images reviewed) of ___ there is a
moderate circurmferential pericardial effusion without
echocardiographic signs of tamponade. The resting heart rate is
faster.
LABS on DISCHARGE ___:
==============================
___ 06:00AM BLOOD WBC-8.4 RBC-3.63* Hgb-10.1* Hct-33.2*
MCV-92 MCH-27.8 MCHC-30.4* RDW-14.6 RDWSD-49.3* Plt ___
___ 06:00AM BLOOD Glucose-148* UreaN-45* Creat-9.0* Na-134*
K-4.7 Cl-87* HCO3-27 AnGap-20*
___ 06:00AM BLOOD Calcium-9.0 Phos-5.9* Mg-2.4
___ 06:00AM BLOOD Vanco-14.6
___ 06:15AM BLOOD CRP-228.8*
PENDING LABS on DISCHARGE:
===============================
___ 06:00 QUANTIFERON-TB GOLD
___ 18:32 BLOOD CULTURE Blood Culture, Routine
___ 18:29 BLOOD CULTURE Blood Culture, Routine
___ 12:58 DIALYSIS FLUID FUNGAL CULTURE
Brief Hospital Course:
___ F with PMH of T1DM (c/b neuropathy, gastroparesis), ESRD (on
PD c/b recurrent culture-negative peritonitis), fibromyalgia,
and migraines who is presenting with hypoglycemia, increasing
pain, and failure to thrive found to have moderate size
pericardial effusion without evidence of tamponade on echo.
ACTIVE ISSUES:
=============================
#Acute pericarditis
#Moderate pericardial effusion. Moderate circumferential
pericardial effusion without evidence of cardiac tamponade on
echo with rub heard on physical exam. Most likely due to ESRD
related etiology, either uremic or peritoneal dialysis related
pericarditis in setting of chronic inadequacy of PD. Renal
performed modified peritoneal equilibration test to assess her
peritoneal transport characteristics, results were low-normal
and no changes were made to PD. ___ also be a post-viral
pericarditis. Per cardiology, no indication for
pericardiocentesis at this time as no evidence of tamponade and
limited diagnostic utility. ___ and ___ sent and
pending at the time of discharge. Cardiology recommended repeat
TTE in one week, which is scheduled ___ at 1PM.
#Leukocytosis
#Cough
#Fever. Concern for HAP initially given her symptoms of fever
and cough and recent hospital discharge so she was started on
therapy with vancomycin and cefepime. CTA without evidence of
consolidation. No other signs of infection. Peritoneal fluid was
negative for infection. MRSA screen negative. Treated briefly
with vanc/cefepime but discontinued as her symptoms were thought
to be due to a viral process versus fevers from her pericardial
effusion.
# Failure to thrive
# Nausea
# Gastroparesis: Reported poor PO intake in the past 2 days
prior to admission due to worsening nausea, which is a likely
symptom of patient's underlying gastroparesis. Her symptoms were
at her baseline on admission but due to multiple admissions and
overall failure to thrive, palliative care was consulted at the
request of PCP. Her home Zofran and bowel regimen were
continued. Her outpatient GI recommended relistor or EGD with
botox as potential future interventions however nausea was not a
significant issue during the admission.
# Musculoskeletal pain: Likely due to a combination of
underlying fibromyalgia and trauma from recent fall resulting in
rib contusions. Acute worsening likely in the setting of
self-discontinuation of home pain medications. Per palliative
care recommendations, dilaudid was discontinued and she was
treated with stepwise pain management regiment that included:
For breakthrough pain give 1g IV tylenol first.
If still in pain ___ later offer 4mg tizanidine.
If still in pain ___ min later offer 0.5mg clonazepam q6h PRN
Patient should not be restarted on dilaudid in the future as it
exacerbates her gastroparesis.
CHRONIC ISSUES
==========================
# T1 DM
- Continued home insulin at 10 U glargine and mealtime coverage
with Novalog
- Home 70/30 held in the setting of hypoglycemia on admission.
# ESRD on PD. Pt was continued on home PD and torsemide.
Performed modified peritoneal equilibration test to assess her
peritoneal transport characteristics, results were low-normal
and no changes were made to PD.
# Orthostatic hypotension. Held home midodrine given stable BPs.
# Chronic pain
# Fibromyalgia
# Chronic fatigue
# Peripheral neuropathy. Continued on pregabalin, modafinil,
tizanidine, Nortriptyline 10mg daily.
# Hypothyroidism: Continued home levothyroxine
# Depression/anxiety: Continued home clonazepam, fluoxetine,
nortriptyline.
# GERD: Continued home pantoprazole
# Asthma: Continued home albuterol prn
# HLD: Continued home atorvastatin
# Other home meds
- cont Fish Oil (Omega 3) 1200 mg PO DAILY
- cont HydrOXYzine ___ mg PO QHS:PRN itchiness
===================
TRANSITIONAL ISSUES
===================
[]Patient needs repeat TTE on ___ for evaluation of her
pericardial effusion. Scheduled at 1PM in ___ 4.
[]Consider resuming relistor for nausea if it persists. This
improved her symptoms in the past.
[]Can consider EGD with botox per outpatient GI although she had
little improvement with this the last time it was done.
[]Pending studies: quantiferon gold which were sent for the
workup of pericarditis.
[]Patient started on aspirin 81mg for primary prevention, per
cardiology recommendations.
[]Palliative care to reach out to patient's PCP to discuss the
possible palliative care outpatient follow-up.
[]Please avoid dilaudid/opioids where possible as it seems to
exacerbate her gastroparesis.
# CODE: Full Code. Patient further specified that she must
remain Full Code so long as she is a candidate for transplant.
She explains, however, that she has had life-long religious
beliefs
which run counter to aggressive medical interventions. Should
she no longer be a candidate for renal transplant, she would
like to be made DNAR/DNI.
# HCP: ___, Phone number: ___, Cell phone:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Bisacodyl 10 mg PO BID
3. Calcitriol 0.5 mcg PO DAILY
4. ClonazePAM 1 mg PO BID
5. ClonazePAM 1 mg PO DAILY:PRN anxiety
6. dextrose 40 % oral PRN
7. Docusate Sodium 100 mg PO BID
8. Fish Oil (Omega 3) 1200 mg PO DAILY
9. FLUoxetine 60 mg PO DAILY
10. HYDROmorphone (Dilaudid) 4 mg PO QHS:PRN BREAKTHROUGH PAIN
11. HydrOXYzine ___ mg PO QHS:PRN itchiness
12. Lanthanum 1000 mg PO BREAKFAST
13. Lanthanum 1000 mg PO LUNCH
14. Lanthanum 1500 mg PO DINNER
15. Levothyroxine Sodium 88 mcg PO DAILY
16. Lubiprostone 24 mcg PO BID
17. Midodrine 5 mg PO BID:PRN only if SBP<100
18. Modafinil 300 mg PO QAM
19. Modafinil 200 mg PO DAILY
20. Nortriptyline 10 mg PO QHS
21. Pantoprazole 40 mg PO Q12H
22. Pregabalin 100 mg PO DAILY
23. Senna 34.4 mg PO BID
24. Sodium Bicarbonate 1300 mg PO BID
25. Torsemide 100 mg PO DAILY
26. Vitamin D 1000 UNIT PO DAILY
27. albuterol sulfate 90 mcg/inhalatin inhalation Q4H-Q6H PRN
dyspnea
28. isomethepten-caf-acetaminophen 65-20-325 mg oral ONCE MR1
29. Nephronex (B complex with C#10-folic acid) 900 mcg/5 mL oral
DAILY
30. Ondansetron 4 mg PO TID:PRN nausea
31. Tizanidine 4 mg PO BID:PRN spasms
32. 70/30 10 Units Bedtime
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. 70/30 10 Units Bedtime
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
3. albuterol sulfate 90 mcg/inhalatin inhalation Q4H-Q6H PRN
dyspnea
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PO BID
6. Calcitriol 0.5 mcg PO DAILY
7. ClonazePAM 1 mg PO DAILY:PRN anxiety
8. ClonazePAM 1 mg PO BID
9. dextrose 40 % oral PRN
10. Docusate Sodium 100 mg PO BID
11. Fish Oil (Omega 3) 1200 mg PO DAILY
12. FLUoxetine 60 mg PO DAILY
13. HydrOXYzine ___ mg PO QHS:PRN itchiness
14. isomethepten-caf-acetaminophen 65-20-325 mg oral ONCE MR1
15. Lanthanum 1000 mg PO BREAKFAST
16. Lanthanum 1000 mg PO LUNCH
17. Lanthanum 1500 mg PO DINNER
18. Levothyroxine Sodium 88 mcg PO DAILY
19. Lubiprostone 24 mcg PO BID
20. Midodrine 5 mg PO BID:PRN only if SBP<100
21. Modafinil 300 mg PO QAM
22. Modafinil 200 mg PO DAILY
23. Nephronex (B complex with C#10-folic acid) 900 mcg/5 mL
oral DAILY
24. Nortriptyline 10 mg PO QHS
25. Ondansetron 4 mg PO TID:PRN nausea
26. Pantoprazole 40 mg PO Q12H
27. Pregabalin 100 mg PO DAILY
28. Senna 34.4 mg PO BID
29. Sodium Bicarbonate 1300 mg PO BID
30. Tizanidine 4 mg PO BID:PRN spasms
31. Torsemide 100 mg PO DAILY
32. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
===================
Pericardial effusion without evidence of tamponade
Acute pericarditis
ESRD
Gastroparesis
T1DM
Secondary diagnoses
===================
Fibromyalgia
Chronic pain
Migraines
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. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were having difficulty breathing and low sugars at home.
WHAT HAPPENED WHILE YOU WERE HERE?
-You had a CT scan of your chest that didn't show any clots in
your lungs but showed new fluid around your heart.
-You had an echo that showed the fluid around your heart but the
fluid is not impacting how well your heart is pumping.
-The cardiologists saw you and recommended to repeat the echo in
1 week to ensure that the fluid around your heart is improving.
They also recommended starting a daily aspirin.
-The renal doctors were following ___ and continued you on your
home peritoneal dialysis.
-You were seen by the palliative care doctors who recommended
stopping your dilaudid for pain since it is making your
gastroparesis worse.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Please do not take DILAUDID after you leave the hospital,
continue taking all of your other medications as prescribed.
-Carefully monitor your sugar throughout the day. If you are not
eating as much you should take less of your insulin.
-You should get a repeat echocardiogram in one week ___ at
1PM) to make sure the fluid around your heart is improving.
-Continue with your PD daily as you have been doing.
-Follow up with your primary care doctor.
-___ sure to follow with your psychiatrist and therapist
regularly.
-If you have fevers in the next ___ hours (>100.4F) then you
should call your doctor.
-___ you have worsening chest pain with deep breaths you should
return to the ER.
-Be sure to use your incentive spirometer at home. Ideally you
should use it 10 times per hour every day to keep your lungs
expanded.
-Stop taking your dilaudid. This is making your nausea worse.
It was a pleasure taking care of you,
Your ___ Medicine Team
Followup Instructions:
___
|
19625808-DS-7
| 19,625,808 | 27,890,897 |
DS
| 7 |
2179-09-16 00:00:00
|
2179-09-16 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ondansetron / Linzess / codeine / Percocet
Attending: ___.
Chief Complaint:
Initiation of Hemodialysis
Major Surgical or Invasive Procedure:
___ Fistulogram and Angioplasty
Hemodialysis
History of Present Illness:
Ms. ___ is a ___ year old female with a history of Stage IV
CKD, IDDM complicated by gastroparesis, HTN and HLD who has had
ongoing weakness/lethargy for ___ years, acutely worsened in the
last several days, presenting for initiation of dialysis. The
patient was scheduled to be seen for evaluation of her fistula
on ___ for initiation of HD but has been experiencing worsening
symptoms for the past week. She states that various symptoms
began ___ years ago, with noticable worsening during the past 6
months, especially in the past ___ weeks. These have included
nausea without vomiting, worsening exertional dyspnea,
non-productive cough, fatigue and generalized weakness,
confusion, dysequilibrium and lightheadedness, confusion, and
dysgeusia. Due to lack of appetite she has taken limited fluids
and foods. She also endorses a constant bifrontal ___ headache.
No changes in the frequency or quality of urination; no dysuria.
She also denies fevers, sweats. Denies pruritis. No new rashes,
joint pain, bone pain.
The patient had a left AVF placed in ___ in preparation
for impending HD requirement. She was seen in ___ in
Transplant clinic and at that evaluation, her fistula was not
yet mature. The plan had been for fistulagram in the next
several weeks and there was concern for a developing side branch
which might indicate stenosis.
PCP note in ___ from ___ indicates that the patient has been
seen multiple times over the past several weeks for her
symptoms, including several ED visits at ___ and
an urgent care visit at ___. She has been seen and evaluation
for kidney/pancreas transplant was initiated in ___ of this
year with Dr. ___. Workup to date includes a normal stress
ECHO and PFTs.
In the ED, initial vitals were 97.4, 77/min, 151/67, 14/min, and
100% RA. She had a normal EKG. ___ was notified of her
presentation given likely need for tunneled vs. temporary
catheter. Nephrology was consulted in the ED.
Labs were significant for creatinine of 3.8, Na 127, K 4.6. A
CXR was clear. Vitals prior to transfer were P 79 BP 151/64 RR
11 O2Sat 96% RA.
Past Medical History:
- IDDM
- Peripheral Neuropathy
- Chronic Kidney Disease Stage IV (GFR ___
- Gastroparesis
- OSA
- HLD
- HTN
- Chronic Fatigue
- Depression
- Anxiety
- h/o Bulemia
- s/p Breast lumpectomy (L ___, R ___
- s/p Appendectomy
Social History:
___
Family History:
No history of diabetes or kidney disease
Physical Exam:
ADMISSION:
==========================================
Vitals: T 98.2 BP 145/59 P 81 R 20 O2Sat% 100
General: Alert, NAD
Mental Status: Oriented to exact day, month, year, day of the
week, city. Spells POWER forwards/backwards. Calculates 2.50 in
quarters. Examination limited by cooperation, occassional
innapropriate affect.
HEENT: Mucus membranes dry, sclera anicteric, oropharynx clear
Lungs: CTAB. No w/r/r
CV: RRR, Nl S1, S2. There is a ___ early-peaking systolic murmur
loudest at the LUS border.
Abdomen: Soft, NT/ND bowel sounds present, no palpable
organomegaly
Ext: warm, well perfused, 2+ pulses. Left arm with AVF, palpable
thrill, audible bruit.
Neuro: CNs2-12 intact, strength ___ throughout. Intact
sensation. Mild asterixis present.
DISCHARGE:
=========================================
Vitals: Tm 98.8 Tc 98.0 BP 136/74 P 71 RR 16 O2Sat
98-100% (RA)
General: Alert, NAD
Mental Status: Oriented to city, hospital, floor, date. Spells
POWER forwards and backwards. Calculated 3.25 in quarters.
Serial 7s to 72 without errors.
HEENT: MMM, sclera anicteric, oropharynx clear
Lungs: CTAB. No w/r/r today. Good air movement at the bases.
CV: RRR, Nml S1, S2. There is a ___ early-peaking systolic
murmur loudest at the LUS/LLS border, without radiation to
carotids.
Abdomen: Mild subjective suprapubic/LLQ tenderness. Soft, ND
bowel sounds present, no palpable organomegaly
Ext: warm, well perfused, 2+ pulses. Left arm with AVF, palpable
thrill, audible bruit throughout.
Neuro: CNs2-12 intact, strength grossly intact.
Pertinent Results:
LABS ON ADMISSION:
===========================================
-BLOOD WBC-7.7 RBC-3.67* Hgb-10.6* Hct-32.9* MCV-90 MCH-29.0
MCHC-32.3 RDW-15.1 Plt ___
-BLOOD Neuts-81.7* Lymphs-9.5* Monos-4.3 Eos-3.8 Baso-0.6
-BLOOD ___ PTT-31.9 ___
-BLOOD Glucose-196* UreaN-38* Creat-3.8* Na-127* K-4.6 Cl-89*
HCO3-25 AnGap-18
-BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE
-BLOOD HCV Ab-NEGATIVE
-BLOOD Lactate-1.0
PERTINENT LABS:
===========================================
___ UreaN-38* Creat-3.8* Na-127* K-4.6 Cl-89* HCO3-25
AnGap-18
___ UreaN-37* Creat-3.9* Na-137 K-4.7 Cl-99 HCO3-27
AnGap-16
___ UreaN-27* Creat-3.1* Na-136 K-4.6 Cl-96 HCO3-29
AnGap-16
___ UreaN-33* Creat-3.5* Na-134 K-5.1 Cl-96 HCO3-30
AnGap-13
___ UreaN-22* Creat-3.1* Na-131* K-4.2 Cl-91* HCO3-28
AnGap-16
___ UreaN-15 Creat-3.0* Na-133 K-3.8 Cl-93* HCO3-31
AnGap-13
___ Calcium-9.6 Phos-4.7* Mg-2.5
___ Calcium-9.3 Phos-4.2 Mg-2.3
___ Calcium-9.4 Phos-4.3 Mg-2.5
___ Calcium-9.4 Phos-4.6* Mg-2.4
___ Calcium-9.4 Phos-4.3 Mg-2.2
DISCHARGE LABS:
===========================================
-BLOOD WBC-6.8 RBC-3.70* Hgb-10.9* Hct-33.5* MCV-91 MCH-29.4
MCHC-32.4 RDW-14.9 Plt ___
-BLOOD Glucose-149* UreaN-22* Creat-3.8* Na-132* K-4.5 Cl-91*
HCO3-29 AnGap-17
MICRO:
===========================================
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
===========================================
EKG ___ rhythm. Within normal limits. No change
compared to the previous tracing of ___.
CXR (___): Heart size and cardiomediastinal contours are
normal. Lungs are clear without focal consolidation, pleural
effusion, or pneumothorax.
Brief Hospital Course:
___ year old female with a history of Stage IV CKD, IDDM
complicated by gastroparesis, HTN and HLD with ___ years of
ongoing nausea, weakness/lethargy, presenting with acute
worsening of presumed uremic symptoms, for initiation of
dialysis.
ACTIVE ISSUES:
===========================================
#HD initiation:
The patient was admitted for initiation of hemodialysis due to
worsening symptoms of fatigue, confusion, and nausea, presumed
to be due to uremia in the setting of a moderately elevated BUN.
Her fistula was evaluated by the renal transplant team and felt
to be sufficiently mature to attempt use for hemodialysis. She
underwent hemodialysis on HD2 and HD3, both with successful
cannulation of the fistula. Her third hemodialysis session was
c/b difficulty accessing the fistula. On HD5 she underwent a
fistulagram and balloon angioplasty; her fistula was
sufficiently mature to be used for further hemodialysis. During
this procedure, monitoring detected sustained ventricular
tachycardia that spontaneously resolved to sinus rhythm. She was
maintained on telemetry upon return to the floor, which detected
no further arrhthmias. Throughout her hospitalization, her BUN
downtrended and creatinine remained relatively stable. Her
symptoms of nausea, fatigue, and confusion attributed to uremia
remained stable throughout the hospitalization. A hepatitis
panel and PPD skin test were negative. Due to nausea (and
gastroparesis) she had consistently limited PO intake. She was
continued on her home regimen, including Reglan, and
pantoprazole, and lubiprostone.
#Orthostatic Hypotension:
Presumed to be secondary to uremia, but did not improve with
normalization of the BUN following hemodialysis. Unclear
history, but subjectively unchanged relative to baseline.
Pronounced with sudden standing and ambulation and absent when
supine, consistent with orthostatic hypotension. On HD5 she was
found to be orthostatic, with a drop in SBP from 140 (supine) to
95 (standing), repeated on HD6 as 142 (supine) to 90 (standing).
She was given a 1000cc bolus of fluids and started on
fludrocortisone. By the afternoon of HD6, her dizziness had
subjectively improved; her SBP high upon repeat orthostatic SBP
measurements. The following day (day of discharge), after the
second dose of fludrocortisone, her orthostatic blood pressures
were repeated as follows:
Position HR BP RR O2 RPE
Rest Supine --NT sitting upright EOB-
Sit 81 142/62 99%RA
Stand 88 130/70 100%RA
Activity Standing 88 124/68 100%RA (walk 1)
Standing 88 126/64 100%RA (walk 2)
Recovery Sitting 87 142/62 100%RA (x5 min)
That morning her SBP ranged from 120-150, and she was discharged
on a Fludrocortisone 0.05 mg PO QD; her home diltiazem was held
on discharge.
#SOB:
Unclear etiology, possibly ___ orthostasis, limited PO intake
throughout hospitalization, deconditioning. Pronounced with
standing, although oxygen saturation >99% with ambulation.
Arterial blood gas measurement was deferred given persistently
normal saturations. Pulmonary exam consistently normal, CXR was
unremarkable on admission.
#IDDM:
Complicated by gastroparesis and neuropathy. Her fingerstick
glucose values were largely maintained in the range of 90-180;
there were noepisodes of hypoglycemia or hyperglycemia to above
the mid ___. Her home Glargine, ISS, and post-meal corrective
dosing were continued and modified as necessary for NPO
procedures. Reglan and Lubiprostone were continued for
gastroparesis. Gabapentin was continued for neuropathy.
CHRONIC ISSUES:
=========================================
#HLD: Continued home Atorvastatin 80 mg PO DAILY.
#HTN: Patient with significant orthostatatic hypotension as
above. Her home Diltiazem was held throughout admission and at
time of discharge.
#Chronic Fatigue, Depression, Anxiety: Continued home
Fluoxetine, Clonazepam, Lamictal as well as Dextroamphetamine
and Modafenil.
--------------------
TRANSITIONAL ISSUES:
--------------------
- Please assess blood pressures and requirement for outpatient
HTN regimen adjustments, in particular re-initiation of
Diltiazem, and continuation of fludrocortisone, uptitration of
Fludrocortisone or initiation of another agent for suspected
Diabetic Autonomic Neuropathy
- Please assess ambulation with walker, dizziness
- Please assess recent PO intake, appetite, ongoing nausea
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dextroamphetamine 10 mg PO DAILY
2. Gabapentin 900 mg PO HS
3. LaMOTrigine 200 mg PO BID
4. Topiramate (Topamax) 25 mg PO BID
5. ClonazePAM 1 mg PO BID
6. colesevelam 625 oral BID
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO HS
10. Lubiprostone 24 mcg PO BID
11. Atorvastatin 80 mg PO DAILY
12. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Furosemide 20 mg PO DAILY:PRN edema
14. lactobacillus acidophilus 100 mg (3 billion cell) oral BID
15. Metoclopramide 10 mg PO TID
16. Pantoprazole 40 mg PO Q12H
17. Aspirin 81 mg PO DAILY
18. Sumatriptan Succinate 50-100 mg PO WITH MIGRAINE
19. Fluoxetine 40 mg PO DAILY
20. Levothyroxine Sodium 50 mcg PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. modafinil 1.5 tablets oral upon awakening and 1 tablet ___
hours later
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. ClonazePAM 1 mg PO BID
4. Dextroamphetamine 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Fluoxetine 40 mg PO DAILY
7. Gabapentin 900 mg PO HS
8. LaMOTrigine 200 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Lubiprostone 24 mcg PO BID
11. modafinil 1.5 tablets oral upon awakening and 1 tablet ___
hours later
12. Pantoprazole 40 mg PO Q12H
13. Senna 8.6 mg PO HS:PRN Constipation
14. Sumatriptan Succinate 50-100 mg PO WITH MIGRAINE
15. Topiramate (Topamax) 25 mg PO BID
16. Vitamin D 1000 UNIT PO DAILY
17. Furosemide 20 mg PO DAILY:PRN edema
18. lactobacillus acidophilus 100 mg (3 billion cell) oral BID
19. colesevelam 625 oral BID
20. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. Metoclopramide 5 mg PO TID
While your kidneys are not working well, we recommend reducing
the dose of this medication.
RX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day
Disp #*90 Tablet Refills:*3
22. Fludrocortisone Acetate 0.05 mg PO DAILY
RX *fludrocortisone 0.1 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
23. Nephrocaps 1 CAP PO DAILY
RX *B complex & C ___ acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: End Stage Renal Disease
Diabetic Autonomic Neuropathy
Secondary: Insuline-dependent diabetes
Gastroparesis
Depression/Anxiety/Chronic Fatigue
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 ___ to start hemodialysis treatment
for your renal failure. During your admission, your fistula was
evaluated by the transplant service and found to be usable for
hemodialysis. You underwent four sessions of hemodialysis.
Throughout, your blood sugar levels were monitored, and you were
treated for ongoing symptoms of nausea, dizziness, and shortness
of breath. You were seen by ___ who recommended use of a walker
at home. We started a medication to reduce your dizziness and
stopped your home blood pressure medications. Please follow-up
with your PCP and kidney physicians to further manage your blood
pressure.
It has been a pleasure taking care of you, and we wish you all
the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19626086-DS-14
| 19,626,086 | 20,573,860 |
DS
| 14 |
2131-08-20 00:00:00
|
2131-08-20 15:37:00
|
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 ankle fracture
Major Surgical or Invasive Procedure:
Right ankle ORIF
History of Present Illness:
HPI: ___ with hx of HTN, HLD and alcohol abuse who is presenting
as a transfer from ___ after fall while intoxicated and
was found to have right ankle trimalleolar fracture. She was
reduced at the OSH and splinted with post-reduction films that
showed improved alignment, but persistent displacement. She was
feeling well on ED arrival, but then started having tremors,
nausea, vomiting and heart racing consistent with alcohol
withdrawal. She has no hx of alcohol withdrawal or seizures, but
she has been drinking ___ beers daily with more on the weekends.
She had a mechanical fall tonight with subsequent right ankle
pain. CT scan of the head, c-spine and torso at OSH that were
unremarkable. She had hypotension that was fluid responsive at
the OSH.
Past Medical History:
HTN
HLD
Alcohol abuse
Social History:
___
Family History:
N/C
Physical Exam:
On discharge:
General: well-appearing, breathing comfortably
CV: pink and well perfused
Abd: soft, non-tender, non-distended
RLE: Incision well approximated. Cast in place. Fires FHL, ___.
SILT over exposed toes. Toes WWP distally.
Pertinent Results:
___ 04:35AM BLOOD WBC-10.3* RBC-3.61* Hgb-12.2 Hct-34.7
MCV-96 MCH-33.8* MCHC-35.2 RDW-12.1 RDWSD-42.3 Plt ___
___ 04:35AM BLOOD Glucose-109* UreaN-4* Creat-0.5 Na-134*
K-4.3 Cl-97 HCO3-18* AnGap-19*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fracture of the right ankle, and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of R ankle, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report.
After the procedure the patient was taken from the OR to the
PACU in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. The patient
was given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. She was also closely monitored
on CIWA protocol and treated with Ativan for concern of EtOH
withdrawal.
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 right lower extremity, and will
be discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO Q8H:PRN neuropathic pain
2. Amitriptyline 10 mg PO QHS
3. Simvastatin 20 mg PO QAM
4. Lisinopril 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Baclofen 10 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right ankle trimalleolar fracture
Discharge Condition:
AVSS
NAD
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
RLE: Incision well approximated. Cast in place. Fires FHL, ___.
SILT over exposed toes. Toes WWP distally.
AVSS
NAD
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
RLE: Incision well approximated. Cast in place. Fires FHL, ___,
TA, GCS. SILT over exposed toes. Toes WWP distally.
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 in Right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin daily for 4 weeks
WOUND CARE:
- You may shower but do NOT get cast wet. Your cast must be left
on until follow up appointment unless otherwise instructed.
- 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.
Followup Instructions:
___
|
19626102-DS-20
| 19,626,102 | 25,001,541 |
DS
| 20 |
2129-07-18 00:00:00
|
2129-07-18 20:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Numbness, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ woman with migraines and
hypertension who presents as a code stroke from ___
___ for further evaluation of right-sided
paresthesias/numbness, weakness, and dizziness.
Patient states that she has had a dry cough for the past 2 days.
Yesterday afternoon, she felt slightly off-balance when walking
and decided to lie down at approximately 12:30 ___ in the
afternoon. She woke up at around 18:55 ___ and noticed
paresthesias and heaviness in her right arm and right leg as
well as the right half of her face. This was associated with
dizziness which she characterizes as a spinning sensation. It
was worse if she were to change positions in her bed. With
respect to the paresthesias, she states that the sensation
started in her face and over the course of a few seconds spread
to involve her right arm and right hand. It subsequently involve
the right leg as well.
Despite the symptoms, she was able to ambulate to the door of
her bedroom and call out to her husband for help. She endorses
difficulties "getting the words out" at the time she was asking
for her husband's help but no trouble understanding what he or
other people were telling her.
EMS was called and the patient was brought to ___
for further evaluation. There she underwent CT and CTA head/neck
- both of which were unrevealing. TeleStroke at ___ was
activated and recommended against tPA given low NIHSS. She
received full dose aspirin and was transferred to ___ for
further evaluation. On neurological ROS, the patient denies
headache, loss of vision, blurred vision, diplopia, dysphagia,
lightheadedness, tinnitus or hearing difficulty. Denies
difficulties comprehending speech. No bowel or bladder
incontinence or retention. On general review of systems, the
patient endorses recent cough as noted above. She denies recent
fever or chills. No night sweats or recent weight loss or gain.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Migraine headaches
Hypertension, not on medications
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
Vitals: T 98.5, HR 75, BP 121/71, RR 16, Sa 97% RA
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: Trace ___ edema.
Skin: no rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty though limited slightly by language
differences. 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. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to finger counting.
V: Facial sensation decreased to light touch throughout right
hemi-face compared to left. States that it is 75% of the
sensation on the left.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Mild pronator drift on the
right. No adventitious movements, such as tremor, noted. No
asterixis noted. * Give-way component to weakness.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 4+* 5-* 4* 4* 4* 5-* 5 5-* 4+* 5-* 5-*
-Sensory: Decreased sensation to temperature, light touch, and
pin prick in right arm and right leg. No deficits to vibratory
sense or proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was mute on the right and withdrawal on the
left.
-Coordination: No intention tremor. Finger-taps slowed on the
right. No dysmetria on FNF or HKS bilaterally.
-Gait/Station: Deferred.
ON DISCHARGE:
Temp: 97.3 PO BP: 128/80 L Lying HR: 66 RR: 19 O2 sat: 98% O2
delivery: Ra
-Mental Status: Alert, oriented x 3. Attentive to interview.
Language is fluent with intact repetition and comprehension.
Normal prosody. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOMI without nystagmus. Facial
sensation intact to light touch throughout. No facial droop.
Palate elevates symmetrically. Tongue protrudes in midline with
good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift.
Strength is full in the upper and lower extremities bilaterally.
-Sensory: Decreased sensation to temperature, light touch, and
pin prick in right arm (75% normal), but intact in right leg. No
deficits to vibratory sense or proprioception throughout. No
extinction to DSS.
-DTRs: not tested
-___: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait/Station: Deferred.
Pertinent Results:
___ 06:20AM %HbA1c-5.4 eAG-108
___ 06:20AM TRIGLYCER-97 HDL CHOL-51 CHOL/HDL-3.6
LDL(CALC)-113
___ 06:20AM TSH-5.6*
___ 06:20AM FREE T4-1.0
___ 06:20AM CRP-5.1*
MRI BRAIN W/O CONTRAST:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are normal
in caliber and
configuration. There are no diffusion or susceptibility
abnormalities. The
major vascular flow voids are preserved. There are scattered
bilateral
predominantly subcortical white matter hyperintensities, which
are nonspecific nonspecific but may represent chronic small
vessel ischemic disease, inflammatory changes, or demyelination.
The visualized paranasal sinuses, mastoid air cells, and orbits
are
unremarkable.
IMPRESSION:
1. No evidence of infarction, hemorrhage, or mass.
2. Multiple predominantly subcortical bilateral white matter
hyperintensities of uncertain clinical significance.
Brief Hospital Course:
This is a ___ woman with migraines and hypertension who
presented as a code stroke for evaluation of sudden onset
right-sided paresthesias/numbness, weakness, and dizziness.
Her neurological examination on admission was notable for right
sided sensory changes and primarily right arm weakness though
there is a large give-way component. She has no headache,
aphasia, or dysarthria at this time. Given low NIHSS (2) and no
LVO on OSH CTA, patient was not a candidate for any acute
interventions. She did develop a mild headache, though not
clearly migrainous in nature.
MRI obtained while symptoms were still present did not show any
evidence of stroke. The day after admission, her strength had
returned to normal. She still had some mild sensory complaints
in the right arm, though none in the leg or face.
The cause of her symptoms was unclear. TIA/Stroke were thought
to be unlikely based on her exam and negative MRI despite
persistent symptoms. We wondered about underlying stress or
migraine equivalent, given her history of migraines.
TRANSITIONAL ISSUES:
[ ] Blood pressures well controlled, no need for
antihypertensive therapy at this point
[ ] Follow up with PCP; no need for neurology follow up.
Medications on Admission:
This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Abnormal skin sensations (unspecified)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of right arm and leg
sensory changes as well as weakness. There was concern that
these may have been due to a stroke. However, an MRI did not
show any evidence of stroke. We feel your symptoms were more
likely caused by a migraine, which can cause similar symptoms to
what you experienced.
We are not changing your medications.
Please follow up with your primary care physician.
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:
___
|
19626447-DS-12
| 19,626,447 | 23,712,659 |
DS
| 12 |
2174-03-20 00:00:00
|
2174-03-20 16:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Acute left weakness/numbness and difficulty speaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with history of active alcohol use
disorder and cocaine use who presents with acute left
weakness/numbness and difficulty speaking with subsequent
significant improvement.
Mr. ___ slept well last night and woke up this morning
feeling well. Today, approx. 1255, he was dropping off packages
in ___. While in the elevator, he was holding two
packages with both hands, and it felt like one dropped from his
left hand. He went to catch it and he couldn't bend down to pick
it up (it was on his left side). His left arm and leg wouldn't
move at all. He bent down on right knee to pick up package but
couldn't use his left hand to pick up the package and had no
movement of his left hand. This was associated with tingling
over left face/arm/leg followed seconds to 1.5 min later by lack
of sensation over this area. He also noted saliva dripping from
left corner of mouth.
The elevator door then opened, and someone said "are you all
right?" He couldn't answer. He endorses difficulty finding the
words and difficulty forming words. He could make some sounds
but couldn't speak. He was able to understand what people said
to him. He couldn't stand up from that position bended on right
knee. Bystander helped him up and out of the elevator. He was
seen by physicians who happened to be nearby, and was given
324mg ASA. EMS was called and symptoms resolved within 15
minutes after onset. By the time EMS arrived, weakness and
numbness, speech had dramatically improved.
Past Medical History:
HTN - was prescribed a medication but is noncompliant.
Does not regularly follow with physicians.
Social History:
___
Family History:
Mother HTN
Father deceased, thinks he may have had cancer. Died in early
___. Had stroke, details unknown.
sister HTN
brother HTN
Mat cousin with stroke, unknown details.
No fam history of DVT/PE
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 98 HR: ___ BP: 148-160/77-100 RR: ___ SaO2: 99%
RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Mildly inattentive. With MOYB he
interposes ___ and ___, then says ___, ___,
___, then loses track to the task. Attentive, able to name ___
backward without difficulty. Speech is fluent with normal
grammar and syntax. No paraphasic errors. Naming intact to low
frequency words. Repetition intact. Comprehension intact to
complex, cross-body commands. Normal prosody.
-Cranial Nerves: PERRL 2.5->2. VFF to confrontation. EOMI with
___ beats bilateral end-gaze nystagmus. Facial sensation intact
to light touch. Face symmetric at rest and with activation.
Hearing intact to conversation. Palate elevates symmetrically.
___ strength in trapezii bilaterally. Tongue protrudes in
midline and moves briskly to each side. No dysarthria.
- Motor: Normal bulk and tone. Sight left pronation. No tremor
nor asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5 4+ 4+ 4+ ___ 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Sensory: Proprioception decreased to the smallest movements L
fifth finger, intact left seond digit. Some pseudoathetosis LUE.
Intact to LT throughout, mild decr PP LUE.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Normal initiation. Narrow base. Short strides with LLE,
slight dragging L foot.
DISCHARGE EXAM:
===============
VS: Temp: 98.3 (Tm 98.3), BP: 152/90 (124-152/77-90), HR: 79
(64-79), RR: 18, O2 sat: 97% (97-99), O2 delivery: RA
Exam
General: Awake, cooperative, NAD. Getting TTE done.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with normal grammar and
syntax. No paraphasic errors. Naming intact to low frequency
words. Normal prosody.
-Cranial Nerves: PERRL 2.5->2. VFF to confrontation. EOMI with
___ beats bilateral end-gaze nystagmus. Facial sensation intact
to light touch. Face symmetric at rest and with activation.
Hearing intact to conversation. Palate elevates symmetrically.
___ strength in trapezii bilaterally. Tongue protrudes in
midline and moves briskly to each side. No dysarthria.
- Motor: Normal bulk and tone. Sight left pronation. No tremor
nor asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5 4+ 4+ 4+ ___ 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Sensory: Proprioception decreased to the smallest movements of
left fifth finger, intact left seond digit. Intact to LT
throughout, mild decrease to PP LUE.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Normal initiation. Narrow base. Short strides with LLE,
mild dragging L foot.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00PM URINE HOURS-RANDOM
___ 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:00PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:00PM URINE HYALINE-1*
___ 03:00PM URINE MUCOUS-RARE*
___ 02:16PM %HbA1c-5.6 eAG-114
___ 02:11PM COMMENTS-GREEN TOP
___ 02:11PM CREAT-1.7*
___ 02:11PM estGFR-Using this
___ 01:50PM GLUCOSE-102* UREA N-22* CREAT-1.7* SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-12
___ 01:50PM estGFR-Using this
___ 01:50PM ALT(SGPT)-17 AST(SGOT)-24 ALK PHOS-123 TOT
BILI-0.3
___ 01:50PM cTropnT-<0.01
___ 01:50PM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-3.0
MAGNESIUM-2.1 CHOLEST-203*
___ 01:50PM TRIGLYCER-144 HDL CHOL-67 CHOL/HDL-3.0
LDL(CALC)-107 ___
___ 01:50PM TSH-0.34
___ 01:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 01:50PM WBC-5.8 RBC-5.15 HGB-14.7 HCT-46.0 MCV-89
MCH-28.5 MCHC-32.0 RDW-13.2 RDWSD-43.0
___ 01:50PM NEUTS-54.0 ___ MONOS-12.0 EOS-1.7
BASOS-0.5 IM ___ AbsNeut-3.15 AbsLymp-1.84 AbsMono-0.70
AbsEos-0.10 AbsBaso-0.03
___ 01:50PM PLT COUNT-235
___ 01:50PM ___ PTT-26.3 ___
DISCHARGE LABS:
===============
___ 05:45AM BLOOD WBC-5.0 RBC-4.80 Hgb-14.1 Hct-43.2 MCV-90
MCH-29.4 MCHC-32.6 RDW-13.2 RDWSD-43.2 Plt ___
___ 05:45AM BLOOD Glucose-102* UreaN-26* Creat-1.7* Na-138
K-4.6 Cl-103 HCO3-19* AnGap-16
___ 05:45AM BLOOD ALT-17 AST-20 LD(LDH)-186 AlkPhos-104
TotBili-0.2
___ 05:45AM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.3 Mg-2.0
___ 02:16PM BLOOD %HbA1c-5.6 eAG-114
___ 01:50PM BLOOD Triglyc-144 HDL-67 CHOL/HD-3.0
LDLcalc-107 ___
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING:
========
CTA HEAD/NECK ___:
1. No evidence of an acute intracranial abnormality.
2. The major vessels of the neck, circle of ___, and their
principal
intracranial branches appear normal without flow limiting
stenosis, occlusion, or aneurysm formation. Final read pending
reformats.
CHEST X-RAY ___:
The lungs are clear. There is no consolidation, effusion, or
edema. Cardiac silhouette is mildly enlarged. No acute osseous
abnormalities. Chronic deformity of the distal left clavicle,
likely prior fracture.
IMPRESSION:
No acute cardiopulmonary process. Cardiomegaly.
MRI HEAD ___:
1. Subacute right prefrontal gyrus and corona radiata infarcts.
2. Susceptibility artifact in the right thalamus probably
reflects chronic
sequela of prior hemorrhagic infarct.
TTE ___:
The left atrial volume index is SEVERELY increased. There is no
evidence of an atrial septal defect or patent foramen ovale by
2D/color Doppler or agitated saline at rest and with maneuvers.
The estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a mildly increased/dilated
cavity. There is mild regional left ventricular systolic
dysfunction with inferior near akinesis (see schematic) and mild
global hypokinesis of the remaining segments. No thrombus or
mass
is seen in the left ventricle. Quantitative biplane left
ventricular ejection fraction is 33 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract
gradient. Normal right ventricular cavity size with focal
hypokinesis of the apical free wall. Tricuspid annular plane
systolic excursion (TAPSE) is normal. The aortic sinus diameter
is normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. There is no evidence for an aortic
arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is moderate [2+]
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.
IMPRESSION: Mild left ventricular cavity dilation with mild
regional and global systolic dysfunction most c/w a diffuse
process (e.g. toxin, metabolic or multivessel CAD). Moderate
mitral regurgitation. Mild pulmonary artery systolic
hypertension. Normal right ventricular cavity size with distal
free wall hypokinesis.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with active alcohol use
disorder and cocaine use who presented with acute onset left
sided weakness/numbness and difficulty speaking with subsequent
improvement found to have right prefrontal gyrus and corona
radiata infarcts.
Etiology likely cardioembolic in the setting of active cocaine
use disorder and global systolic dysfunction. Atheroembolic and
vasospasm due to cocaine use are also both possible.
The patient underwent TTE this admission which showed mild left
ventricular cavity dilation with mild regional and global
systolic dysfunction most c/w a diffuse process (e.g. toxin,
metabolic or multivessel CAD). Moderate mitral regurgitation.
Mild pulmonary artery systolic hypertension. Normal right
ventricular cavity size with distal free wall hypokinesis.
LDL was 120, A1c 5.6. The patient was started on aspirin 81 mg
daily, atorvastatin 80 mg daily, and lisinopril 5 mg daily. The
patient was also provided a ZioPatch for extended cardiac
monitoring to assess for occult atrial fibrillation.
The patient was seen by our addition psychiatry team but refused
therapy or resources at the present time.
He was also evaluated by our occupational therapist who
recommended outpatient OT.
TRANSITIONAL ISSUES:
====================
# Blood pressure goal is normotension. Lower slowly over next
few days. He was started on lisinopril 5 mg daily while in
house. This can be further uptitrated as an outpatient.
# Patient with creatinine of 1.7 this admission. Unclear if this
is acute or chronic. Please continue to monitor for progression
of CKD.
# Please consider addition of beta blocker in this patient given
reduced EF.
# Please consider outpatient TEE to assess for PFO.
# Outpatient occupational therapy
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 120) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not -> patient at baseline
functional status
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*6
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
4. 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
Discharge Diagnosis:
Acute ischemic Stroke
Acute kidney injury
Substance use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-High cholesterol
-Hypertension
-Drug use
-Drinking a lot of alcohol
We are changing your medications as follows:
-START aspirin 81mg daily
-START Atorvastatin 80mg every night
-START lisinopril
-Avoid illegal substances
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:
___
|
19626923-DS-10
| 19,626,923 | 28,933,569 |
DS
| 10 |
2189-06-02 00:00:00
|
2189-06-02 16:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w/ PMHx of recurrent DVT/PE ___ years ago, ___, on
life-long anticoagulation), presented with left leg and chest
pain. Patient has not taken coumadin for ___ weeks ___ visiting
his sister in the hospital. Per office records, last
therapeutic INR in ___, was on 5mg coumadin. Patient
reports left calf pain/tightness 5 days ago, similar to what he
experienced with prior DVT. On DOA, patient experienced sharp,
___, non-radiating substernal chest pain suddenly. Associated
with dyspnea, and fatigue. Chest pain worse with cough and deep
inspiration. No recent travel, no h/o malignancy, no h/o GI,
GU, intracranial bleed.
In the ED, initial VS. 99.0 103 127/83 16 99%. CTA showing b/l
subsegmental PE. EKG showing new RBBB and S1Q3T3 pattern. Given
100mg Lovenox, 5mg Morphine IV and full dose ASA.
Currently, patient c/o ___ substernal pain.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
COPD
DVT/PE in ___ and ___
Social History:
___
Family History:
Cancer (mom and GM, uterine and colon)
Physical Exam:
ADMISSION EXAM:
VS - 97; 114/80; 1028; 100RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tachycardic, regular, no MRG, nl S1-S2, no parasternal
heave
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
+ ___ sign on L. calve, tenderness on palpation
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
DISCHARGE EXAM:
VS - 98.5; 117/75; 80; 20; 95%RA
Exam otherwise unchanged since admission
Pertinent Results:
ADMISSION LABS:
___ 10:13AM BLOOD WBC-10.8 RBC-4.46* Hgb-13.5* Hct-41.4
MCV-93 MCH-30.2 MCHC-32.6 RDW-12.0 Plt ___
___ 10:13AM BLOOD ___ PTT-28.9 ___
___ 10:13AM BLOOD Glucose-81 UreaN-13 Creat-1.0 Na-138
K-3.8 Cl-100 HCO3-29 AnGap-13
___ 10:13AM BLOOD proBNP-36
___ 10:13AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 07:45AM BLOOD Hct-38.2*
INR:
___ 10:13AM ___
___ 07:50AM ___
___:50AM ___
___ 07:45AM ___
IMAGING:
CXR ___:
PA and lateral views of the chest were obtained. Lung volumes
are low with bibasilar plate-like atelectasis, left greater than
right. No definite signs of pneumonia or CHF. No large pleural
effusion or pneumothorax is seen. Heart size is difficult to
assess though appears grossly stable. Mediastinal contour is
normal. Bony structures appear intact.
IMPRESSION: Bibasilar plate-like atelectasis, left greater than
right. Please refer to subsequent CTA chest for further details.
CTA chest ___:
There are bilateral subsegmental and lingular pulmonary emboli.
Consolidations in the bases may be atelectasis, however, lack of
enhancement is suggestive of early infarct. In addition, seen
anterior to the heart is a consolidation which is likely an
infarct from a lingular pulmonary embolus. There is no evidence
of right heart strain. There is no axillary, mediastinal or
hilar lymphadenopathy. No pulmonary nodules or masses are seen.
There is no pneumothorax. The bones are unremarkable.
Although this study was not tailored to evaluate the
subdiaphragmatic
contents, a right adrenal adenomyolipoma is seen but not fully
imaged. The imaged portion of the spleen, liver and left
adrenal gland is normal.
IMPRESSION: Bilateral subsegmental and lingular pulmonary
emboli with
probable early infarction.
Brief Hospital Course:
___ y/o M with PMHx of DVT, recently off coumadin, presenting
with left leg pain, chest pain, CTA c/w b/l subsegmental PE.
# PE/Chest pain: Patient presented with chest pain and leg pain.
CTA showing bilateral subsegmental PEs. EKG with S1Q3T3.
Patient with h/o recurrent DVT/PE x2, on life-long
anticoagulation. These DVT/PEs did not seem provoked. Unclear
whether he had hypercoagulable workup as outpatient. Per outpt
records, last time INR within goal was ___, on coumadin 5mg
daily. Patient with med non-compliance due to social reasons.
Will continue to require lifelong anticoagulation given this is
his third episode. On admission, patient mildly tachycardic,
but not hypotension and had no O2 requirement. Chest/leg pain
controlled with oxycodone 5mg BID prn. Will likely be able to
wean off as PE/DVT resolves. Started Lovenox ___ bid (1mg/kg
bid) and coumadin 5mg daiy on ___. INR on ___ was 1.1.
Patient will go to ___ for Lovenox/coumadin bridging
and continued monitoring. Once INR ___, can discontinue
lovenox. Please arrange follow up and INR monitoring with
patient's PCP- ___.
# COPD: Patient only with ___ year smoking history, but recently
diagnosed with COPD. Uses rescue inhalers every few days.
Continue tiotropium and albuterol prn.
# Depression: Continued celexa daily.
# Transitional issues:
- code status: full code
- pending labs: none
- follow up issues: INR check, Lovenox- coumadin bridging;
Please arrange follow up and INR monitoring with patient's PCP-
___ prior to discharge from ___
Medications on Admission:
Coumadin ___ daily (last took ___ weeks ago)
Celexa 40mg daily
Albuterol inhaler prn
tiotropium inhaler prn
Discharge Medications:
1. enoxaparin 120 mg/0.8 mL Syringe Sig: One ___ (110)
mg Subcutaneous Q12H (every 12 hours): as directed.
Disp:*14 syringes* Refills:*0*
2. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB,
wheezing.
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Disp:*14 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
___
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Pulmonary Emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure participating in your care at ___. You were
admitted because you had chest and leg pain. We found that you
have blood clot in your lungs. We are treating you with Lovenox
(injection blood thinner). You will continue to take Lovenox
until your coumadin level builds up in your blood.
We made the following changes to your medications:
STARTED Lovenox (you will stop once your coumadin level is at
goal)
RESTARTED Coumadin
STARTED Oxycodone as needed for pain
Followup Instructions:
___
|
19626923-DS-11
| 19,626,923 | 27,005,072 |
DS
| 11 |
2189-08-03 00:00:00
|
2189-08-03 23:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ATTG ADMIT NOTE
.
DATE ___
TIME 0400
.
PCP: ___.
Location: ___ MULTI-SERVICE CENTER
Address: ___
Phone: ___
.
___ yo homeless M with recurrent DVT/PE in ___ presents to
the ED reporting that he has been off his coumadin for 1.5 weeks
due to depression.
.
Patient was recently hospitalized ___ with leg and chest
pain after being off coumadin for 3 weeks and found to have
bilateral subsegmental PE's. Previously had DVT/PE in ___ and
___, instructed to be on lifelong AC. Patient treated with
lovenox and discharged to ___ for Lovenox/coumadin
bridge. He reports good compliance with coumadin until 1.5
weeks ago when he was too depressed to take his medications.
Denies any SI or HI, just states he couldn't take any of his
medications due to "depression". Patient was previously on
alternating doses of 15mg and 12.5mg of coumadin. INRs have
been followed at the ___. Patient is currently
homeless.
.
Patient denies any leg pain, swelling, cp or sob. He endorses
worsening of chronic lower back pain which he attributes to
carrying heavy belongs with him (homeless) and sleeping on
benches. Back pain does not radiate, no leg weakness or
numbness. No bowel or bladder incontinence.
.
ED: 99.7 120 123/65 20 100%; given 2L NS. CTA chest with new
acute right upper lobar and segmental pulmonary embolism.
Patient spiked to 100.9 - blood cultures sent. Developed RUQ
ttp - ruq ultrasound wnl. LFTs wnl. Rectal guaiac negative.
Heparin gtt started.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
COPD
Anxiety
Depression
DVT/PE ___ on lifelong AC
Social History:
___
Family History:
Mother and GM deceased from uterine and colon ca
Physical Exam:
Admission Labs:
VS: 98.2 114/65 92P 18 97%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, 2+ L > R edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally, diminished at bases
Abd: soft, obese, nt, nd, +bs
Msk: ___ strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical ___
___ Labs:
Unchanged
Oropharyngeal exam notable for bilateral tonsillar hypertrophy
with minimal erythema. No exudates noted.
Pertinent Results:
Admission Labs:
___ 09:25PM BLOOD WBC-8.0 RBC-4.51* Hgb-13.8* Hct-41.1
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.0 Plt ___
___ 09:25PM BLOOD Neuts-70.2* ___ Monos-7.8 Eos-1.8
Baso-0.2
___ 09:25PM BLOOD ___ PTT-28.5 ___
___ 09:25PM BLOOD Glucose-84 UreaN-19 Creat-1.1 Na-140
K-4.0 Cl-102 HCO3-27 AnGap-15
___ 09:25PM BLOOD ALT-20 AST-15 AlkPhos-56 TotBili-0.3
___ 09:25PM BLOOD Lipase-33
___ 09:25PM BLOOD Albumin-4.2
Discharge Labs:
___ 06:00AM BLOOD WBC-7.2 RBC-4.32* Hgb-12.9* Hct-38.8*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.0 Plt ___
___ 05:55AM BLOOD ___ PTT-43.3* ___
___ 06:00AM BLOOD Glucose-102* UreaN-11 Creat-1.0 Na-138
K-4.3 Cl-99 HCO3-28 AnGap-15
___ 02:30AM URINE Color-Straw Appear-Clear Sp ___
___ 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Micro:
___ 11:46 am THROAT FOR STREP: NO BETA STREPTOCOCCUS GROUP
A FOUND.
___ 3:15 am BLOOD CULTURE: Pending
ECG - Sinus tachycardia. Within normal limits. Compared to the
previous tracing of ___ the heart rate is increased, the
other findings are similar.
CXR - FINDINGS: PA and lateral views of the chest were
obtained. Lung volumes are low, though no focal consolidation
is seen. No effusion or pneumothorax. Cardiomediastinal
silhouette appears grossly stable, though lung volumes are low,
limiting evaluation of the heart size. Bony structures are
intact.
IMPRESSION: Limited, negative.
CTA Chest - IMPRESSION:
1. New right lobar and segmental pulmonary emboli in the upper
lobe. The patient's previously known pulmonary emboli have
resolved.
2. Bilateral lower lobe ground-glass opacities, likely
represent sequelae of previously noted infarction.
3. Small hiatal hernia.
RUS U/S - FINDINGS:
The liver is normal in echogenicity with no focal lesions
present. The partially imaged pancreas is unremarkable. The
portal vein is patent with hepatopetal flow. The common bile
duct measures 3 mm and is normal. The gallbladder is normal. An
8 mm echogenic focus seen in the gall bladder on initial images
(1:27) was subsequently not reproducible by the technologist or
the scanning radiologist.
IMPRESSION:
Normal right upper quadrant ultrasound.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Gray scale and
Doppler sonogram of bilateral common femoral, superficial
femoral and popliteal veins show normal compressibility, flow,
augmentation, color Doppler appearance and normal waveforms on
spectral analysis. Bilateral posterior tibial and peroneal
veins showed normal flow. Mild calf edema is noted bilaterally.
IMPRESSION: No evidence of DVT in bilateral lower extremity
veins.
Brief Hospital Course:
___ yo homeless M with recurrent DVT/PE in ___ admitted with
acute PE in the setting of being non-compliant with coumadin.
#Acute PE: patient very hypercoagable given that this is his
second PE in the last few months after being off coumadin;
unclear if hypercoagable work-up his been done in the past per
last discharge summary. Not symptomatic from this PE. ___
negative for DVT. Started on heparin gtt and then switched to
lovenox bridge on HD 1. Coumadin also started at 12.5 mg daily
(home dose was 12.5 mg and 15 mg alternating). After three
days, INR still not rising, so coumadin dose increased to 15 mg
daily. Pt is being discharged to continue lovenox bridge until
INR therapeutic (___) for at least 24 hours.
# Sore Throat: Developed sore throat during admission. No
fevers. Exam significnat for bilateral tonsillar hypertrophy as
well as some mild pharyngeal erythema. No exudates. Throat was
negative for strep. Given cepacol and chloraseptic. Should
continue to monitor for improvement.
#Depression: Pt cited this as reason he stopped meds. enied
SI/HI. Seen by psych during admission who recommended outpt f/u
with his normal treaters.
# Fever: Only reported in the ED. No further episodes on the
floor.
#Back pain: Likely MSK. Improved throughout admission. Given
small amount of oxycodone.
#RUQ abdominal pain: Reported in ED. Normal LFTs and RUQ
ultrasound. Pt did not report pain once on the floor.
#COPD: albuterol and spiriva inhalers
FULL CODE
HCP ___ (sister) # in OMR
Medications on Admission:
*Patient has not taken any medications x 1.5 weeks
Albuterol inhaler prn
tiotropium inhaler prn
Effexor XR 75mg daily
Coumadin
MVI
Discharge Medications:
1. Tiotropium Bromide 1 CAP IH DAILY
2. Venlafaxine XR 75 mg PO DAILY
3. Warfarin 15 mg PO DAILY16
4. Cepacol (Menthol) 1 LOZ PO PRN sore throat
5. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN sore throat
6. Enoxaparin Sodium 120 mg SC Q12H
7. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN pain
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or
wheezing
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Pulmonary Embolism
- Viral URI
Secondary Diagnosis:
- Depression
- Chronic Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ after having stopped your coumadin. You
had a CAT scan and were found to have a blot clot in your lungs.
You were started on lovenox injections and coumadin thin your
blood. You are now being discharged to ___
for further monitoring until your blood is completely thinned.
Please see below for a complete list of changes to your
medications. We have started lovenox injections until your INR
(coumadin levels) are high enough. We also have started cepacol
lozenges and chloraseptic throat spray for your sore throat.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
19626923-DS-12
| 19,626,923 | 22,986,424 |
DS
| 12 |
2189-10-29 00:00:00
|
2189-10-29 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Generalized Malaise, Low INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ y/o M w/ PMHx of COPD and PE/DVT on lifelong
anticoagulation with multiple recurrent clots when stopping
coumadin, presents with multiple c/o. First of all, pt reports
that he was told last week that his INR was subtherapeutic.
Additionally, he has recently developed worsening generalized
body aches. He is unable to give further details, but does
report that his pain is worst in his lower back (he has know
chronic lower back pain). In the ED, he also endorsed bilateral
ankle pain worse with walking. Additionally, during this time,
the patient has developed a worsening cough productive of brown
sputum. + chills, no fevers. Given all of these concerns, he
presented to the ED for evaluation.
ED course:
Initial VS: 98.2 99 122/76 18 96%
Labs significant for INR 1.9.
CXR showed linear bibasilar opacities suggestive of atelectasis
(but could not rule out PNA).
Bilateral ___ were performed because of leg pains and were
negative for DVT
Meds given: coumadin 15 mg, lovenox ___ mg, percocet x 1,
levofloxacin 750 mg (given CXR findings)
VS prior to transfer: 98.1 97 116/72 19 100%
On arrival to the floor, the patient is asking for pain meds for
his generalized pains. He does endorse walking with a cane for
the past few months ___ pains but does not give further details.
He also endorses recent diarrhea.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
nausea, vomiting, constipation, urinary symptoms, muscle or
joint pains, focal numbness or tingling, skin rash. The
remainder of the ROS was negative.
Past Medical History:
COPD
Anxiety
Depression
DVT/PE ___ on lifelong AC
Social History:
___
Family History:
Mother and GM deceased from uterine and colon ca.
Physical Exam:
VS - 98.1 142/88 89 18 96%RA
GEN - Alert, NAD
HEENT - EOMI, PERRL, OP clear
NECK - no cervical LAD, supple
CV - RRR, no m/r/g
RESP - CTA bilaterally
ABD - S/NT/ND, BS present
EXT - 1+ BLE edema noted, generalized TTP
SKIN - no rashes
NEURO - ___ strength in all 4 extremities, 2+ DTRs throughout
PSYCH - flat affect
Pertinent Results:
___ 04:00PM BLOOD WBC-9.1 RBC-4.48* Hgb-14.1 Hct-41.2
MCV-92 MCH-31.4 MCHC-34.1 RDW-12.8 Plt ___
___ 04:00PM BLOOD Neuts-61.7 ___ Monos-4.3 Eos-3.5
Baso-0.7
___ 04:00PM BLOOD ___ PTT-38.4* ___
___ 04:00PM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-139
K-4.6 Cl-102 HCO3-26 AnGap-16
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Bilateral LENIs - FINDINGS: Bilateral common femoral,
superficial femoral, and popliteal veins demonstrate normal
compressibility, flow, and augmentation. Flow is demonstrated
in the regions of bilateral posterior tibial and peroneal veins.
IMPRESSION: No sonographic evidence for lower extremity deep
vein thrombosis.
CXR - FINDINGS: AP and lateral views of the chest are compared
to previous exam from ___. There are linear
bibasilar opacities. Superiorly, the lungs are clear. There is
no effusion. Cardiomediastinal silhouette is within normal
limits. Osseous and soft tissue structures are unremarkable.
IMPRESSION: Linear bibasilar opacities suggestive of
atelectasis, noting that infection cannot be excluded.
Brief Hospital Course:
___ y/o M w/ PMHx of COPD and PE/DVT on lifelong anticoagulation
with multiple recurrent clots when stopping coumadin, presents
with multiple c/o including generalized malaise, cough,
subtherapeutic INR.
discharge exam
98.2 127/77 78 100% RA
no wheezes
no focal tenderness along spine
able to ambulate independently in hall and easily move in and
out of bed
no focal motor weakness
no peripheral edema
DATA:
CXR: FINDINGS: AP and lateral views of the chest are compared
to previous exam
from ___. There are linear bibasilar opacities.
Superiorly, the
lungs are clear. There is no effusion. Cardiomediastinal
silhouette is
within normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: Linear bibasilar opacities suggestive of
atelectasis, noting that
infection cannot be excluded.
___:
IMPRESSION: No sonographic evidence for lower extremity deep
vein thrombosis.
INR ___
no leukocytosis on CBC
#Acute Bronchitis: Given these symptoms as well as bilateral
atelactasis on CXR, pt treated empirically for PNA in the ED
with levofloxacin. However, given lack of fever, lack of clear
infiltrate on CXR, suspicion for PNA is quite low at this time.
Flu also seems unlikely given lack of fever. At this point, most
likely etiology would be a viral URI. However, given his h/o
COPD, he could have mild acute bronchitis and will be treated
with 5 days of azithromcin. He will take 3 additional days of
azithromcin on discharge with insructions to have his INR
checked early next week to ensure INR remains stable while on
antibitoic. No evidence of wheezing and RA sat 100 on discharge
status
# H/o DVT/PE: Pt on lifelong anticoagulation. H/o multiple
recurrent clots in the setting of briefly stopping coumadin. INR
1.9 in the ED. INR 2.6 on ___ and 2.6 on ___ He received
lovenox to bridge his subtherapeutic INR and this was stopped on
___. He will coumadin 12.5-15mg daily on discharge.
# Chronic COPD: Lungs clear on exam. continude albuterol and
spiriva
# Chronic Pain: Pt with long-standing history of chronic lower
back pain. Of note, he reports walking with a cane for the past
few months ___ "body pains" but is unable to give specifics.
Neuro exam non-focal on admission.
# Anxiety/Depression continued venlafaxine
# Homelessness: Likely a contributor to patient's presentation,
as he reports that he has been living outside or in shelters and
may be exposed to URI pathogens in close quarters.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Venlafaxine XR 75 mg PO DAILY
3. Warfarin Dose is Unknown mg PO DAILY16
generally, alternates daily between 15 mg and 12.5 mg; however,
he recently has been taking 15 mg daily for the past few days
because of subtherapeutic INRs
4. Enoxaparin Sodium 0 mg SC Frequency is Unknown
Pt reports that he has intermittently been on lovenox when his
INRs are subtherapeutic
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or
wheezing
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or
wheezing
2. Multivitamins 1 TAB PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Venlafaxine XR 75 mg PO DAILY
5. Warfarin 0 mg PO DAILY16
generally, alternates daily between 15 mg and 12.5 mg; however,
he recently has been taking 15 mg daily for the past few days
because of subtherapeutic INRs
6. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute bronchitis
chronic COPD, stable
chronic DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with a cough that is likely bronchitis
related to your COPD. You also needed 2 days of lovenox as your
INR was 1.9 on admission. Since our INR is now therapeutic, you
should remain on coumadin for your chronic DVT. You will need
close f/u at your ___ clinic for monitoring of your
INR level.
Followup Instructions:
___
|
19627403-DS-15
| 19,627,403 | 24,855,970 |
DS
| 15 |
2150-06-26 00:00:00
|
2150-06-26 09:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Slurred speech, not moving left side
Major Surgical or Invasive Procedure:
None
History of Present Illness:
EU Critical ___ (aka ___ is a ___ yo woman with PMH
of HLD and macular degeneration who presents as a code stroke.
Our
knowledge of her history and presentation are limited at this
point. Per reports the patient was last heard from in her usual
state of health at 5pm when she visited her husband in a nursing
home. When her family could not reach her at 6pm they called the
police who found her on the bathroom floor. She was noted to be
dysarthric and was not moving her left side. she had a hematoma
on her left forehead and states that she must have fallen off
the
toilet but was not able to recall. The next report we have is of
her NIHSS at ___ where she scored a 20
(around ___) and was apparently sedated and intubated prior to
transport. CT done at ___ showed "hyperdense distal M1 and
proximal M2 of the right MCA...hypodensity involving the right
frontotemporal love, insula, periventricular white matter and
distribution of the extreme capsule".
Past Medical History:
Hyperlipidemia
Glaucoma
HTN
Left breast cancer s/p lumpectomy, tx with Tamoxifen ___ yrs
Hypothyroidism
Impaired glucose tolerance
Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
General appearance: intubated
HEENT: C-collar in place. hematoma over left eye.
CV: Heart rate is regular
Lungs: vented
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Intubated, off prop/fent for 4 min. able to
follow
simple commands (2 fingers, thumbs up, grip/release, lift arm).
unable to open eyes but attempts. Does not attempt to speak.
Cranial Nerves:
I: not tested
II: no BTT
III-IV-VI: pupils equally small reactive to light. eyes are
conjugate and in mid position. Unable to test VOR given cervical
collar.
V: blink to eye lash bl.
VII: decreased movement of left face with grimace.
IX/X: + cough and gag
Sensory/Motor: Normal muscle bulk throughout. significant
increased tone on the left upper and lower. Movement in the
plane
of the bed with noxious on the left. Appears full strength on
the
right to command. Some tremulousness of the RUE noted when prop
DCed
Reflexes: brisk on the right with crossed adductors.
Toes are down going bilaterally.
Coordination/Gait: unable to test
========================
DISCHARGE PHYSICAL EXAM
========================
GEN - awake, alert, cooperative with examination
CV - NSR
RESP - normal WOB, clear to auscultation bilaterally
ABD - soft, non-tender, non-distended, +BS
Neurological Examination
MS - A&Ox3, speech is dysarthric but otherwise fluent and
appropriate; per family, she is sharp and at her baseline mental
status on the day of discharge, does not appear to neglect the L
hemifield
CN - VFF, PERRL, EOMI without nystagmus, mild R gaze preference
but is able to track to the L and count fingers in the L visual
field; L facial weakness, speech is dysarthric
MOTOR - grossly full on R side; LUE is flaccid and essentially
___ throughout, LLE does have some scant internal rotation but
otherwise ___
SENSORY - no extinction to DSS on the left
COORD - R side without evidence of ataxia
GAIT - deferred
Pertinent Results:
=======
LABS
=======
___ 02:30AM BLOOD ALT-22 AST-45* CK(CPK)-3297* AlkPhos-62
TotBili-0.4
___ 10:40AM BLOOD CK(CPK)-355*
___ 12:27AM BLOOD Lipase-22
___ 02:30AM BLOOD cTropnT-<0.01
___ 01:30AM BLOOD cTropnT-<0.01
___ 02:30AM BLOOD %HbA1c-6.0* eAG-126*
___ 02:30AM BLOOD Triglyc-498* HDL-46 CHOL/HD-3.6
LDLmeas-94
___ 02:30AM BLOOD TSH-0.92
___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:30AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINE CULTURE (Final ___: NO GROWTH.
U/A ___ - benign
=============
IMAGING
=============
ECHO (___):
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
to mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Biatrial enlargement. Normal biventricular chamber
size and systolic function. Mild dilation of the ascending
aortia. Mild pulmonary hypertension. No cardiac source of
embolism seen.
CTA HEAD AND NECK (___):
1. No significant interval change in right frontal, parietal,
and temporal lobe MCA territory infarction. A dense MCA sign is
noted. No evidence of hemorrhagic transformation.
2. Abrupt occlusion of the M1 segment of the right MCA.
3. Unremarkable CTA of the neck without evidence of internal
carotid stenosis by NASCET criteria.
MRI HEAD WITHOUT CONTRAST (___):
1. Subacute infarcts involving the right frontal and temporal
lobes as well as the basal ganglia in the expected distribution
of the right anterior and posterior MCA territories.
2. Small amount of petechial hemorrhage in the right lentiform
nucleus.
3. Persistent slow flow or collateral flow of the right MCA.
MRI C-SPINE WITHOUT CONTRAST (___):
1. No evidence of acute injury to the cervical spine. Normal
cord signal.
2. Mild multilevel cervical spine degenerative changes, most
prominent at C3/C4.
3. Increased T2 signal at the left lung apex, not fully
characterized on this study. Correlate with CTA neck performed
on the same day.
RIGHT KNEE XRAY (___):
No previous images. There is a total knee arthroplasty in place
that appears to be well seated without evidence of
hardware-related complication. Specifically, no evidence of
fracture.
R SHOULDER XRAY (___)
No acute fractures or dislocations are seen. There are mild
degenerative
changes of the AC joint. Moderate degenerative changes of the
glenohumeral joint is seen with a prominent inferomedial humeral
head osteophyte. There is also a 7 mm loose body within the
inferior aspect of the glenohumeral joint. There is normal
osseous mineralization.Visualized left lung apex is grossly
clear.
VIDEO SWALLOW (___)
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is aspiration with thin
barium. No evidence of aspiration with nectar thick liquid or
cracker administration IMPRESSION: Gross aspiration with thin
barium. Please refer to the speech and swallow division note in
OMR for full details, assessment, and recommendations.
POST-TREAMTENT VIDEO SWALLOW PERFORMED ON ___, RESULTS PENDING.
Brief Hospital Course:
Mrs. ___ was admitted to the ICU in stable condition. She was
not a candidate for IV or IA tPA or embolectomy and she was
outside the window. CTA head and neck confirmed a R M1 clot and
MRI confirmed a stroke in the right frontal and temporal lobes
as well as the basal ganglia. As CTA showed good collateral
flow, permissive hypertension was allowed for 48 hrs following
the stroke.
Pt was noted to have new atrial fibrillation upon admission to
the unit. Therefore, stroke was presumed to be due to a
cardioembolic etiology. An echo showed a normal ejection
fraction without intracardiac thrombus. She was initially placed
on aspirin for stroke prevention; she was transitioned to
coumadin with an aspirin bridge.
For additional stroke prevention, she was also continued on her
home Omega 3 and pravastatin (LDL was 94 and ___ was 498). As ___
was notably elevated, the level was repeated and showed...
Hemoglobin A1C was found to be 6.0%. Pt underwent physical,
occupation and speech and swallow therapy for rehabilitation
during hospital stay.
Otherwise, pt was admitted intubated due to poor mental status.
On hospital day #2, pt's mental status improved and she was
successfully extubated. She was also admitted in C-spine collar
as she had had a fall at home. After trauma surgery evaluated
the pt and MRI c-spine was normal, pt was cleared and the
C-spine collar was removed. Pt also had right knee and shoulder
xrays due to tenderness; these did not show any fractures.
*On ___, prior to her planned discharge, Ms. ___ had an
episode of Afib w RVR w HR to the 150s. The heart rate did not
resolve immediately with IV metoprolol, and Ms. ___ discharge
to rehab in ___ had to be postphoned. Later that afternoon, her
HR improved to < 100. On ___, her home atenolol was increased
to 50mg qD with good effect. On ___, Ms. ___ also had a
temperature of 100.3 x1, which resolved without treatment. A U/A
was checked prior to d/c and was found to be negative. No
further therapy was initiated.
=========================
TRANSITIONS OF CARE
=========================
Please follow up daily INRs until stable in goal range of 2.0 -
2.5.
Discharged on aspirin bridge, please discontinue aspirin when
INR therapeutic. It may be reasonable to consider substituting
warfarin with a newer oral anticoagulant, such as apixaban, in
___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Ibuprofen 200 mg PO Q6H:PRN pain
4. Osteo Bi-Flex (glucosamine-chondroitin) 250-200 mg oral DAILY
5. Pravastatin 40 mg PO QPM
6. Atenolol 25 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. lisinopril-hydrochlorothiazide ___ mg oral DAILY
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Pravastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Benzonatate 100 mg PO TID:PRN cough
6. Warfarin 3 mg PO DAILY16
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
8. Osteo Bi-Flex (glucosamine-chondroitin) 250-200 mg oral DAILY
9. Atenolol 50 mg PO DAILY
10. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
11. Famotidine 20 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: R MCA stroke
Secondary: paroxysmal Afib, HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- irregular heart beat called atrial fibrillation, high blood
pressure, high cholesterol
We are changing your medications as follows:
- adding a blood thinning medication called warfarin (e.g.
coumadin)
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
It was a pleasure caring for you during this hospitalization.
Followup Instructions:
___
|
19627768-DS-17
| 19,627,768 | 20,701,334 |
DS
| 17 |
2111-10-08 00:00:00
|
2111-10-08 14:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
left open ankle fracture
Major Surgical or Invasive Procedure:
I&D and ORIF of left ankle fracture
History of Present Illness:
Ms. ___ a ___ who was in her car with her left foot out
the door as she was adjusting her parking. As the car was
moving,
her foot got crushed against the wall. She was brought to the
___
ED and was noted to be neurovascularly intact with an open Left
foot fracture. No other injuries. She is uptodate on tetanus and
she received ancef upon arrival.
Past Medical History:
Unremarkable
Social History:
___
Family History:
NC
Physical Exam:
NAD
Breathing comfortably
LLE:
- Incisions clean and dry, notable swelling of leg
- Cast intact
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D and open reduction internal
fixation of her ankle fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation. She received longer duration of IV antibiotics
due to concern for increased risk of infection given open
fracture. She will also be discharged on oral antibiotics for
infection prevention. The patient was placed into a bivalved
cast to facilitate wound care. 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
NWB in left lower extremity, and will be discharged on Lovenox
for DVT prophylaxis. The patient will follow up with Dr.
___ at 1 week for wound check. 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 1000 mg PO Q8H
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth ever 4 hours Disp #*70
Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left open ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing of left leg
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 2 weeks to prevent blood clots
WOUND CARE:
- Cast must be left on until follow up. Please do not get cast
wet. You can re-tighten the straps if needed.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___
on ___ for wound check. Call ___ to schedule
appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Non weight bearing in cast, no range of motion at ankle of left
leg
Treatments Frequency:
- Physical therapy
Followup Instructions:
___
|
19627901-DS-20
| 19,627,901 | 29,341,440 |
DS
| 20 |
2152-03-31 00:00:00
|
2152-04-01 00:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recent ortho surgery ___ for patella fx and giant cell
tumor of bone who presents after a syncopal episode. Pt reports
she was washing up in the bathroom early this afternoon when she
began to feel nauseous and hot. She sat down on the commode to
rest and the nausea worsened. She developed a HA with feelings
of "needles in her skull". She closed her eyes and then passed
out and awoke on the floor (approx 1pm). She believes she had a
head strike. She denies associated palpitations, CP. No urinary
incontinence or confusion after. She reports she had some L-side
chest tightness which made it difficult to take a deep breath.
She reports this occurred on and off overnight when she awoke.
She reports she had this pain in the past as well so did not
think much of it. Pt reports she has noted swelling of the R leg
since her surgery and thought was improving overall. She noted
some pain behind her R knee today. She reports taking daily
lovenox (40mg daily), last dose last night.
Pt was admitted ___ and had an open reduction internal
fixation, right patella fracture and extended curettage and
cement internal fixation of right distal femur fracture and
giant cell tumor of bone. Pt initially presented after tripping
and sustaining a twisting injury to her R knee. She was found to
have a transverse R patellar fracture and nondisplaced fracture
of the R distal femur. Review of imaging showed a large
osteolytic lesion in the lateral condyle of the R distal femur
for which path revealed a giant cell tumor of bone.
In the ED intial vitals were: 98.1 104 128/70 16 97%. Labs
notable for d-dimer of 3032, WBC count 11.5; other labs black.
CTA showed filling defect within the basal segment of the left
lower lobe pulmonary artery (2:43), consistent with ___
with Patient was given: dilaudid 2mg PO and heparin gtt was
started (bolus start 20:20). Pt given 1L NS Vitals on transfer:
98.2 82 108/53 16 96% RA.
On arrival to the floor, pt is without complaints. Denies CP,
SOB, leg pain.
Past Medical History:
- Morbid obesity
- Giant cell tumor of bone
- S/p right distal femur with pathologic fracture and right
traumatic patellar fracture status post ORIF of the patella
fracture curettage and cementation of the giant cell tumor on
___
Social History:
___
Family History:
No family history of bone cancers
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.1, 112/67, 85, 18, 100% RA
General- obese young female, in NAD
Neck- supple
CV- RRR, no murmurs
Lungs- CTAB, breathing comfortably
Abdomen- soft, NT, ND, obese
Ext- R ___ asymmetrically larger than the L, 2+ DP pulses
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.2 ___ 20 98% r/a
General- obese young female, sitting up in bed in NAD, breathing
comfortably
Neck- supple
CV- RRR, S1, S2 auscultated, no murmurs
Lungs- CTAB, breathing comfortably
Abdomen- soft, NT, ND, obese
Ext- R ___ asymmetrically larger than the L, in soft brace, 2+ DP
pulses
Pertinent Results:
ADMISSION LABS:
===============
___ 04:15PM BLOOD WBC-11.5* RBC-4.43# Hgb-12.4# Hct-39.2#
MCV-88 MCH-27.9 MCHC-31.6 RDW-14.4 Plt ___
___ 04:15PM BLOOD Neuts-78.5* Lymphs-16.6* Monos-4.2
Eos-0.1 Baso-0.6
___ 04:15PM BLOOD ___ PTT-28.1 ___
___ 04:15PM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-140
K-4.4 Cl-102 HCO3-27 AnGap-15
___ 04:15PM BLOOD cTropnT-<0.01 proBNP-76
___ 04:15PM BLOOD Calcium-9.9 Phos-3.4 Mg-1.9
___ 04:15PM BLOOD D-Dimer-3032*
___ 04:15PM BLOOD HCG-<5
PERTINENT LABS:
===============
___ 03:00AM BLOOD WBC-8.3 RBC-4.07* Hgb-11.2* Hct-36.2
MCV-89 MCH-27.6 MCHC-31.0 RDW-14.2 Plt ___
___ 03:00AM BLOOD Plt ___
___ 03:00AM BLOOD ___ PTT-61.4* ___
___ 07:35AM BLOOD ___ PTT-83.4* ___
___ 04:15PM BLOOD cTropnT-<0.01 proBNP-76
___ 04:15PM BLOOD D-Dimer-3032*
DISCHARGE LABS:
===============
___ 03:00AM BLOOD WBC-8.3 RBC-4.07* Hgb-11.2* Hct-36.2
MCV-89 MCH-27.6 MCHC-31.0 RDW-14.2 Plt ___
___ 03:00AM BLOOD Plt ___
___ 03:00AM BLOOD ___ PTT-61.4* ___
PERTINENT STUDIES:
==================
CTA Chest (___):
IMPRESSION: Isolated PE in the left lower lobe posterior basal
segmental branch.
___ Venous doppler (___):
IMPRESSION:
1. Nonocclusive DVT within the right distal superficial femoral
vein,
extending to the right popliteal vein.
2. No evidence of DVT in the left lower extremity. The
bilateral calf veins are not well visualized.
R Knee XR (___):
RIGHT KNEE THREE VIEWS
REASON FOR EXAM: Patient with patellar fracture and excision of
giant cell
tumor with recent trauma. Assess for acute fracture.
Comparison is made with prior study ___.
The previously seen cortical fracture in the distal lateral
femur is slightly more offset than before. If this is the site
of pain, this may represent an acute fracture.
Bands and percutaneous screw fixating the complex fracture of
the patella are again noted. Graft material in the lateral
femoral condyle is in unchanged position. There is no evidence
of dislocation.
PERTINENT MICRO:
================
None
Brief Hospital Course:
___ s/p recent orthopedic surgery in ___ presents with
syncope and DVT/PE.
ACTIVE ISSUES:
==============
# Syncope
The patient had a pathologic patellar fracture following a fall
in ___ at that time she was also found to have a giant cell
tumor of R distal femur. The tumor was curettaged and cement
was injected to fill the space, and the patella was repaired.
She was discharged home and doing well until she experienced an
episode of syncope most consistent with vasovagal etiology (felt
warm, flushed, nauseated, and dizzy, sat down, and then lost
consciousness). As per below, she was found to have a small L
segmental PE, but this was not felt to be significant enough to
cause her syncope. The patient was not orthostatic, and cardiac
and neurologic etiologies were clinically not compatible with
the patient's presentation. Syncope did not recur.
# DVT/PE
On admission, she was found to have a small L segmental PE, as
well as a non-occlusive R DVT. She was hemodynamically stable
throughout her hospitalization and reported no shortness of
breath. She was started on a heparin gtt and bridged to
therapeutic dosing of Coumadin. She received dietary education
about eating a diet with consistent levels of Vitamin K;
nutrition recommended outpatient follow-up with a registered
dietician. Follow-up was arranged with a new PCP at ___ as well
as in the ___ clinic.
# Old R knee fracture
At the time of her fall at home, the patient was not wearing her
knee brace and twisted her knee, noting increased pain during
her hospitalization than before she came in. While in-house,
the ortho oncology team evaluated her and determined that she
did not have a new fracture, and that no operative intervention
was required. Outpatient follow-up with her orthopedic surgeon
was arranged prior to discharge
CHRONIC ISSUES:
===============
# Morbid obesity
Stable, not an active issue on this hospitalization
# Giant cell tumor of bone
No new pathologic fracture was identified on this admission, as
above. She will follow-up as an outpatient with her orthopedic
surgeon.
TRANSITIONAL ISSUES:
====================
- Patient will require frequent monitoring in ___
clinic with INR checks
- Patient may benefit from outpatient follow-up with a
registered dietician to reinforce dietary modifications required
while on coumadin
- Patient will need compression stockings with 30-40 mm Hg as
prophylaxis for post-phlebitic syndrome
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 40 mg SC DAILY
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
3. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain Duration: 15
Days
3. 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
4. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*0
5. Outpatient Lab Work
Please check INR on ___ and fax results to ___
___ clinic at ___
6. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vasovagal syncope, deep vein thrombosis, pulmonary
embolism
Secondary: Giant cell tumor of bone, recent orthopedic surgery
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 to the hospital because you
had an episode of syncope, or loss of consciousness. You were
also found to have a blood clot in your right leg, as well as in
your lung. You were started on a blood thinner called Coumadin
to prevent the clots from getting bigger. You will be on this
medication for 3 - 6 months, during which time your body will
dissolve the clots in your leg and lung. While you were
hospitalized, we also did an X-ray of your knee, which did not
show any new fracture. Our orthopedic surgeons evaluated you
and felt that no surgery was needed on this hospitalization.
Once your blood became thin enough (as measured by the
International Normalized Ratio, or "INR"), you were discharged
home.
It is EXTREMELY important that you have your blood checked
regularly to make sure that you are taking the correct dose of
Coumadin. If your blood level (called the International
Normalized Ratio, or "INR") is too low, you could get another
clot, and if the INR is too high, you could experience bleeding.
Therefore, it is very important to make sure that you follow-up
with your scheduled appointments in the ___ clinic.
Additionally, the blood thinner (warfarin) causes birth defects
so it is very important to use contraception if having sex to
avoid pregnancy while you are taking this medication.
You will have your blood work checked ___ at ___
___ on the ___ floor of ___ building, no
appointment is necessary.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19628074-DS-14
| 19,628,074 | 26,669,871 |
DS
| 14 |
2134-11-27 00:00:00
|
2134-11-28 06:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
metastatic colon cancer, vaginal bleeding
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo G0 post-menopausal woman with a history of metastatic
colon cancer presented with increased abdominal girth, menstrual
like cramps, several day of vaginal bleeding, nausea and
vomiting.
She was feeling well until the past two weeks when she noticed a
sudden increase in abdominal girth with bloating, nausea, and
menstrual like cramps. Over the course of two weeks she
developed shortness of breath.
She initially presented to her PCP ___ who ordered a CT scan
showing ascites and tumor involving her uterus and ovaries. She
was admitted to ___ and had a therapeutic paracentesis with
removal of 3L of fluid. The nausea and vomiting and pain
improved and she was able to tolerate POs and was discharged to
home for outpatient follow up.
She was again admitted to to ___ ___ for a second large
volume paracentesis. After paracentesis she her pain was
controlled with PO meds and she was tolerating a regular diet.
Over the course of the past several weeks she developed vaginal
discharge and now reports a three day history of vaginal
bleeding. The bleeding is staining but not soaking pads and she
denies passing clots.
She then presented to ___ requesting expedited work up and to
discuss possible surgical management.
Currently she reports only light vaginal bleeding without
passage of clots. She denies vomiting and reports only mild
nausea and is tolerating a regular diet. Her pain is minimal and
is controlled with PO meds. She denies fevers, chills. She
reports stable constipation but has regular bowel movements and
denies changes in bladder function or urinary symptoms. She is
passing flatus and denies melena or BRBPR.
10 system review of systems otherwise negative.
Past Medical History:
PMH:
- colon cancer diagnosed ___ with biopsy proven mets to liver,
treated with colectomy and then 6 months of FOLFOX
- PE diagnosed in ___ in the setting of chemo treated with
three months of Lovenox
- small bowel obstruction ___ after colectomy, managed
conservatively
- GERD
- depression
- neuropathy secondary to chemotherapy
PSH:
- tonsillectomy
- open appendectomy
- open colectomy
- open BTL
- port-a-cath placement
POB: G0
PGYN: Postmenopausal for ___ years, no previous post-menopausal
bleeding. Sexually active with one male partner, mutually
monogamous. No dysmenorrhea. No hormone replacement therapy.
Social History:
___
Family History:
Sister with pancreatic cancer at age ___. Father died of an MI.
Another sister with thyroid cancer. Mother with skin cancer. No
family history of GYN malignancy or other GI malignancies.
Physical Exam:
On admission:
Vitals: T:98.3 BP:114/78 P:93 R:18 O2:97% RA
___: 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, mildly TTP in LLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Site of paracentesis on R abd wall dressed, intact, no e/o
drainage. Central abd scar.
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: no lesions or ecchymoses
Neuro: aaox3. CNs ___ intact. Strength and sensation grossly
intact
Psych: pleasant, appropriate
On discharge:
AF VSS
___: NARD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, nontender, nondistended, no rebound or guarding.
Vertical midline scar, well-healed.
Ext: Nontender, no edema
Pertinent Results:
___ 09:35PM BLOOD WBC-10.4 RBC-4.30 Hgb-13.5 Hct-39.6
MCV-92 MCH-31.3 MCHC-33.9 RDW-12.6 Plt ___
___ 07:12AM BLOOD WBC-8.5 RBC-4.12* Hgb-12.8 Hct-38.3
MCV-93 MCH-31.1 MCHC-33.4 RDW-12.3 Plt ___
___ 09:35PM BLOOD Neuts-75.6* Lymphs-13.0* Monos-9.2
Eos-1.7 Baso-0.4
___ 09:35PM BLOOD Glucose-99 UreaN-6 Creat-0.6 Na-133 K-3.5
Cl-104 HCO3-21* AnGap-12
___ 07:12AM BLOOD Glucose-89 UreaN-5* Creat-0.4 Na-133
K-3.8 Cl-103 HCO3-25 AnGap-9
___ 09:35PM BLOOD ___ PTT-32.0 ___
___ 09:35PM BLOOD ALT-7 AST-19 AlkPhos-53 TotBili-0.3
___ 09:35PM BLOOD Lipase-33
___ 09:35PM BLOOD Albumin-2.8* Calcium-7.6* Phos-1.8*
Mg-1.8
___ 07:12AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.9
___ 07:12AM BLOOD CEA-2.0 CA125-486*
MRI Abdomen/Pelvis: 16.6 x 14.5 x 10.7 cm heterogeneous mass
within the pelvis which arises from the left ovary. This almost
certainly represents a colonic metastasis involving the left
ovary and has increased substantially in size since the CT dated
___. A primary left ovarian malignancy is much less
likely. Thickening and enhancement of the peritoneum with
adjacent enhancement of the small bowel - these features are
highly suggestive of malignant peritoneal involvement. Moderate
volume ascites which has developed since ___. Uterine
adenomyosis.
Brief Hospital Course:
Ms. ___ was admitted to the gynecology oncology service after
presenting with new onset ascites and vaginal bleeding with
concern for a new gynecologic malignancy vs. advanced metastatic
colon cancer. She was initially admitted to the Internal
Medicine service and was seen in consult by gynecology oncology.
She was then transferred to gynecologic oncology for further
evaluation.
On presentation, she reported vaginal bleeding. She was
hemodynamically stable with a hematocrit of greater than 38%
throughout her hospitalization.
CT of the abdomen/pelvis obtained at ___ revealed
carcinomatosis and an 11 cm pelvic mass involving the left ovary
and a 3 cm mass on the uterus. Cytology for paracentesis of
ascites obtained from ___ was unrevealing.
She underwent MRI of the abdomen/pelvis revealing a large
heterogeneous mass within the pelvis arising from the left ovary
likely representing a colonic metastasis Thickening and
enhancement of the peritoneum with adjacent enhancement of
the small bowel was present, likely representing peritoneal
involvement. A moderate amount of ascites was present.
On hospital day 2, she was hemodynamically stable and tolerating
a regular diet. Given a diagnosis of likely advanced metastatic
colon cancer, she was discharged home. She was discharged in
stable condition. She desired transfer of care to ___ and
thus, she was provided contact information to schedule an
appointment with Hematology-Oncology at ___ for discussion of
further treatment of colon cancer.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Ondansetron 8 mg PO BID
3. Paroxetine 10 mg PO DAILY
4. Docusate Sodium 50 mg PO BID
5. Gabapentin 900 mg PO HS
6. Temazepam 30 mg PO DAILY
7. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q8H:PRN pain
8. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
9. Gabapentin 600 mg PO QAM
Discharge Medications:
1. Docusate Sodium 50 mg PO BID
2. Gabapentin 900 mg PO HS
3. Gabapentin 600 mg PO QAM
4. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q8H:PRN pain
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 8 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
8. Paroxetine 10 mg PO DAILY
9. Temazepam 30 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology oncology service with
concern for a large pelvic mass. MRI revealed that this is
likely recurrence of colon cancer, less likely a GYN cancer. The
team feels that it is safe for you to be discharged home. You
should follow-up with your original Hematology-Oncology
physician or you may call the numbers below to see
Hematology-Oncology here at ___. Please follow the
instructions below.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* You may eat a regular diet.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor ___ ___-Oncology ___
until established with Hematology-Oncology) for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
Followup Instructions:
___
|
19628074-DS-15
| 19,628,074 | 24,159,713 |
DS
| 15 |
2135-01-20 00:00:00
|
2135-01-24 18:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
- removal of peritoneal PleurX drain by interventional radiology
___
History of Present Illness:
___ w/ h/o metastatic colon cancer, on C2D1 ___ ___ who
presents to the ER with nausea and vomiting. She had an
abdominal pleurex placed on ___ which afterwards caused her
a significant amount of pain which has gradually been resolving
but not gone completely. For the past 5 days, she has been
constantly nauseous with non-bloody vomiting which is not
relieved by home Zofran. As a result she has felt tired and
weak and has not been able to keep pills down. She has lost 6
pounds in the past 8 days; she denies current abdominal "pain"
but does have "discomfort." She has flatus and last BM was day
of admission.
.
Vitals in the ER: 96.6 88 ___ 99%. Pt received Zofran and
1L IVF. Initial CT showed concern for peritoneal cathater
causing acute obstruction; surgery was consulted and recommended
calling ___ who said the problem was not urgent and could be
addressed in the morning. In addition, the large abdominal
mass, originally thought to be a metastasis might be of primary
ovarian origin, but this was not an urgent issue. I confirmed
these findings with my conversation with the resident
radiologist.
.
Of note, her Pleurex has been draining small amounts of
urine-colored fluid. She notes some redness at the inferior
border of her dressing which she thinks may be related to skin
irritation with the dressing but is unsure if it has felt warm.
REVIEW OF SYSTEMS:
(+) Per HPI, chronic diarrhea, non-bloody, unchanged
(-) Denies fever, cough, shortness of breath, chest pain, chest
pressure, constipation, dysuria, arthralgias or myalgias. All
other ROS negative
Past Medical History:
ONCOLOGY HISTORY:
Ms. ___ is a ___ old woman with metastatic colon cancer
who presented with increased abdominal girth, abdominal cramping
nausea and vaginal bleeding to ___ on ___. She was
admitted
to the GYN-oncology service and was found to have presumed
recurrence of her colon cancer.
Her cancer course initially began in ___. At that
time,
she presented with abdominal pain to her PCP. Work-up was
remarkable for profound anemia that prompted an upper and lower
endoscopy that revealed a colonic mass. ___ ultrasound showed
evidence of metastatic disease. She was initially cared for by
Dr. ___ from ___ On___. She underwent
colectomy at ___ and then received FOLFOX
from ___. Her course was complicated by a
PE requiring treatment with lovenox and a SBO requiring
hospitalization.
Since she completed chemotherapy in ___, she has seen
Dr. ___ for serial clinical exams, tumor marker
evaluations and CTs when she developed increased abdominal girth
and discomfort in early ___. ON ___, CT imaging showed
ascites and tumor involving her uterus and ovaries. She
was admitted to ___ and had a therapeutic paracentesis with
removal of 3L of fluid. The nausea and vomiting and pain
improved and she was able to tolerate POs and was discharged to
home for outpatient follow up.
On ___ she was again admitted to ___ for a second large
volume paracentesis with 2L of fluid removed. She had also
developed vaginal discharge and bleeding, which prompted
transfer
to the ___ Surgical Oncology team for further evaluation. She
was
admitted to Dr. ___ and on clinical evaluation and
pelvic MRI imaging, her symptoms were attributed to recurrence
of
her colon cancer. The pelvic MRI imaging showed large
heterogeneous mass within the pelvis arising from the left ovary
likely representing a colonic metastasis. There was thickening
and enhancement of the peritoneum with adjacent enhancement of
the small bowel was present, likely representing peritoneal
involvement. A moderate amount of ascites was present. It was
Dr.
___ that "her presentation and distribution of
disease on imaging was consistent with recurrent colon cancer
that had metastasized to the ovaries and uterus.
___ C1D1 ___
___ C2D1 ___
PMH:
- colon cancer diagnosed ___ with biopsy proven mets to liver,
treated with colectomy and then 6 months of FOLFOX
- PE diagnosed in ___ in the setting of chemo treated with
three months of Lovenox
- small bowel obstruction ___ after colectomy, managed
conservatively
- GERD
- depression
- neuropathy secondary to chemotherapy
PSH:
- tonsillectomy
- open appendectomy
- open colectomy
- open BTL
- port-a-cath placement
OB/GYN: No children. Postmenopausal for ___ years, no previous
post-menopausal bleeding. Sexually active with one male partner,
mutually monogamous. No dysmenorrhea. No hormone replacement
therapy.
Social History:
___
Family History:
Sister with pancreatic cancer at age ___. Father died of an MI.
Another sister with thyroid cancer. Mother with skin cancer. No
family history of GYN malignancy or other GI malignancies.
Physical Exam:
Vitals: T 98.8 HR 88 BP 117/66 SaO2 97 RA
GEN: NAD, awake, alert, laughing, smiling
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: tense, distended with large palpable mass, no rebound or
guarding, + BS, abdominal drain is in place with intact dressing
EXT: normal perfusion
SKIN: right abdomen skin is red on inferior border of dressing
but not appreciably warmer than surrounding skin
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 12:55PM GLUCOSE-123* UREA N-5* CREAT-0.6 SODIUM-133
POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-29 ANION GAP-17
___ 12:55PM ALT(SGPT)-7 AST(SGOT)-22 ALK PHOS-135* TOT
BILI-0.4
___ 12:55PM LIPASE-71*
___ 12:55PM ALBUMIN-3.7
___ 12:55PM WBC-7.2 RBC-4.04* HGB-12.0 HCT-35.7* MCV-88
MCH-29.8 MCHC-33.7 RDW-13.4
___ 12:55PM NEUTS-63 BANDS-0 LYMPHS-15* MONOS-17* EOS-5*
BASOS-0 ___ MYELOS-0
___ 12:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:55PM PLT SMR-NORMAL PLT COUNT-314
.
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-8.0 RBC-3.63* Hgb-11.2* Hct-32.5*
MCV-90 MCH-30.9 MCHC-34.6 RDW-13.9 Plt ___
___ 06:10AM BLOOD ___ PTT-32.4 ___
___ 06:18AM BLOOD Glucose-108* UreaN-8 Creat-0.9 Na-133
K-3.7 Cl-94* HCO3-28 AnGap-15
___ 06:18AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9
___ 12:00AM BLOOD CEA-3.9 CA125-406*
___ 07:46PM BLOOD Vanco-15.5
.
MICRO:
___. difficile DNA amplification assay-FINAL
negativeINPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL {BACILLUS SPECIES; NOT ANTHRACIS, BACILLUS
SPECIES; NOT ANTHRACIS -- sensitive to vancomycin}; ANAEROBIC
CULTURE-FINAL
.
CT Abdomen/Pelvis ___:
1. Large complex (cystic and solid) abdominopelvic mass
measuring pproximately 17.2 x 12.0 x 16.8 cm, significantly
increased in size from prior examination. A pleurex tube
terminates within this mass. Recommend ___ consult re: catheter
position.
2. New right lower lobe segmental pulmonary embolus.
3. Two large new nodule in the right lower lobe, likely new
metastatic disease.
4. Diffuse mild colitis without bowel obstruction.
5. Mild peritoneal thickening and enhancement with small ascites
could reflect peritoneal carcinomatosis.
6. Stable hepatic metastatic lesions.
7. Small left pleural effusion and a trace sliver of adjacent
pneumothorax could be from prior instrumentation such as
thoracentesis. Clinical correlation advised
Brief Hospital Course:
Patient was admitted for nausea and vomiting. She was found to
have an incidental PE and was started on IV heparin and then
Lovenox. CT also showed that the peritoneal PleurX drain was no
longer in the ascites fluid, but rather was in the pelvic colon
cancer metastasis. Fluid was removed and sent for cytology
(still pending) and micro. Bacillus grew from the fluid, and
vancomycin was initiated. She will complete a 10-day course on
___. The peritoneal drain was removed by interventional
radiology on ___.
- FULL CODE confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Gabapentin 600 mg PO HS
3. Gabapentin 300 mg PO QAM
4. Omeprazole 20 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Paroxetine 10 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Furosemide 20 mg PO DAILY
9. Spironolactone 25 mg PO BID
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC DAILY
RX *enoxaparin 100 mg/mL ___aily Disp #*30 Syringe
Refills:*0
2. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 g IV twice a day Disp #*7 Bag Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 20 mg PO DAILY
5. Gabapentin 600 mg PO HS
6. Gabapentin 300 mg PO QAM
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Paroxetine 10 mg PO DAILY
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Spironolactone 25 mg PO BID
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
14. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
15. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
16. Heparin/Saline Flush 1
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
17. Heparin/Saline Flush 2
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Bacterial peritonitis
Pulmonary embolism
Secondary:
Metastatic colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with nausea, vomiting, and abdominal
discomfort. Fluid was taken from the PleurX catheter in your
abdomen and grew a type of bacteria called Bacillus. This was
treated with an antibiotic called vancomycin. You will need to
continue the vancomycin through ___.
We also found that the abdominal PleurX tube had migrated from
your peritoneum to inside tumor. It was removed by
interventional radiologists on ___. Do not shower or
otherwise get the area wet until ___. Do not
intentionally remove the Steri-strips. Cover the area with
clean, dry dressing after showering. Do not take a bath, swim,
or submerge your self in water until a physician confirms that
the area is fully healed.
You also were found to have a new pulmonary embolism, and this
was treated with heparin and then with Lovenox (enoxaparin),
which you should continue to take until instructed otherwise by
your physician.
It was a pleasure caring for you here at ___
___.
Followup Instructions:
___
|
19628074-DS-16
| 19,628,074 | 24,389,192 |
DS
| 16 |
2135-03-03 00:00:00
|
2135-03-03 10:50:00
|
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:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with metastatic colon cancer
with a large ovarian mass who presents with nausea/vomiting and
abdominal pain starting 1 day prior to admission. She is
currently undergoing treatment with FOLFIRI chemotherapy and
received cycle 3 day 15 on ___. On the day prior to
admission she started having abdominal pain, nausea and vomiting
similar to a prior episode of small bowel obstruction about ___
year ago. She had no diarrhea, melena, BRBPR, fevers, chills,
hematemesis.
In the emergency department, initial vitals: 97.5 118 113/79 16
99%. A CT showed a SBO with a transition point around a large
ovarian mass. Surgery was consulted and advised against
surgical options. She was given 4 doses of dilaudid 1 mg IV and
2 doses of Zofran and admitted for further management.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea.
No dysuria. Denied arthralgias or myalgias.
Past Medical History:
ONCOLOGY HISTORY:
Ms. ___ is a ___ old woman with metastatic colon cancer
who presented with increased abdominal girth, abdominal cramping
nausea and vaginal bleeding to ___ on ___. She was
admitted
to the GYN-oncology service and was found to have presumed
recurrence of her colon cancer.
Her cancer course initially began in ___. At that
time,
she presented with abdominal pain to her PCP. Work-up was
remarkable for profound anemia that prompted an upper and lower
endoscopy that revealed a colonic mass. RUQ ultrasound showed
evidence of metastatic disease. She was initially cared for by
Dr. ___ from ___ Oncology. She underwent
colectomy at ___ and then received FOLFOX
from ___. Her course was complicated by a
PE requiring treatment with lovenox and a SBO requiring
hospitalization.
Since she completed chemotherapy in ___, she has seen
Dr. ___ for serial clinical exams, tumor marker
evaluations and CTs when she developed increased abdominal girth
and discomfort in early ___. ON ___, CT imaging showed
ascites and tumor involving her uterus and ovaries. She
was admitted to ___ and had a therapeutic paracentesis with
removal of 3L of fluid. The nausea and vomiting and pain
improved and she was able to tolerate POs and was discharged to
home for outpatient follow up.
On ___ she was again admitted to ___ for a second large
volume paracentesis with 2L of fluid removed. She had also
developed vaginal discharge and bleeding, which prompted
transfer
to the ___ Surgical Oncology team for further evaluation. She
was
admitted to Dr. ___ and on clinical evaluation and
pelvic MRI imaging, her symptoms were attributed to recurrence
of
her colon cancer. The pelvic MRI imaging showed large
heterogeneous mass within the pelvis arising from the left ovary
likely representing a colonic metastasis. There was thickening
and enhancement of the peritoneum with adjacent enhancement of
the small bowel was present, likely representing peritoneal
involvement. A moderate amount of ascites was present. It was
Dr.
___ that "her presentation and distribution of
disease on imaging was consistent with recurrent colon cancer
that had metastasized to the ovaries and uterus.
___ C1D1 ___
___ C2D1 F___
___ C3D1 FOLFIRI
PMH:
- colon cancer diagnosed ___ with biopsy proven mets to liver,
treated with colectomy and then 6 months of FOLFOX
- PE diagnosed in ___ in the setting of chemo treated with
three months of Lovenox
- small bowel obstruction ___ after colectomy, managed
conservatively
- GERD
- depression
- neuropathy secondary to chemotherapy
PSH:
- tonsillectomy
- open appendectomy
- open colectomy
- open BTL
- port-a-cath placement
OB/GYN: No children. Postmenopausal for ___ years, no previous
post-menopausal bleeding. Sexually active with one male partner,
mutually monogamous. No dysmenorrhea. No hormone replacement
therapy.
Social History:
___
Family History:
Sister with pancreatic cancer at age ___. Father died of an MI.
Another sister with thyroid cancer. Mother with skin cancer. No
family history of GYN malignancy or other GI malignancies.
Physical Exam:
PHYSICAL EXAM
VS: 98.8 115/73 82 18 95%RA
___: alert and oriented, NAD
HEENT: No scleral icterus. PERRL/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: clear bilaterally
ABDOMEN: soft NTND. normal bowel sounds today, no rebound or
guarding
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. Preserved sensation throughout. ___
strength throughout. ___ reflexes, equal ___. Gait assessment
deferred
Pertinent Results:
___ 10:45PM BLOOD WBC-5.0 RBC-4.21 Hgb-12.6 Hct-36.9 MCV-88
MCH-30.0 MCHC-34.3 RDW-16.0* Plt ___
___ 10:45PM BLOOD Neuts-62.7 ___ Monos-6.7 Eos-2.5
Baso-0.6
___ 10:45PM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-134
K-3.5 Cl-94* HCO3-29 AnGap-15
___ 10:45PM BLOOD ALT-26 AST-27 AlkPhos-83 TotBili-0.6
___ 10:45PM BLOOD Lipase-40
___ 10:45PM BLOOD Albumin-3.7
___ 06:00AM BLOOD WBC-4.0 RBC-3.38* Hgb-10.1* Hct-30.1*
MCV-89 MCH-29.9 MCHC-33.7 RDW-15.5 Plt ___
___ 06:00AM BLOOD Glucose-86 UreaN-5* Creat-0.7 Na-141
K-3.0* Cl-107 HCO3-24 AnGap-13
___ 06:41AM BLOOD ALT-25 AST-23 AlkPhos-85 TotBili-0.7
CT abd/pelvis ___
IMPRESSION:
1. Small bowel distension with a transition point in the RLQ,
near the right
side of the large intrapelvic mass.
2. Left-sided pleural effusion, simple and layering, which is
increased from
the prior study.
3. Probably slightly smaller intrapelvic mass with solid and
cystic
components as well as air, from the recently removed Pleurx
catheter. Decrease
in the size of the pulmonary nodules in the right lower lobe.
Stable hepatic
hypodensities, presumably metastatic lesions.
Brief Hospital Course:
Assessment and Plan: ___ female with metastatic colon cancer
including large ovarian mass, presenting with nausea, vomiting,
abdominal pain, found to have small bowel obstruction.
#SBO: resolved with conservative management. Pain controlled
with dilaudid 1mg IV q3h prn. nausea controlled
--NPO including meds
--IV fluids NS 75cc/hr while NPO
--NG tube to low intermittent wall suction
--
--zofran 4mg IV q4h prn for nausea
#colon cancer: just finished cycle 3. next due for chemo in 2
weeks
#pulmonary embolism: diagnosed on last hospitalization
--continue lovenox ___ SC daily
#h/o htn
--hold PO meds for now
#peripheral neuropathy
--hold gabapentin
# DVT ppx: on tx dose lovenox
# Diet: NPO
# GI Prophy:
# IV access: Port
# Precautions: None
# Code status: Full
# Contact
# Discussed with: Patient Nursing Houses___ ___ PCP
___ ___ Oncologist Consultant MDs
# Dispo:
[ ] Discharge documentation reviewed, pt is stable for
discharge.
[ ] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
# Active meds: See below.
____________________________________
___, MD, pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 20 mg PO DAILY
4. Gabapentin 600 mg PO HS
5. Gabapentin 300 mg PO QAM
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Spironolactone 25 mg PO BID
11. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
12. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
13. Metoclopramide 10 mg PO TIDAC
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 20 mg PO DAILY
Do not restart this medication until you see your doctor next
week.
4. Gabapentin 600 mg PO HS
5. Gabapentin 300 mg PO QAM
6. Metoclopramide 10 mg PO TIDAC
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Spironolactone 25 mg PO BID
Do not restart this medication until you see your doctor next
week.
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Home with Service
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a small bowel obstruction which resolved
on its own without surgical intervention.
Followup Instructions:
___
|
19628126-DS-11
| 19,628,126 | 20,305,359 |
DS
| 11 |
2151-02-02 00:00:00
|
2151-02-02 18:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Reglan / Compazine
/ onions
Attending: ___.
Chief Complaint:
headache, mania
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ female with depression, bipolar disorder presenting
with severe headache. Pt states sudden onset "worst headache of
my life" this morning while brushing her teeth. Felt like band
around her head associated with photophobia and nausea. Pain was
___ and continues to persist despite several narcotic
medications. Not associated with vision changes or neurologic
deficits. Pt reports no previous history of headaches or
migraines. Has neck stiffness at baseline after surgery for
parotid mass and after MVA during which she was whiplashed.
Denies fevers/chills. No sick contacts.
.
She also had recently had symptoms of mania with increased
energy, racing thoughts, and lack of sleep. Reports sleeping ___
hours each night for the last 6 weeks; states that she has been
drinking a bottle of wine every night in an effort to sleep. Her
doctor prescribed her ativan recently. She has also enrolled in
a partial hospitalization program at ___. She
attended the first session yesterday. Pt states that her
psychiatric symptoms began after surgery for a parotid mass in
___. Per pt, the prolonged period during which she was
under anesthesia caused brain damage and she subsequently
developed depression.
.
In the ED, initial VS: 98.4 93 155/94 18 100%. CT head w/o
contrast showed no acute process. Lumbar puncture was also
unremarkable (1 WBC, 1 RBC). She requested several pain
medications at the ED and was dissatsfied with small doses. She
received morphine 2mg IV x 2, zofran 4mg and 8mg IV, fiorciet
po, and dilaudid 1mg IV. She was evaluated by psychiatry who
felt that she was safe for discharge home as she had close
follow-up at her partial program.
.
REVIEW OF SYSTEMS:
Reports chills and cold intolerance, sweaty feet, chronic
rhinorrhea
Denies fever, vision changes, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-benign parotic tumor, removed ___
-HTN
-s/p hysterectomy
-s/p appendectomy
-hospitalized ___ for suicide attempt with overdose on
antidepressants
Social History:
___
Family History:
Father: ___
Mother: thyroid
No known history of depression, suicide, psychosis, bipolar d/o
Physical Exam:
VS - 99 156/89 81 18 100%RA
GENERAL - Alert, interactive, well-appearing in NAD, wearing
sunglasses
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, cerebellar exam intact
Pertinent Results:
Admission labs:
___ 10:40AM BLOOD WBC-5.7 RBC-4.29 Hgb-13.9 Hct-38.9 MCV-91
MCH-32.4* MCHC-35.7* RDW-12.6 Plt ___
___ 10:40AM BLOOD Neuts-75.9* Lymphs-17.5* Monos-4.2
Eos-1.1 Baso-1.4
___ 10:40AM BLOOD ___ PTT-29.3 ___
___ 10:40AM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-26 AnGap-14
___ 10:40AM BLOOD TSH-0.95
Iron studies
___ 04:35AM BLOOD calTIBC-207* Ferritn-67 TRF-159*
___ 04:35AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.9 Iron-63
CSF:
___ 02:58PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 02:58PM CEREBROSPINAL FLUID (CSF) TotProt-35 Glucose-60
___ CT head: FINDINGS: There is no evidence of hemorrhage,
edema, mass, mass effect, or infarction. The lateral ventricles
and sulci are normal in size and configuration. There is
preservation of gray-white matter differentiation. The basal
cisterns appear patent.
There is no evidence of fracture. The paranasal sinuses,
mastoid air cells and middle ear cavities are clear. No soft
tissue abnormalities are present.
IMPRESSION: No evidence of acute intracranial process.
Brief Hospital Course:
___ female with depression, bipolar disorder presenting
with severe headache
.
# Headache: Ruled out for intracranial hemmorhage or CSF
infection in ED. Likely tension-type headache, given
significant social stressors and ongoing mania. Patient
received aggressive oral and IV analgesia in the ED. By morning
after admission, her headache was down to a ___ in severity,
and was further managed with oral, non-narcotic analgesics and
IV fluids. TSH was checked given family history of thyroid
disease, and was within normal limits.
.
# Bipolar disease/Mania: Seen by psychiatry in ED, and initially
not felt to require inpatient psychiatric treatment. Her case
was discussed with her outpatient pyschiatrist (Dr. ___
___, ___) and her daughter, who both felt
that she was going to improve with outpatient treatment plans.
According to Dr. ___ had been very disruptive during
group therapy sessions, and had not accepted the treatment
offered to her, during her one day in the ___ partial program
(one day prior to admission). Both Dr. ___
daughter also confirmed that the ___ employer had
threatened arrest for trespassing if she were to show up to
work, given her recent behavior and threats made towards the
existing administration. The patient herself displayed
irrational decision-making as evidenced by her plan to fly to
___ on ___, without having the means to make such a
trip. Her overall mental status exam was stable--she displayed
minimal hyperactivity, pressured speech, or racing thoughts;
although it was felt that the standing lorazepam and
barbiturate-containing fioricet may have kept her manic symptoms
somewhat suppressed. Furthermore, she had poor judgement as
evidenced by her taking antihistamines and regular alcohol
intake, as an attempted sleep aid. On re-evaluation by
psychiatry, with further discussion with ___ daughter and
Dr. ___ was decided that she did meet criteria for
inpatient psychiatric admission.
.
# Alcohol abuse: Reports daily alcohol use recently due to
insomnia. She did not score on a CIWA scale, but was receiving
BID lorazepam as recommended by her outpatient psychiatrist.
She was started on thiamine, folate, and multivitamin.
.
# Anemia: Pt had hct drop on arrival, with low-normal MCV. Iron
studies were not concerning for significant iron deficiency.
Hct improved without RBC transfusion.
.
# CODE: full
Medications on Admission:
ativan 1mg morning and afternoon, 2mg at night
Vivelle 0.1 mg/24 hr Transderm Patch
Discharge Medications:
1. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for pain for 2 weeks: Always take this
medication with food.
Disp:*30 Tablet(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Vivelle Transdermal
8. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen Extra Strength 500 mg Tablet Sig: ___ Tablets
PO every ___ hours as needed for pain: Do not exceed eight
tablets in 24 hours, to avoid liver toxicity.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Headache
Bipolar disorder
.
Secondary:
Anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
.
You were admitted to ___ for an
intractable headache. You had tests done to work up the cause
of your headache, and several life-threatening problems were
ruled out, such as intracranial bleed and meningitis. Your
headache improved with medications and IV fluids.
.
You were also seen by the psychiatry team, who felt you require
further psychiatric care as an inpatient.
.
The following medication changes were recommended for you:
1. Take ARIPIPRAZOLE 10 mg by mouth, once daily
2. Take LORAZEPAM 1 mg by mouth twice daily, and 2 mg by mouth
at bedtime
3. Take THIAMINE 100 mg by mouth, once daily
4. Take FOLIC ACID 1 mg by mouth, once daily
5. Take MULTIVITAMIN, 1 tab by mouth, once daily
.
For your headaches, you should take the following medications as
prescribed:
1. NAPROXEN 500 mg by mouth, twice daily AS NEEDED. Always have
food when you take this medication.
2. ACETAMINOPHEN 500 mg tabs, ___ tabs every ___ hours AS
NEEDED. Do not take more than eight tabs in a 24 hour period,
to avoid liver toxicity.
Followup Instructions:
___
|
19628527-DS-10
| 19,628,527 | 27,340,892 |
DS
| 10 |
2148-07-15 00:00:00
|
2148-07-15 15:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Alcohol Intoxication
Major Surgical or Invasive Procedure:
Intubation ___
Extubation ___
History of Present Illness:
Ms. ___ is an ___ with no known PMHx who presented for
acute alcohol intoxication.
She was found unresponsive in her dorm room. She was alone on
the scene and no collateral was obtained. On arrival she was
vomiting and unable to protect her airway therefore she was
intubated.
In the ED,
Initial Vitals: HR 103, BP 94/76, RR 19, 97% Non-Rebreather
Exam: Obtunded, no signs of trauma, non-focal exam
Labs: ETOH 225, AG 17, CO2 19
Imaging: CXR wnl
Consults: None
Interventions: Intubated
VS Prior to Transfer: 98.1, 74, 109/87, 20, 100% intubated
ROS: Unable to obtain due to intubation
Pt was unresponsive on arrival to the floor.
Past Medical History:
None
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 86, BP 118/81, 98% intubated
GEN: Lying in bed intubated and unresponsive
HEENT: ___, pinpoint
NECK: Left neck bruising, no JVD
CV: RRR, no MRG
RESP: CTAB, no crackles or wheezing
GI: Abd soft, non-tender, non-distended, no organomegaly
NEURO: Unresponsive
EXT: Extremities cool, no edema, cyanosis or clubbing, cap
refill
<3s
DISCHARGE PHYSICAL EXAM:
======================
GEN: Conversant, lying in bed, NAD
HEENT: PERRLA
NECK: No JVD, bruising over left neck
CV: RRR, no M/R/G
RESP: CTAB, no crackles or wheezing
GI: Abd soft, non-tender, non-distended, no organomegaly
Neuro: No focal deficits
Pertinent Results:
ADMISSION LABS:
=============
___ 12:16AM BLOOD WBC-8.6 RBC-3.97 Hgb-12.1 Hct-36.4 MCV-92
MCH-30.5 MCHC-33.2 RDW-13.1 RDWSD-43.5 Plt ___
___ 12:16AM BLOOD Neuts-62.3 ___ Monos-6.6 Eos-1.7
Baso-0.5 Im ___ AbsNeut-5.39 AbsLymp-2.45 AbsMono-0.57
AbsEos-0.15 AbsBaso-0.04
___ 03:51AM BLOOD ___ PTT-21.4* ___
___ 12:16AM BLOOD Glucose-149* UreaN-10 Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-19* AnGap-17
___ 03:51AM BLOOD ALT-13 AST-24 LD(LDH)-288* AlkPhos-39
TotBili-0.5
___ 03:51AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
___ 12:16AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 02:57AM BLOOD Type-ART pO2-173* pCO2-27* pH-7.46*
calTCO2-20* Base XS--2
___ 02:57AM BLOOD O2 Sat-98
DISCHARGE LABS:
==============
___ 03:51AM BLOOD WBC-11.1* RBC-4.05 Hgb-12.5 Hct-37.7
MCV-93 MCH-30.9 MCHC-33.2 RDW-13.1 RDWSD-45.0 Plt ___
___ 03:51AM BLOOD Neuts-77.4* Lymphs-16.5* Monos-5.0
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.61* AbsLymp-1.83
AbsMono-0.55 AbsEos-0.03* AbsBaso-0.02
___ 09:36AM BLOOD Glucose-104* UreaN-8 Creat-0.7 Na-143
K-3.7 Cl-106 HCO3-22 AnGap-15
IMAGING:
=======
CXR ___
IMPRESSION:
1. Appropriately positioned endotracheal tube.
2. Distal tip of endotracheal tube terminates approximately 3 cm
above the
carina. The proximal side-port of the enteric tube terminates in
the distal
esophagus, above the gastroesophageal junction. Advancement by
approximately 5
to 7 cm recommended.
3. No radiographic evidence of acute cardiopulmonary process.
CXR ___
IMPRESSION:
1. The proximal side-port of the enteric tube now terminates
within the body
of the stomach, beneath the gastroesophageal junction.
2. Otherwise, no significant change from radiograph obtained an
hour ago. No
acute cardiopulmonary process.
Brief Hospital Course:
Pt is an ___ year-old female with no significant past medical
history who was found unresponsive in her dorm room, due to
alcohol intoxication.
TRANSITIONAL ISSUES:
====================
[ ] Will need trauma-informed care and additional counseling
resources at ___; social work met with the patient and provided
this information.
[ ] Would recommend that patient establish care with PCP in
___. Provided information on referral to ___.
[ ] Would recommend testing for HIV, Gonorrhea, chlamydia, and
syphilis given unclear nature of patient's black-out and
possible sexual assault. She declined this work-up, as well as
pelvic exam, while admitted.
[ ] Reinforce education re: safe drinking practices and safety
when meeting strangers from online.
ACUTE ISSUES
===============
# Loss of Consciousness
# Alcohol intoxication
# Possible unknown substance intoxication
Pt found unresponsive in her dorm room and was intubated on
arrival for airway protection. Alcohol level here was elevated
(225). He serum tox screen was also positive for
benzodiazepines, but this was confounded by the fact that she
received benzodiazepines in the ED. Medical work-up was largely
unrevealing and labs were reassuring. She was quickly extubated
and was able to give a clearer account of what happened; she had
met some strangers online and met with them in ___, were
she ingested drinks that she did not realize contained alcohol.
She later blacked out, and is not sure of the exact
circumstances that led her back to her dormitory. We recommended
screening/examination for sexual assault, but the patient
declined. We counseled her on safety and alcohol use. Social
work was consulted and recommended trauma-informed care, and
provided resources to the patient re: providers/counselors she
could see at ___. Education was also provided on the importance
#Anion gap metabolic acidosis:
Anion gap of 17 on arrival, likely due to her alcohol ingestion.
HDS and afebrile, low suspicion for lactic acidosis. Repeat
labwork in the morning was improved, AG of 15 and CO2 of 22. She
was treated supportively as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___!
You came to the hospital because you were found unresponsive in
your dorm room after drinking alcohol. A breathing tube was
placed when you arrived in the emergency room to protect your
airway, as you were vomiting, and you were admitted to the ICU
for close monitoring. Your breathing tube was removed after you
arrived to the ICU, and your labs were reassuring. You recovered
quickly and felt ready to go home.
You met with our social worker to discuss what happened to you,
and you were given various resources to help you cope. Given
that you did not recall what happened, and that you blacked out
while you were with your acquaintances in ___, we also
suggested you get a work-up for a possible sexual assault, but
you declined.
Going forward, it is very important you use caution whenever
anyone offers you a drink; you should refuse any drinks if
you're not sure if they contain alcohol or other substances.
Being careful in these situations is extremely important for
your health and safety. We would also recommend using caution
when meeting strangers online, for your safety.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19628692-DS-20
| 19,628,692 | 28,990,657 |
DS
| 20 |
2119-05-26 00:00:00
|
2119-05-27 12:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ PMHx afib on warfarin and HTN who
presents with HA, lethargy and aphasia x 3 days; he was found to
have a L parietal IPH at ___ and transferred to ___ for
further
management. History is primarily provided by patient's GF with a
___ interpreter.
Since ___, pt has been feeling sleepy and unwell. Pt
has had a headache (further details unavailable) and has "not
been talking right". He has also had a cough and fevers
(girlfriend did not take temperature). He did not have any
traumatic accident. He has not been vomiting or complaining of
nausea, weakness, numbness or vision changes. Otherwise, pt has
never had any similar symptoms before and there is no history of
dementia or memory issues. Pt has also been intermittently
complaining of chest pain and URI symptoms since ___.
His GF first brought him to an OSH on ___ where he
reportedly had a normal CXR, EKG and bloodwork (records
unavailable). GF states that a head CT was not done.
On the day of presentation, GF brought pt to an OSH after he
became more sleepy and less responsive.
At OSH, vitals: 162/85 115 20 100.0. Labs notable for WBC 14.1,
INR 1.5 and Na 133. Pt was initially given Azithro 500 IV x1 and
Ceftriaxone 1g x1 prior to ___ due to concern for CAP. After
___ showed L parietal IPH, he was given vitamin K 10mg IV and
started on nicardipine gtt and then transferred to ___.
Past Medical History:
Atrial fibrillation on warfarin
HTN
HLD
Plantar fasciitis
Nephrolithiasis
Social History:
___
Family History:
Unremarkable per ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
___: Ill-appearing
HEENT: NCAT, no oropharyngeal lesions, dry mucous membranes,
sclerae anicteric
___: Irregularly irregular
Pulmonary: Decreased breath sounds at bases bilaterally
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Drowsy and eyes closed but will arouse and
open
eyes to voice. Poor sustained arousal and must have repetitive
stimulation to partake in history and exam. Speaks ___ words in
___. Does not answer orientation Qs. Does not follow complex
commands, will follow simple 1-step midline and appendicular
commands during neurological exam. Purposefully moves limbs.
- Cranial Nerves - PERRL 3->2 brisk. +BTT throughout. EOMI with
tracking of examiner. +blinks to eyelash stimulation. ?slight R
NLFF. Mild dysarthria in ___.
- Motor - Normal bulk. Decreased tone on R. No tremor or
asterixis. Moves all extremities antigravity ?less movement on R
side.
- Sensory - Withdraws to noxious in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response mute bilaterally.
- Coordination - Deferred.
- Gait - Deferred.
===============================
Discharge Exam
Vitals: T 98.5, BP 124-146/78-93, HR 79-97, RR 22, SpO2 96%
___: Hispanic male, awake, cooperative
HEENT: Sclera white, MMM
CV: irregular rate
Lungs: breathing comfortably room air
Abdomen: NT, distended
Ext: warm, well perfused
Neuro:
MS: Awake, oriented to person, "hospital" not to date
___. Follows simple commands. Some word finding difficulty
but language appears fluent, unable to repeat
CN: PERRL 3-2mm, Intact gaze on EOM exam. Subtle RT NLFF. Tongue
midline, palate symmetric.
Sensorimotor: Appears full over b/l UEs and ___
___: Deferred
Pertinent Results:
___ 02:43AM BLOOD WBC-9.1 RBC-5.14 Hgb-16.1 Hct-47.6 MCV-93
MCH-31.3 MCHC-33.8 RDW-11.9 RDWSD-40.0 Plt ___
___ 06:15PM BLOOD WBC-12.5* RBC-4.53* Hgb-14.3 Hct-43.6
MCV-96 MCH-31.6 MCHC-32.8 RDW-12.0 RDWSD-42.1 Plt ___
___ 02:43AM BLOOD ___ PTT-27.2 ___
___ 06:15PM BLOOD ___ PTT-28.8 ___
___ 02:43AM BLOOD Glucose-103* UreaN-10 Creat-0.7 Na-136
K-3.7 Cl-100 HCO3-22 AnGap-18
___ 06:15PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-137 K-3.9
Cl-102 HCO3-21* AnGap-18
___ 06:17AM BLOOD ALT-13 AST-16 LD(LDH)-196 AlkPhos-85
TotBili-1.5
___ 11:28PM BLOOD cTropnT-<0.01
___ 02:43AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3
___ 06:17AM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.2* Mg-1.8
CT HEAD WITHOUT CONTRAST:
There is an intraparenchymal hematoma in the left parietal
region measuring approximately 3.3 x 6.9 cm, with surrounding
associated edema (series 4: Image 15) there is mild mass effect
on the occipital horn of the left lateral ventricle with mild
midline shift measuring approximately 4 mm (series 4: Image 18).
Mucous retention cysts are seen in the bilateral maxillary
sinuses. There is mild mucosal thickening noted in the ethmoid
air cells. Otherwise, the remaining visualized paranasal
sinuses, mastoid air cells, and middle ear cavities appear
clear. The orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear patent without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. There
is no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria
___ ___
Unchanged acute left parietal intraparenchymal hemorrhage with
surrounding edema measuring up to 6.6 cm. No evidence of new
hemorrhage. Increasing left-to-right midline shift, currently
measuring 6 mm. Unchanged complete effacement of the left
occipital horn with asymmetric dilatation of the left temporal
horn. Effacement of the left frontal horn may have slightly
progressed.
TTE ___
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (biplaneLVEF 52%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). 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 structurally normal. There
is no mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and low normal global biventricular systolic
function. Mild pulmonary artery systolic hypertension.
Mild-moderate mitral regurgitation. Increased PCWP.
MRI w/wo contrast ___
IMPRESSION:
1. Study is mildly degraded by motion.
2. Large left temporoparietal subacute intraparenchymal hematoma
with mass
effect on left lateral ventricle, small left uncal herniation
and dilated left
lateral ventricle temporal horn are stable compared to ___.
3. No new hemorrhage or definite mass is identified. Recommend
follow-up
imaging to resolution to evaluate for presence of underlying
mass.
4. Nonspecific left parietal and occipital foci of enhancement
may represent
evolving subacute infarcts with differential consideration of
enhancing areas
of intraparenchymal hemorrhage, and masses. Recommend attention
on followup
imaging.
Brief Hospital Course:
Pt is a ___ year old male on Coumadin for ___ transferred from
___ with 3 days of HA, lethargy and
aphasia found to have a L parietal IPH at OSH and transferred to
___ for further management. Upon arrival, pt was admitted to
NeuroICU for further monitoring.
#Left Parietal IPH
CTA performed on ___ showed vascular findings suggestive of L
MCA infarct w/ complication of hemorrhagic transformation. He
was initially started on 3% HTS due to midline shift of 4mm seen
on initial imaging, stopped on ___. Repeat NCHCT was performed
on ___ with stable hemorrhage and mild increase in midline
shift to 6mm. Echo was performed which showed no acute findings.
Pt's neurochecks were decreased in frequency due to stable
neurologic exam with intact motor strength and global aphasia.
On ___, pt received one dose of Mannitol due to lethargy in the
morning concerning for increased ICP, with subsequent
improvement. Underwent MRI brain w/wo contrast which showed the
area of L MCA ischemic stroke with hemorrhagic conversion but
did not show any additional lesions.
#Afib/HTN
Pt was initially placed on Cardene drip with blood pressure
goal<160, slowly weaned off as Lopressor was started for rate
control of Afib. Statin was started at low dose (Atorvastatin
10mg) for preexisting hyperlipidemia.
#?PNA/sore throat
Due to fever of 102 in ED, elevated WBC of 12.2, and complaint
of recent URI symptoms, pt was started on Abx for possible PNA,
initially Vanc/Zosyn later changed to Vanc/Ceftazidime. Due to
resolution of WBC with no recurrent fevers, Abx were stopped on
___ with no recurrent issues while in ICU. On ___, pt began to
complain of pain in his throat w/ hyperemia noted upon
oropharyngeal examination. Rapid strep test was obtained as well
as CT Neck which was negative. ENT was consulted who recommended
throat spray and humidified air for treatment.
On ___, pt was transferred to ___.
On ___, pt transferred to floor.
Evaluated by ___ who recommended rehab.
********************
Transitional issues:
-MRI w/wo contrast in 2 months
-will need to start apixiban 5mg BID in 2 weeks (___). Will
need CT head prior to ensure bleed is stable. CT head order has
been placed. Please call ___ scheduling the CT
head.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
xYes - () No
4. LDL documented? (x) Yes (LDL =157 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) ()Yes - (x) No [if LDL
>100, reason not given: because of recent bleed ]
6. Smoking cessation counseling given? () Yes - xNo [reason (x)
non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A ** because of
recent bleed will wait 2 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO DAILY
2. Warfarin 3 mg PO DAILY16
3. Lovastatin 40 mg oral daily
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
3. GuaiFENesin ER 600 mg PO Q12H
4. Nystatin Oral Suspension 5 mL PO QID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Metoprolol Tartrate 25 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke in left middle cerebral artery with
hemorrhagic transformation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of headache and difficulty
speaking resulting from an ACUTE ISCHEMIC STROKE which
transformed into a hemorrhagic stroke (Bleeding stroke), a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
atrial fibrillation
high blood pressure
high cholesterol
We are changing your medications as follows:
-STOP Lovastatin 40 mg oral daily
-STOP WARFARIN
-START atorvastatin 10 mg daily
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:
___
|
19628717-DS-18
| 19,628,717 | 25,606,041 |
DS
| 18 |
2171-04-05 00:00:00
|
2171-04-05 21:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Encephalopathy
UTI
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
History Obtained From:
[x] Patient [x] Husband [ ] Interpreter [x] Medical records
Patient unable to provide history:
[x] Encephalopathic [ ] Cognitively impaired [ ] intubated
PRIMARY CARE PHYSICIAN: ___, ___
___
CHIEF COMPLAINT: Altered mental status, lethargy
HISTORY OF PRESENT ILLNESS:
Mr. ___ is an ___ male with a history of AS s/p
AVR and HIV (on ___, last CD4
UKN) presenting with 4 days of altered mental status, weakness,
and lethargy.
Patient's husband, ___, is his caregiver. At baseline, he
describes patient as clearly conversant, able to cook and feed
self, able to ambulate independently with cane in L hand. He
wears depends only at night for urge incontinence. He has ___
hearing aids, eyeglasses, and dentures.
Patient encephalopathic, mumbling, able to answer some yes/no
questions and give brief history. Largely history obtained from
husband as below:
Beginning ___, patient has had gradually increasing
lethargy
and weakness. He has had difficulty eating, drinking, standing
or
ambulating without husband's assistance. He has been speaking
more softly, had difficulty maintaining conversation, and closes
eyes, muttering to self. He has been confused, chewing without
successfully placing food in mouth. He has had weakness, leaning
to his right. He could not make it to his bed ___ night,
complaining of weakness and knees and R foot pain, so he slept
on
the couch. He awoke with neck pain which husband attributes to
upright sleeping position.
Husband ___ endorses tactile fever morning on ___. Denies
nausea, vomiting, constipation, diarrhea, cough, rhinorrhea,
abdominal pain, chest pain, recent illnesses or recent falls
(last fall ___ at ___'s office). No sick contacts. No
recent travel over past 6mo.
He describes finding a bloody sock 1wk ago; on questioning
patient reports studding his R big toe.
Although husband does not recall last CD4 count (measured in
office ___, he states that patient takes his antiretrovirals
reliably and there were no concerns at last visit.
Pertinent ED course:
Exam notable for: T 36.7 HR 80 BP 140/80 RR 20 97% RA, Glu 125
Minimally conversant, unintelligible with eyes intermittently
open and closed. Right ankle with a large area of erythema and
warmth to palpation. Sacrum has abrasions, large stool load,
fecal occult negative. No signs of Fournier's gangrene.
UA: Clear yellow, >182RBC, 57 WBC, Few Bacteria, -Nitr, 100Prot
Labs notable for 11.5 WBC with left shift
Bedside US negative for pericardial effusion
EKG: HR 84, NSR, QTc 447, RBBB
NCHCT: No acute intracranial process or fracture.
R Ankle (Ap, Mortise & Lat) ___: No acute fracture or
dislocation. Soft tissue swelling along the partially imaged
dorsal foot. Degenerative changes.
CXR: Streaky right base opacity could be due to aspiration or
PNA.
Received:
1L NS
IV CefTRIAXone 1 gm
IV Clindamycin 600 mg
Upon arrival to the floor, the patient speaks softly, keeping
eyes mostly closed, A&Ox1. He is able to answer questions but is
not fully understandable, mumbling softly. Shortly after
arrival,
he had an episode of diarrhea followed by extreme agitation,
hitting nurses and repeating "get out" to staff.
REVIEW OF SYSTEMS:
General: no weight loss, sweats. +fever.
Eyes: no vision changes.
ENT: + dysphagia, neck stiffness.
Cardiac: no chest pain, palpitations, orthopnea.
Resp: no shortness of breath or cough.
GI: no nausea, vomiting, diarrhea.
GU: no dysuria, frequency, urgency.
Neuro: no numbness, headache. leaning to right x4 days.
MSK: + arthralgia ___ knees and ankles, with R ankle>L, L wrist,
R hip).
Heme: no bleeding or easy bruising.
Lymph: no swollen lymph nodes.
Integumentary: no new skin rashes or lesions.
Psych: less interested in activity, conversation x4 days
Past Medical History:
1. HIV +
2. HTN
3. AS
4. Bicuspid AV
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: BP 157/70 HR 63 RR 18 97% RA
GENERAL: A&Ox1. Resting in bed with eyes intermittently open
and
closed while conversing. Speaks softly, with dysarthria.
EYES: PEERL ___ 3-->2mm. Yellow discharge in medial corner of L
eye.
ENT: Dry mucus membranes, palate with flat white and black
coloration.
CV: Normal rate, regular rhythm. Soft S1. Holosystolic murmur.
No
gallops, rubs.
RESP: Poor inspiratory effort, symmetric air entry to bases
GI: NTND.
GU: Wearing adult diaper.
MSK: Swollen joints (wrists, knees, and ankles bilaterally),
___, left knee mildly erythematous, no palpable effusion,
not warm, tender to deep palpation
SKIN: Skin over R medial ankle erythematous, edematous,
___. Blanching, ___.
NEURO: Moving all 4 extremities spontaneously. Deaf.
PSYCH: Agitated, yelling "get out." waxing mental status
DISCHARGE PHYSICAL EXAM:
VITALS:T:97.6, BP:158/61, HR:69, RR:18, Pox:94% on Ra
GENERAL: NAD, A&Ox2.
HEENT: EOMI, Dry mucus membranes, no JVD
CV: Normal rate, regular rhythm. ___ holosystolic murmur loudest
at RUSB with audible S2 and radiation to carotids.
Pulm: Lungs clear to auscultation in anterior and lateral lung
fields without wheezes, rales, or rhonchi
GI: ___. +BS
MSK: Joint are not erythematous, edematous or tender
SKIN: No rashes
Neuro: A&Ox2, at baseline and stable. Making jokes. No other
focal deficits.
Pertinent Results:
ADMISSION LABS:
___ K+-3.8
___ UREA ___ TOTAL
___ ANION ___
ALT(SGPT)-21 AST(SGOT)-37 ALK ___ TOT ___
___ 09:30AM ___
___
MICROBIOLOGY
___ 3:05 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: ___.
__________________________________________________________
___ 7:00 am STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT ___
OVA + PARASITES (Final ___:
CANCELLED.
Three separate stool specimens collected EVERY OTHER
DAY are
recommended for optimum sensitivity. Duplicate
specimens collected
on the same day will not be processed, since this does
not
increase diagnostic yield. Make sure to label date and
time of
collection on each stool specimen submitted to ensure
appropriate
processing. PATIENT CREDITED.
__________________________________________________________
___ 7:02 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 7:02 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference ___.
__________________________________________________________
___ 12:38 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 10:55 am SEROLOGY/BLOOD ADDED TSH,B12,RPR ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: ___.
__________________________________________________________
___ 12:55 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 9:30 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 12:12 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:04 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
___
___ Plt ___
___
___
HIV1 Viral Load -NOT DETECTED
IMAGING:
___ CT Head
IMPRESSION:
1. No acute intracranial process.
2. No fracture.
___ L Knee XR
IMPRESSION:
Large dense suprapatellar joint effusion. No acute osseous
abnormality.
___
IMPRESSION:
No acute fracture or dislocation. Soft tissue swelling along
the partially imaged dorsal foot. Degenerative changes.
Brief Hospital Course:
Mr. ___ is an ___ male with a history of aortic
stenosis s/p aortic valve repair and HIV (on
___ with a ___ gradual
cognitive decline, who presented with 4 days of acute altered
mental status, weakness, and lethargy.
ACTIVE ISSUES:
#Encephalopathy:
#Dementia
#Aspiration Risk
The patient's mental status had been worsening over 4 days
prior to admission in the context of gradual cognitive decline
over the past year, and the change in mental status was most
likely in the setting of a urinary tract infection superimposed
on underlying dementia. Urinalysis was significant for >182 red
blood cells, 57 white blood cells, few Bacteria, negative for
nitrites, 100 Protein. Labs were notable for 11.5 WBC with left
shift. He was diagnosed with a complicated UTI and started on
Ceftriaxone. Blood Cultures, Urine Cultures, and Strep pneumonia
urine antigen were collected and all negative. Due to the
patient's dementia, he was evaluated for swallowing capacity.
Evaluation showed he should be monitored 1:1 for all meals, and
eat SOFT SOLIDS and NECTAR THICK LIQUIDS, and medications whole
with nectar thick liquids.
A non contrast CT scan was negative for intracranial process and
a chest ___ was clear without evidence of Pneumonia.Specialty
labs including B12, TSH, RPR TSH were all negative/within normal
limitis. Infectious Disease was consulted and recommended
continuing current work up and continuing to empirically treat
Urinary Tract Infection a total of 7 days of antibiotic therapy
(Day 1 was ___. Per Infectious Disease, it is unclear when
antibiotics were given in the emergency department so even
though his urine culture was negative, infection cannot rule out
based on this. In addition, per ID the patient absolute CD4
count drop is not as alarming bc CD4% has remained stable. Thus
no major workup for opportunistic infections was pursued. Both
the infectious disease consulting service and neurology
consulting service recommended against lumbar puncture and MRI.
Pt's chronic decline likely ___ HIV dementia.
#Joint Pain in Left Knee, Right Ankle: Patient complained of
pain with movement of left knee and right ankle. Ortho consulted
for knee effusion, and did not feel the
area was large enough to tap. ___ protein of 160 on ___.
The knee erythema resolved. Right ankle found to be
erythematous, however, likely secondary to pressure, and little
concern for cellulitis.
#Diarrhea:
During the hospitalization, the patient was experiencing
diarrhea, which resulted in some mild skin breakdown secondary
to irritant dermatitis in the glutteal cleft. Infectious stool
studies were all negative. The diarrhea ___ without
Imodium.
# Hypertension: The patient was normotensive on presentation,
but became persistently hypertensive with systolic blood
pressures into to ___ overnight. The patient started
Amlodipine 10 mg PO daily on ___, and Hydralazine 25 mg PO
Q6H:PRN Systolic BP >180, which controlled his blood pressure
well.
CHRONIC ISSUES:
# HIV: Last CD4 count was in ___ and was 418, now
patient's CD4 is now ___. Per Infectious Disease the patient's
absolute CD4 count drop is not as alarming because the CD4% has
remained stable. The patient's home
___ was continued.
TRANSITIONAL ISSUES
===================
[] Please continue to monitor patient's blood pressure and
titrate medications as needed
[] Patient's husband will be providing home
___
# Code status: Has MOLST, per husband: attempt CPR, DNI or
ventilate. Use ___ ventilation. No dialysis, artificial
nutrition.
# Contact: ___ (husband): ___ (h), ___ (c)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rilpivirine 25 mg oral DAILY
2. Oxybutynin 5 mg PO DAILY urge incontinence
3. Emtricitabine 200 mg PO Q24H HIV
4. FoLIC Acid 1 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. Viagra (sildenafil) 50 mg oral DAILY:PRN
9. Naproxen 220 mg PO DAILY:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. amLODIPine 10 mg PO DAILY
3. HydrALAZINE 25 mg PO Q6H:PRN Systolic BP >180
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. LOPERamide 2 mg PO QID:PRN Diarrhea
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Emtricitabine 200 mg PO Q24H HIV
9. FoLIC Acid 1 mg PO DAILY
10. Naproxen 220 mg PO DAILY:PRN Pain - Mild
11. Oxybutynin 5 mg PO DAILY urge incontinence
12. rilpivirine 25 mg oral DAILY
13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
14. Viagra (sildenafil) 50 mg oral DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Encephalopathy
Urinary Tract Infection
Dementia
Secondary Diagnoses:
HIV
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure to take care of you here at ___
___.
WHY WAS I HERE?
You were admitted to the hospital because you had become more
confused and weren't feeling well.
WHAT WAS DONE WHILE I WAS HERE?
- We treated you with antibiotics for a Urinary Tract Infection
- We treated you with antibiotics for possible skin infection of
your right foot and lower back/buttock
- We ordered blood tests to evaluate for why you were confused.
These were all normal.
- We had the orthopedic surgeons look at your knee swelling
- We started you on blood pressure medications because you had
high blood pressure.
WHAT SHOULD I DO WHEN I GO HOME?
- Follow up with your PCP
- ___ up with cognitive neurology
Best wishes,
Your ___ Care Team!
Followup Instructions:
___
|
19628850-DS-4
| 19,628,850 | 21,965,077 |
DS
| 4 |
2184-10-13 00:00:00
|
2184-10-13 12:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left tibial plateau fracture
Major Surgical or Invasive Procedure:
ORIF left tibial plateau
History of Present Illness:
Mr. ___ is a ___ gentleman with history of
developmental delay, psychosis, mood disorder, and alcoholism
who was an intoxicated pedestrian struck by a motor vehicle on
___ ___. He was reportedly wandering in traffic on the
highway when he was struck at approximately 35 miles per hour
with positive head strike but unknown loss of consciousness. He
was hemodynamically normal and stable at the scene and upon
arrival to the ___ ___. Upon my evaluation, Mr. ___
complains of pain isolated to the forehead. He denies pain about
his left knee at rest and elsewhere in his body. He denies
paresthesias in the left lower extremity. He is unclear about
his tetanus vaccination history. He denies suicidal ideation or
intent.
Of note, Mr. ___ informed the ___ that he lives in a group
home. The ___ was able to make contact with said group home and
subsequently learn that he has a state appointed guardian from
the ___ (___):
Ms. ___ ___. I spoke with Ms. ___ on ___
evening and discussed Mr. ___ medical history, as
documented below.
Past Medical History:
Developmental delay
Mental retardation
Alcoholism
Psychosis
Mood disorder
Social History:
___
Family History:
non-contributory
Physical Exam:
Gen: NAD, aaox4
LLE: incisions c/d/I without drainage or erythema. There is some
soft-tissue erythema over the anterior tibia distal to incisions
which has improved since last exam. There is no fluctuance. He
is minimally tender to palpation. There is some pitting edema to
LLE, about 1+. He has palpable distal pulses. SILT
s/s/spn/dpn/tn; fires ___.
Pertinent Results:
___ 07:00AM BLOOD WBC-11.6* RBC-4.01* Hgb-12.7* Hct-37.5*
MCV-94 MCH-31.7 MCHC-33.9 RDW-11.6 RDWSD-39.5 Plt ___
___ 08:28PM BLOOD WBC-8.5 RBC-4.87 Hgb-15.6 Hct-45.3 MCV-93
MCH-32.0 MCHC-34.4 RDW-11.9 RDWSD-40.3 Plt ___
___ 09:30AM BLOOD Neuts-73.3* Lymphs-11.5* Monos-11.0
Eos-1.7 Baso-0.9 Im ___ AbsNeut-6.31* AbsLymp-0.99*
AbsMono-0.95* AbsEos-0.15 AbsBaso-0.08
___ 09:30AM BLOOD Plt ___
___ 03:45PM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 08:28PM BLOOD Plt ___
___ 08:28PM BLOOD ___ PTT-21.6* ___
___ 03:45PM BLOOD Glucose-126* UreaN-12 Creat-0.8 Na-135
K-4.1 Cl-99 HCO3-26 AnGap-14
___ 07:00AM BLOOD Glucose-142* UreaN-8 Creat-0.8 Na-134
K-3.8 Cl-98 HCO3-26 AnGap-14
___ 07:00AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.9
___ 08:28PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:28PM BLOOD Glucose-86 Lactate-2.3* Na-141 K-3.8
Cl-102 calHCO3-24
___ 08:28PM BLOOD Hgb-16.2 calcHCT-49 O2 Sat-74
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of his left tibial plateau
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. On
POD#3, the patient had increasing pain and swelling in the LLE,
which was concerning for cellulitis. Dopplers were done to rule
out a DVT in this leg, and were negative. He was thus started on
IV ancef for treatment of a cellulitis, and by POD4 this had
much improved. He was transitioned to PO Keflex for discharge
and was prescribed a 14 day course of Keflex for treatment of
cellulitis. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT and ROMAT in an unlocked ___ in the left lower
extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Valproic acid ___ mg daily
Olanzapine 15 mg daily
Buspirone 20 mg bid
Paxil 50 mg qhs
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H pain
2. BusPIRone 20 mg PO BID
3. Cephalexin 500 mg PO Q12H Duration: 14 Days
4. Diazepam 10 mg PO Q4H:PRN ciwa>10
5. Docusate Sodium 100 mg PO BID
6. OLANZapine 15 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every three hours Disp
#*50 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Sarna Lotion 1 Appl TP QID:PRN rash
10. Senna 8.6 mg PO BID constipation
11. Valproic Acid ___ mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left tibial plateau fracture
left leg cellulitis
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:
- WBAT, ROMAT LLE in unlocked ___ brace
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
19629135-DS-10
| 19,629,135 | 26,713,460 |
DS
| 10 |
2150-10-08 00:00:00
|
2150-10-08 22:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Appendicitis
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
___ w/hep C p/w acute appendicitis. Patient started having lower
abdominal pain after a BBQ on ___, 4 days ago. Pain was
relatively mild then increased dramatically yesterday and today
and started to localize to the RLQ. No fevers, + nausea and
emesis x 4. No PO intake since yesterday evening. Having
diarrhea, no brbpr but dark. No dysuria or CP or SOB. WBC 14 and
CT shows acute appendicitis with 11mm appendix, with fat
stranding, no phlegmon or abscess.
Past Medical History:
Past Medical History:
hepatitis C (had some treatment in the 1990s)
Past Surgical History:
none
Social History:
___
Family History:
N/A
Physical Exam:
On admission
Vitals: 98.5, 63, 150/83, 16, 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, TTQ RLQ
Ext: No ___ edema, ___ warm and well perfused
On discharge
AVSS
NAD
RRR
CTAB
Abd incisions c/d/i, soft, nondistended, incisionally tender
only
Brief Hospital Course:
Mr ___ was admitted to the acute care surgery service after he
underwent his operation. He tolerated the operation well.
Post-operatively, he tolerated first clears then a regular diet.
He was voiding, ambulating, and his pain was controlled on PO
pain medications. Thus, he was discharged home on POD1.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take more than 3000 mg a day
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN PAIN
Do not drive while taking. Take with a stool softener.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours as
needed for pain Disp #*15 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Do not take if you have diarrhea
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after you had appendicitis. You underwent a
laparoscopic appendectomy (removal of your appendix) and are
recovering well. You are ready to go home.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19629147-DS-12
| 19,629,147 | 23,916,320 |
DS
| 12 |
2163-11-23 00:00:00
|
2163-11-21 21:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o HTN, intracerebral aneurysm, pancreatic cancer with
liver metastasis s/p Whipple on chemotherapy seen at the ___ and
___ presenting after a mechanical fall down ___ steps.
At home the patient was noted to be A&Ox3 with a GCS of 15. On
arrival to the ED, she was found to have bilateral rib fxs (R
___, L 5,6) and T11, T12 burst fx, and T2, T4 compression
fractures. She was admitted to the Trauma service and
transferred to from the ED to the ___. She currently remains
under ___ care.
Past Medical History:
PMH: HTN, intracerebral aneurysm, pancreatic cancer with liver
metastasis
PSH: s/p bile duct stenting (___), hysterectomy (___), R
craniotomy for aneurysm clipping, appendectomy (___), whipple
procedure
Social History:
___
Family History:
Father and aunt with history of aneurysms.
Physical Exam:
Vitals: T 98,1 HR 90, BP 163/80, RR 18, sat 93/4L NC
General: mildly to moderately distressed secondary to pain
HEENT: abrasion on top of head, MMM
Neck: c-collar has been removed, trachea is midline
CV: RRR
Lungs: Decreased breath sounds bilaterally, worse at lung
bases, wet-sounding cough, no sputum production
Abdomen: soft NT/ND
GU: foley in place
Ext: able to mobilize all extremities equally
Neuro: alert and oriented
Skin: pale skin
Pertinent Results:
___ 10:46PM WBC-4.8 RBC-2.95* HGB-9.0* HCT-26.0*# MCV-88
MCH-30.5 MCHC-34.6 RDW-16.8* RDWSD-51.8*
___ 10:46PM PLT COUNT-64*
___ 03:44PM GLUCOSE-106* UREA N-17 CREAT-1.0 SODIUM-136
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-12
___ 03:44PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-1.5*
___ 03:43PM HCT-19.0*
___ 09:43AM WBC-4.4 RBC-2.43* HGB-7.6* HCT-22.0* MCV-91
MCH-31.3 MCHC-34.5 RDW-16.8* RDWSD-53.7*
___ 09:43AM PLT COUNT-66*
___ 09:43AM ___ PTT-30.4 ___
___ 09:43AM ___ 09:21AM URINE HOURS-RANDOM UREA N-380 CREAT-211
SODIUM-LESS THAN POTASSIUM-51 CHLORIDE-10
___ 09:21AM URINE OSMOLAL-480
___ 09:21AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:21AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 09:21AM URINE RBC-6* WBC-5 BACTERIA-NONE YEAST-NONE
EPI-1
___ 09:21AM URINE HYALINE-12*
___ 09:21AM URINE MUCOUS-OCC
___ 07:41AM WBC-4.5 RBC-2.37* HGB-7.4* HCT-21.4* MCV-90
MCH-31.2 MCHC-34.6 RDW-16.7* RDWSD-53.0*
___ 07:41AM PLT COUNT-65*
___ 03:57AM GLUCOSE-165* UREA N-20 CREAT-1.2* SODIUM-137
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
___ 03:57AM CALCIUM-8.0* PHOSPHATE-4.1 MAGNESIUM-1.7
___ 03:57AM WBC-4.9 RBC-2.18* HGB-6.9* HCT-20.4* MCV-94
MCH-31.7 MCHC-33.8 RDW-16.8* RDWSD-55.9*
___ 03:57AM PLT SMR-VERY LOW PLT COUNT-72*
___ 03:57AM ___ PTT-30.6 ___
___ 03:05AM TYPE-ART TEMP-36.7 O2-100 PO2-116* PCO2-46*
PH-7.33* TOTAL CO2-25 BASE XS--1 AADO2-551 REQ O2-91
INTUBATED-NOT INTUBA
___ 03:05AM GLUCOSE-169* LACTATE-0.8 NA+-134 K+-3.9
CL--104
___ 03:05AM GLUCOSE-169* LACTATE-0.8 NA+-134 K+-3.9
CL--104
___ 03:05AM HGB-6.8* calcHCT-20 O2 SAT-96 CARBOXYHB-2
___ 03:05AM freeCa-1.07*
___ 10:08PM PO2-56* PCO2-40 PH-7.41 TOTAL CO2-26 BASE
XS-0 COMMENTS-GREEN TOP
___ 09:59PM UREA N-19 CREAT-1.1
___ 09:59PM estGFR-Using this
___ 09:59PM LIPASE-11
___ 09:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:59PM WBC-4.2 RBC-2.04* HGB-6.6* HCT-19.4* MCV-95
MCH-32.4* MCHC-34.0 RDW-18.0* RDWSD-60.9*
___ 09:59PM ___ PTT-33.7 ___
___ 09:59PM PLT COUNT-100*
___ 09:59PM ___
Brief Hospital Course:
___ with h/o HTN, intracerebral aneurysm, pancreatic cancer
with liver metastasis s/p Whipple on chemotherapy seen at the
___ and ___ presents on ___ after a mechanical
fall down ___ steps. At home the patient was noted to be
A&Ox3 with a GCS of 15. On arrival to the ED, she was found to
have bilateral rib fractures (R ___, L 5,6) and T11, T12 burst
fracture, and T2, T4 compression fractures. She was admitted to
the Trauma service and transferred to from the ED to the TSICU.
Trauma work up and imaging:
NCHCT: No acute intracranial process
CT Torso:
*acute R lateral ___ rib fx ___ displaced)
*non displaced R posterior 6,7th rib fx
*non displaced acute anterior L ___ and 6th rib fx
*acute burst fx T11, T12 2mm retropulsion
*compression T4 and T2 superior endplate compression
small R pleural effusion
simple free pelvic fluid
anterior mediastinal soft tissue vs. hematoma
possible lung nodules
negative abdomen/pelvis
CT C spine: No acute fracture or traumatic malalignment
In summary, ___ with metastatic pancreatic adenocarcinoma (most
recent chemo 1 week prior to presentation) s/p traumatic fall,
found to have bilateral rib fxs (R ___ L 5,6) and T11, T12
burst fx, and T2, T4 compression fractures. On presentation she
had intact airway, GCS of 15, able to maintain her own airway,
HDS but did have Hct of 20 for which she was transfused 1 Unit
of PRBC and was given 250 cc bolus of albumin.
Based on negative imaging and negative clinical exam her C spine
was cleared on HD1,
Acute pain service was consulted for pain management and she had
bilateral paravertebral catheter placement. Her hospital course
was complicated with low UOP
which was managed with 5% albumin 500cc after which she was KVO
due to concern for respiratory status. She required BIPap
overnight but was able to transfer to nasal canula during the
day.
After an appropriate response to initial transfusion with post
transfusion hct of 26 she had another drop to 19, with no
identified source of bleeding. She was not able to provide
history on where her current baseline Hct stands. She was
transfused 2 units of PRBC due to hypotension, low UOP and poor
crystalloid response.
Given the history of pancreatic cancer, recent poly trauma and
increased risk for thrombotic complications she was started on
prophylactic lovenoc 30 BID on HD3.
Summary by system:
Neurologic: She presented with GCS of 15, neurologically intact
and continues to remain so. She is off sedation, with bilateral
paravertebral catheters for pain control, dialudid PCA and
standing IV Tylenol, She was continues on her home sertraline
and lamictal.
Cardiovascular: She has been hemodynamically stable with no
need for pressors with some epidodic hypotension which was
responsive to albumin. Her antihypertensives were held while in
ICU
Pulmonary: Due to pain she had poor effort and ability with IS
despite multiple attempts of instruction on proper use. she
required bipap in evenings and overnight but close monitoring of
respiratory status but was able to transition to NC during the
day. Her CXR initially was consistent with mild pulmonary edema,
she had worsening R sided pleural effusion on the day of
transfer
GI/Abdomen: Her nausea was controlled with prochlorperazine prn
and Ativan. She was on prophylactic PPI and the plan was to
start home creon once diet is resumed.
Nutrition: She was kept NPO and the plan was to advance as
tolerated.
Renal: She initially was resuscitated with albumin for low UOP
and hypotension but later was KVO for concern of fluid overload.
She has a foley in place for UOP monitoring. Her admission Cr
was 1.1.
Hematology:
DVT PPx: Boots, started SQH ___ due to appropriate post-chemo.
transfusion Hct and high risk for DVT/PE given
hypercoagulability due to known metastatic pancreatic
adenocarcinoma and relative immobility. Switched to ___.
MSK:
- Injuries:
*acute R lateral ___ rib fx ___ displaced)
*non displaced R posterior 6,7th rib fx
*non displaced acute anterior L ___ and 6th rib fx
*acute burst fx T11, T12 2mm retropulsion
*compression T4 and T2 superior endplate compression
*moderate R pleural effusion
*simple free pelvic fluid
*anterior mediastinal soft tissue vs. hematoma
*possible lung nodules
- Ortho spine recs: WBAT, non-operative management, pain
control, no activity restrictions
- ___ consult when able
Endocrine:
RISS
Infectious Disease:
No acute issues at present time
Lines/Tubes/Drains: Bilateral thoracic paravertebrals, foley
catheter, left port-a-cath, RUE PIV
Medications on Admission:
- Amlodipine 5mg daily
- Atenolol 50mg daily
- Lamotrigine 150mg BID
- Sertraline 50mg daily
- Lorazepam 1mg BID PRN anxiety
- Creon TID
- Omeprazole 20mg BID
- Oxycodone 5mg QID PRN left shoulder pain
- Compazine 10mg daily PRN nausea
- Multivitamin
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H Duration: 48 Hours
2. Calcium Gluconate sliding scale (Critical Care-Ionized
calcium) IV Sliding Scale
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Enoxaparin Sodium 30 mg SC Q12H
Start: ___ - ___, First Dose: Next Routine Administration
Time
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
9. HYDROmorphone (Dilaudid) 0.24 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 2.4 mg(s)
10. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using REG Insulin
11. LamoTRIgine 150 mg PO BID
12. LORazepam 0.5 mg IV Q4H:PRN anxiety/incomnia/nausea
13. Magnesium Sulfate Replacement (Critical Care and Oncology)
IV Sliding Scale
Start: Today - ___, First Dose: Next Routine Administration
Time
14. Pantoprazole 40 mg IV Q24H
15. Prochlorperazine 10 mg IV Q6H:PRN nausea
16. Ropivacaine 0.2% ___ mL/hr PERIPHNERVE INFUSION
17. Ropivacaine 0.2% ___ mL/hr PERIPHNERVE INFUSION
For Paravertebral Infusion /
18. Sertraline 50 mg PO DAILY
19. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Discharge Diagnosis:
s/p mechanical fall, with bilateral rib fractures and T11, T12
burst fracture with retropulsion, T2, T4 compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Patient is getting transferred to ___ for continuous care.
Please see the transfer summary.
Followup Instructions:
___
|
19629401-DS-21
| 19,629,401 | 24,626,764 |
DS
| 21 |
2125-05-25 00:00:00
|
2125-05-26 10:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenothiazines
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
___ w/ chronic progressive MS ___ since ___ and
wheelchair bound, incontinence of urine/stool, with baseline
spastic dysarthric speech and worsening upper extremity
weakness), hypothyroidism who presents with subacute progression
of disorganized thoughts. She was seen by Atrius Neurologist Dr.
___, in which she was compliant on Copaxone with
increased tone in left arm and left > right leg, was only able
to slightly lift right arm against gravity (later notes 3 to 4
strength except ___ in wrist extension), but no antigravity
movements in lower extremities. Psychiatry evaluated patient and
recommended inpatient psychiatric hospitalization.
Patient is accompanied with her sister who lives with her and
is her caretaker. Reportedly she has had altered mental status
for one week, though possibly longer. She has had recent
hospitalization at ___ with similar mental status changes, but
unclear diagnosis.
She saw neurologist one week ago who started her on Divalproex,
though symptoms have worsened since then. She then saw PCP ___
___ where labs were notable for UA with positive leuk esterase,
polymicrobial urine culture.
She endorses chills but not fevers. Has urine incontinence and
constipation at baseline and is wheelchair bound (from MS).
Endorses "whole body hurts", unclear if this is new.
She reports "I can't sleep and I can't stop talking, I need to
see a psychiatrist. Can I have some marijuana. Can I go to ___
to get some tea."
In the ED
=============
Initial vitals: 96.0 90 140/85 16 99% RA
Neurologically, she is quiet, with slowed, incomprehensible
speech. She follows simple motor commands to open eyes. She has
slowly reactive pupils, no definite APD identified. Grimace
relatively symmetric and tongue midline. No spontaneous
extremities movements, with trace right shoulder elevation with
noxious stimulation of right arm and no movement in left arm and
legs, despite grimace with nailbed pressure. Brisk reflexes in
brachioradialis, but otherwise diminished at patellae.
Labs were significant for TSH 6.3 otherwise unremarkable,
negative utox, stox
Imaging showed:
___ ___
IMPRESSION:
1. Involutional changes are advanced for age however there is no
evidence of acute hemorrhage or territorial infarction. MRI is
more sensitive for the detection of acute infarction.
CXR ___
IMPRESSION:
Bibasilar opacities, probably atelectasis but to be correlated
clinically as
infection is not excluded.
XR ___
IMPRESSION:
No visualized radiopaque foreign body.
The patient received:
PO Divalproex (EXTended Release) 1000 mg PO RisperiDONE 1 mg
PO/NG Mirtazapine 7.5 mg
IV Pantoprazole 40 mg
IV Levothyroxine Sodium 12.5 mcg
Vitals on transfer: 97.5 107 138/95 16 96% RA
The patient was shifted to the floor. On the floor, patient is
drowsy but whispers appropriate answers to questions.
Past Medical History:
Chronic progressive multiple sclerosis (diplegia since ___ and
wheelchair bound, incontinence of urine/stool, with baseline
spastic dysarthric speech and worsening upper extremity
weakness)
Hypothyroidism
Social History:
___
Family History:
___: Niece in her ___ just diagnosed with colon cancer. No
other MS or colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Unable to do full exam as limited patient cooperation.
VS: 97.3
PO 104 / 61 114 18 96 Ra
GEN: somnolent, lying in bed, oriented x3
HEENT: Moist MM, anicteric sclerae, sluggish pupils bilaterally
NECK: Mild thyromegaly
PULM: clear anteriorly, poor air movement
HEART: tachycardiac, regular rhythm no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: UE weakness, ___ diplegia
DISCHARGE PHYSICAL EXAM:
VS: 97.4
PO 117 / 49 81 18 99 RA
GEN: somnolent, lying in bed, oriented x3
HEENT: Moist MM, anicteric sclerae, sluggish pupils bilaterally
NECK: Mild thyromegaly
PULM: clear anteriorly, poor air movement
HEART: tachycardiac, regular rhythm no m/r/g
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: UE weakness bilaterally ___ left>right, ___ diplegia
Pertinent Results:
ADMISSION LABS:
___ 09:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:40PM GLUCOSE-101* UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
___ 08:40PM estGFR-Using this
___ 08:40PM cTropnT-<0.01
___ 08:40PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 08:40PM TSH-6.3*
___ 08:40PM T4-9.8 T3-140
___ 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:40PM WBC-6.0 RBC-4.81 HGB-13.7 HCT-43.0 MCV-89
MCH-28.5 MCHC-31.9* RDW-15.1 RDWSD-49.1*
___ 08:40PM NEUTS-74.1* ___ MONOS-4.8* EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-4.44 AbsLymp-1.23 AbsMono-0.29
AbsEos-0.01* AbsBaso-0.01
___ 08:40PM PLT COUNT-263
___ 06:00AM BLOOD Ammonia-116*
MICROBIOLOGY:
___ 05:25PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-19* Polys-0
___ Macroph-40
___ 05:25PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-700*
Polys-0 ___ Macroph-50
___ 05:25PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-54
___ 05:25PM CEREBROSPINAL FLUID (CSF) NMDA RECEPTOR AB,
CSF-PND
___ 5:25 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
___ 5:25 pm CSF;SPINAL FLUID Source: LP TUBE 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB ___ take ___ weeks to grow..
HSV PCR negative.
IMAGING:
NCHCT ___
IMPRESSION:
1. Involutional changes are advanced for age however there is no
evidence of acute hemorrhage or territorial infarction. MRI is
more sensitive for the detection of acute infarction.
SKULL ___
IMPRESSION:
No visualized radiopaque foreign body.
MRI Head/C-spine ___
IMPRESSION:
1. Supratentorial white matter lesions, likely related to known
history of
multiple sclerosis. No evidence of enhancement to suggest
active
demyelinating process.
2. No evidence of acute infarction, hemorrhage, or edema. No
enhancing mass
or abnormal enhancement.
3. Involutional changes, greater than would be expected for the
patient's age,
likely related to patient's underlying multiple sclerosis.
IMPRESSION:
1. Diffuse atrophy of the spinal cord with multiple spinal cord
lesions as
described above, likely related to patient's history of multiple
sclerosis.
No evidence of active demyelinating process.
2. Lesions within the pons and medulla likely reflect
infratentorial
demyelinating plaques.
3. Cervical spondylosis as described above, most prominent at
C5-C6 where
there is moderate severe right neural foraminal narrowing. No
high-grade
spinal canal narrowing is noted.
EEG ___
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
(1) intermittent delta slowing in the bilateral temporal
regions, indicative
of focal subcortical dysfunctions. There are intermittent
generalized theta
slowing, which could be seen due to subcortical or deep midline
dysfunction.
There are no pushbutton activations. There are no electrographic
seizures or
epileptiform discharges. Compared to the prior day's recording,
there is no
significant change.
DISCHARGE LABS:
___ 06:00AM BLOOD HIV Ab-Negative
___ 01:57PM BLOOD Ammonia-55
___ 05:50AM BLOOD Valproa-51
Brief Hospital Course:
***Due to the patient's multiple sclerosis and other medical
conditions, it is medically necessary that the patient travels
by ambulance from the hospital to home upon discharge***
___ woman with history of chronic progressive multiple
sclerosis w/ resulting diplegia, hypothyroidism admitted with
altered mental status.
#Altered mental status: Subacute progression of disorganized
thought process with slow, incomprehensible speech initially
concerning for psychosis and mania. Evaluated by neurology and
thought to be catatonia related to her underlying psychiatric
disease vs. MS ___ vs. ___ processes vs.
seizures though low suspicion. Utox, stox negative. Labs
unremarkable other than a TSH of 6.3. UA with trace leuks.
Cultures negative. NCHCT negative. CXR with bibasilar opacities
likely atelectasis given no symptoms or signs of PNA. MRI
negative for an acute process. Patient underwent a LP on ___
with negative studies, though anti-NMDA pending on discharge.
Ammonia level 119 on presentation, likely medication induced
from AED, Depakote. Normalized with L-carnitine. EEG with focal
temporal slowing but MRI negative and LP HSV PCR negative.
Patient returned cognitively to baseline on ___ with no
recollection of what had happened in the preceding days.
Reportedly as per PCP, patient had a similar presentation ___
years prior and no clear diagnosis was made at that time.
Considered inpatient psychiatry admission, but given return to
baseline this was deferred.
#Hypoglycemia: Persistent hypoglycemia since admission requiring
D5 for resolution likely related to poor PO intake. Hypoglycemia
labs with low c-peptide, normal insulin, and high
beta-hydroxybutrate, proinsulin pending, not consistent with
insulinoma. Pending proinsulin on discharge.
#Progressive MS: Held copaxone while inpatient as non-formulary.
Will continue on discharge. Continued home bowel regimen. Held
tizandine as interacts with psychiatric medications. Continued
to hold this on discharge.
#Hypothyroidism: ___ 6.3 with normal FT4/T3. Continued home
levothyroxine. Will need repeat TFTs outpatient.
#Underlying psychiatric disorder: Unclear what the actual
diagnosis is. ___ records indicate a diagnosis of
depression/anxiety as per their psychiatric evaluation. Patient
___ in the ED. Initially started on
mirtazapine/Risperdal, but these were held on the floor as the
etiology of her confusion was not clear. His Depakote was
discontinued as per psychiatry recommendations. In her altered
state, patient did briefly express suicidal ideation, but this
resolved on discharge.
TRANSITIONAL ISSUES
===================
- Holding tizanidine as ___ contribute to AMS
- Holding mirtazapine, Depakote, and Risperdal as per psychiatry
recommendations
- Pending anti-NMDA, pro-insulin on discharge
- CONTACT: Name of health care proxy: ___, Phone
number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 7.5 mg PO QHS
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Divalproex (EXTended Release) 500 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN constipation
5. Docusate Sodium 100 mg PO TID:PRN constipation
6. Polyethylene Glycol 17 g PO DAILY
7. mineral oil rectal ___ PRN
8. Generlac (lactulose) 10 gram/15 mL oral Q8H:PRN
9. pantoprazole 20 mg oral Q24H
10. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
11. Desonide 0.05% Cream 1 Appl TP BID
12. biotin 1 mg oral DAILY
13. Tizanidine 2 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) [Vitamin B-12] 100 mcg 1
tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0
2. Mineral Oil 1 enema rectal ___ PRN constipation
3. biotin 1 mg oral DAILY
4. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
5. Desonide 0.05% Cream 1 Appl TP BID
6. Docusate Sodium 100 mg PO TID:PRN constipation
7. Generlac (lactulose) 10 gram/15 mL oral Q8H:PRN
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. pantoprazole 20 mg oral Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Encephalopathy NOS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were confused. We treated
you with medications that improved your mood and mental status.
We also did a procedure called a lumbar puncture to test for an
infection in your brain. This was negative. It is now safe for
you to go home. It was a pleasure caring for you.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
19629401-DS-22
| 19,629,401 | 26,389,765 |
DS
| 22 |
2125-10-08 00:00:00
|
2125-10-10 19:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / Ativan
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ PEG placement
___ ECT was started, now on weekly ___ sessions.
History of Present Illness:
___ w/ chronic progressive MS ___ since ___ and
wheelchair bound, incontinence of urine/stool, with baseline
spastic dysarthric speech and worsening upper extremity
weakness), hypothyroidism presenting one month of gradual
decline in function accompanied by agitation, confusion and no
longer speak ___ but only ___. Patient lives with
the son, has not walked in ___ years, son reports that nothing
new has changed just a gradual decline and one reason he is
bringing her in because she has been yelling at home and more
agitated. No fever, chills, vomiting, diarrhea.
Pt's sister reports that she has been having some "psychosis"
for a while which has gotten worse. A month ago she was having
delusions such as being pregnant, that she has a lot of money,
etc. She has not been having these delusions anymore but within
the past few weeks she has been "talking jibberish" and not able
to have a conversation.
Recently, as of approx. 1 week ago, she has been eating and
drinking less and has even been refusing food, as well as making
sexual references and behaviors such as lifting her skirt, etc.
She has also been staying up at night talking to herself and not
sleeping. Also, on ___ she tried to open the door while her
brother in law was driving her to the hospital. On ___ she
drove her electric wheelchair straight into the couch and was
driving it around with no sense of direction. (Per the pt's
sister neither of these behaviors are typical).
The pt's sister reported that the morning of ___ she was
complaining that her mouth was hurting, but then she ate
breakfast and did not complain of it again (sister is not sure
if this was legitimate or not).
She was admitted at ___ and after that the pt
had a home nurse coming; nurse just stopped coming 1 week ago
because was deemed that pt did not need anymore. She still has
an aide 7d/week.
Of note, the patient was seen in ___ clinic here at ___ by Dr.
___ & fellow on ___, labwork was ordered to workup the
pt's progressively worsening mental status as well as to clear
the pt to switch to ocrelizumab (dosing is IV q6mos) from
copaxone, however the pt was apparently dehydrated making
phlebotomy difficult at the office visit. Blood draw was
attempted again at a recent PCP apt and was unsuccessful again.
- In the ED, initial vitals:
___: 96.1 73 83/38 18 100% RA
- Labs notable for:
ALT: 52, AST: 62
Alk phos: 119
- Imaging notable for:
___ 14:37 CT Head ___ Contrast:
No acute intracranial process such as hemorrhage or large
vascular territory infarction. No evidence of fracture.
- Vitals prior to transfer:
___ 69 120/83 18 100% RA
On the floor, the patient was not accompanied by any family
members and she unable to provide a history as she is
cognitively impaired. She is speaking slowly and in both Creole
and ___ off and on.
Past Medical History:
Chronic progressive multiple sclerosis (diplegia since ___ and
wheelchair bound, incontinence of urine/stool, with baseline
spastic dysarthric speech and worsening upper extremity
weakness)
Hypothyroidism
Social History:
___
Family History:
___: Niece in her ___ just diagnosed with colon cancer. No
other MS or colon cancer.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
Vitals: T 97.6 HR 117 BP 105/62 19 97% ra
General: Thin ___ female; babbling incoherently,
alert and in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular tachycardia, no m,r,g
Lungs: CTAB, breathing comfortably
Abdomen: Soft, NTTP, NBS, ND
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox2 (says she's in the hospital, unknown date and
unable to say dowb). Babbling incoherently, but CN II-XII intact
bilaterally. Has nystagmus w/ right gaze (chronic). No
spontaneous movement of b/l upper and lower extremities. Does
not grasp fingers. Plegic ___/ upgoing toes L>R.
======================
DISCHARGE PHYSICAL EXAM
======================
Vitals: 97.4F, 84, 102/57, 16, 100% on RA
General: Thin, ___ female, lying comfortably in
bed,
NAD.
CV: RRR, ___ systolic ejection murmur
in right upper quadrant.
Pulm: CTAB on anterior exam
Abd: Soft, nondistended, nontender.
Ext: Warm and well-perfused. No edema.
Neuro: Alert, contracted upper extremity, cannot move her lower
extremities.
Psych: alert and oriented x3, quiet and responding appropriately
to questioning
Pertinent Results:
============================
ADMISSION LABS:
============================
___ 01:20PM BLOOD WBC-3.4* RBC-4.79 Hgb-12.8 Hct-41.3
MCV-86 MCH-26.7 MCHC-31.0* RDW-16.0* RDWSD-49.6* Plt ___
___ 01:20PM BLOOD Neuts-34.8 Lymphs-59.3* Monos-4.7*
Eos-0.9* Baso-0.3 AbsNeut-1.20*# AbsLymp-2.04 AbsMono-0.16*
AbsEos-0.03* AbsBaso-0.01
___ 03:15AM BLOOD ___ PTT-41.8* ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD Glucose-85 UreaN-19 Creat-0.6 Na-137
K-6.9* Cl-97 HCO3-28 AnGap-12
___ 01:20PM BLOOD ALT-52* AST-62* AlkPhos-119* TotBili-0.4
___ 03:15AM BLOOD CK-MB-6 cTropnT-<0.01
___ 03:15AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.6
___ 01:20PM BLOOD Albumin-4.1
___ 05:42AM BLOOD %HbA1c-5.3 eAG-105
___ 03:18AM BLOOD Type-ART Temp-36.7 pO2-183* pCO2-33*
pH-7.49* calTCO2-26 Base XS-3 Intubat-NOT INTUBA
___ 03:18AM BLOOD Lactate-1.3 Na-138 K-4.7
===========================
DISCHARGE LABS:
===========================
___ 06:40AM BLOOD WBC-7.4 RBC-3.99 Hgb-10.9* Hct-35.6
MCV-89 MCH-27.3 MCHC-30.6* RDW-16.5* RDWSD-54.1* Plt ___
___ 06:40AM BLOOD Glucose-77 UreaN-13 Creat-0.6 Na-141
K-4.5 Cl-101 HCO3-31 AnGap-9*
___ 06:40AM BLOOD ALT-14 AST-16 AlkPhos-83 TotBili-0.4
___ 06:40AM BLOOD Albumin-3.8 Calcium-9.7 Phos-3.7 Mg-2.1
============================
MICRO:
============================
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ Lyme IgG, IgM: NEGATIVE BY EIA.
___ Enterovirus Culture: No Enterovirus isolated.
___ CSF culture:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ RAPID PLASMA REAGIN TEST: NONREACTIVE.
___ Blood Culture x2 (final ___: NO GROWTH.
___ URINE CULTURE (Final ___: NO GROWTH.
___ HSV PCR CSF: negative
============================
STUDIES:
============================
G-TUBE PLACEMENT ___
Successful placement of a 16 ___ MIC gastrostomy tube.
MR ___ SCAN WITH CONTRAST ___
1. Diffuse chronic atrophy of the cervical spinal cord with
numerous T2/STIR hyperintense spinal cord lesions compatible
with the patient's history of multiple sclerosis. The overall
extent of these lesions appears similar to the previous
examination.
2. No evidence of contrast enhancing lesion to suggest active
demyelination.
3. T2 hyperintensities within the pons and medulla for
compatible with
infratentorial demyelinating disease.
4. Cervical spondylosis, as detailed above. Findings are most
significant at C5-6 with moderate to severe right neural
foraminal narrowing. No associated high-grade spinal canal
narrowing is identified at this level.
MR HEAD W & ___ CONTRAST ___
1. No acute intracranial process.
2. Extensive supratentorial T2/FLAIR hyperintense white matter
lesions,
compatible with the patient's known history of multiple
sclerosis. No
evidence for lesion enhancement or restricted diffusion to
suggest active
demyelination.
3. Moderate severe, age advanced global cerebral atrophic
changes, likely
secondary to volume loss in the setting chronic demyelination.
EEG ___
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
slow background rhythm, mostly in the theta range, indicating a
moderate
encephalopathy which is nonspecific with regard to etiology.
Throughout the
recording there were bursts of generalized as well as
independent left and
right focal temporal slowing indicating multifocal subcortical
dysfunction.
There were no epileptiform discharges or electrographic
seizures.
CT HEAD ___ CONTRAST ___
No acute intracranial process such as hemorrhage or large
vascular territory
infarction. No fracture. Atrophy of ventricles and sulci
greater than
expected for age.
Brief Hospital Course:
___ w/ chronic progressive MS ___ since ___ and
wheelchair bound, incontinence of urine/stool, with baseline
spastic dysarthric speech and worsening upper extremity
weakness), hypothyroidism p/w 1 month of FTT and psychosis,
found to be catatonic due to suspected Bipolar I disorder. She
was treated with lithium and zolpidem for bipolar disorder, as
she was unable to tolerate Ativan due to hypotension. She was
initiated on ECT ___ and scheduled for treatments ___. She
was also found to be hypoglycemic and hypothermic early this
admission, which have both since normalized. PEG tube was placed
due to persistent poor PO, and she subsequently tolerated
continuous tube feeds well, without further hypoglycemia.
ACUTE PROBLEMS:
#Catatonia
#Altered Mental Status:
Patient was admitted to the floor, where she was unresponsive &
catatonic, so she was transferred to ICU shortly after
admission. Her mental status improved after receiving dextrose,
with improvement in glucose to 110s-150s. Psych and Neuro were
consulted. CTA and MRI brain showed no anatomical cause for her
AMS. EEG was negative for seizures. Metabolic workup was
unrevealing. LP without evidence of infection, so no antibiotics
were given. Ativan 2mg IV was attempted for catatonia, but
patient became hypotensive & apneic to this, requiring
flumazenil. She was transferred to the floor hemodynically
stable but still altered. MRI Head/Brain demonstrated no
progression of MS lesions, and as such her altered mental status
was thought to represent a primary psychiatric condition.
Psychiatry believes her presentation to be consistent with
catatonia due to bipolar I, and she was started on ambien,
lithium at night, and ECT (initiated on ___, scheduled for
___ thereafter). There was concern that the combination of
ambien and baclofen may have led to an episode of somnolence, so
baclofen was held. By discharge, she had completed 12 sessions
of ECT, most recently on ___. She will be continued on
maintenance ECT.
# Severe protein calorie malnutrition. She was started on tube
feeding owing to poor PO intake secondary to catatonia. She has
initiated wean as PO intake has improved, but will continue on
cycled ___ tube feeds. She will continue her wean under the
direction of her PCP.
# Hypothermia:
Temperature was ~96.1 on transfer to the ICU. Bear hugger was
used and hypoglycemia was treated, with improvement in body
temperature. TSH/FREE T4 checked, and T4 was normal, so no
adjustments were made. She was initially intermittently
hypothermic while on the floor, with use of Bear hugger as
needed. By discharge, she was stably normothermic.
# Hypoglycemia:
Hypoglycemia was present on last admission as well, of unclear
etiology but thought to be due to poor PO intake. She was
started on a D10 drip initially. When her mental status
improved, she passed a speech & swallow evaluation. Due to her
inability to reliably take PO, she had a PEG placed on ___,
and she tolerated continuous tube feeds well. Her hypoglycemia
resolved as her nutritional status improved.
# Urinary tract infection:
Patient was febrile to 101.8 on ___, UA was consistent with
infection at that time. Patient denied dysuria, abdominal pain;
history of symptoms is limited by patient's mental status and
baseline incontinence from MS. ___ culture grew pseudomonas
and gram positive bacteria. She initially received Augmentin
(___) before being switched to Cipro to for a 3-day course
(___).
# Progressive MS:
Last seen in ___ clinic at ___ on ___ at that time, she
was intended to be changed to ocrelizumab (dosing is IV q6mos)
from copaxone in the near future. This admission, her home
copaxone was initially held because it was not formulary to the
hospital, but she was restarted on home copaxone prior to
discharge. Baclofen was held for concern of medication effect in
combination with ambien leading to somnolence.
CHRONIC ISSUES:
# DVT prophylaxis: Patient became therapeutic on BID
subcutaneous heparin for DVT prophylaxis, with an elevated PTT.
She was restarted on DVT prophylaxis with subcutaneous heparin
5000 once daily.
# Hypothyroidism: Continued on home 25mcg daily of
levothyroxine. Thyroid function testing was unremarkable as
above.
TRANSITIONAL ISSUES:
- Noted on CTA head/neck on ___:
"Multiple pulmonary nodules measuring up to 3 mm, potentially
inflammatory
or infectious, with retained secretions in the trachea and left
mainstem
bronchus. However, clinical correlation is recommended and
follow-up chest CT
in 12 months per ___ recommendations.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk
patient, and an
optional CT follow-up in 12 months is recommended in a high-risk
patient."
- Follow coags, to ensure that she is not therapeutically
anticoagulated on once daily sq heparin.
New medications: Initiated on lithium and zolpidem
Changed medications:
Stopped medications:
#Communication: HCP: ___ ___ (sister),
___
___ (brother in law)
#Code: Full
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO TID:PRN constipation
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. pantoprazole 20 mg oral Q24H
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Vitamin D 1000 UNIT PO DAILY
8. biotin 1 mg oral DAILY
9. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
10. Desonide 0.05% Cream 1 Appl TP BID
11. Generlac (lactulose) 10 gram/15 mL oral Q8H:PRN
12. Mineral Oil 1 enema rectal ___ PRN constipation
13. Cyanocobalamin 100 mcg PO DAILY
14. Baclofen 20 mg PO TID:PRN Muscle Spasms
15. QUEtiapine Fumarate Dose is Unknown PO QHS
Discharge Medications:
1. Lithium Carbonate 450 mg PO QHS
RX *lithium carbonate 450 mg 1 tablet(s) by mouth at bedtime
Disp #*7 Tablet Refills:*0
2. Ondansetron 4 mg PO TID ___ Prior to meal
RX *ondansetron 4 mg 1 tablet(s) by mouth Before each meal Disp
#*21 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*7 Tablet Refills:*0
4. Zolpidem Tartrate 5 mg PO BID
RX *zolpidem 5 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
5. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
RX *glatiramer [Copaxone] 40 mg/mL 40 mg SC Three times a week
(___) Disp #*6 Syringe Refills:*0
6. Docusate Sodium 100 mg PO TID:PRN constipation
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Mineral Oil 1 enema rectal ___ PRN constipation
9. Multivitamins 1 TAB PO DAILY
10. pantoprazole 20 mg oral Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Vitamin D 1000 UNIT PO DAILY
14.Tube feeds
Jevity 1.5 or equivalent @ 70 cc/hr over ___ontinuously if better tolerated. Dispense one month supply with
2 refills.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=======================
PRIMARY DIAGNOSIS
=======================
Catatonia
Bipolar I disorder
Failure to thrive
Hypoglycemia
Hypothermia
Urinary tract infection
=========================
SECONDARY DIAGNOSIS
=========================
Multiple sclerosis
Hypothyroidism
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. ___,
It was a pleasure to care for you at ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you were becoming increasingly
confused and agitated, behaving erratically at home.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- You were found to have a serious medical and psychiatric
condition called catatonia, most likely caused by underlying
bipolar disorder, though it could also be related to your MS.
- You had episodes of low blood sugar, which also caused
episodes of low body temperature. You briefly went to the ICU
because of this.
- You were not eating, so you had a PEG tubed placed in order to
give you nutrition with tube feeds.
- You were started on medications to treat your bipolar
disorder.
- You received multiple sessions of ECT (electroconvulsive
therapy) for your psychiatric illness.
- You were found to have a urinary tract infection, for which
you completed a course of antibiotics.
- You responded very well to ECT and medications, and you are
becoming less confused and more interactive.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please go to all your follow up appointments as scheduled.
- Please take all your medications as directed.
- Please continue to go to ECT sessions every ___.
- Each ___ night before ECT, do not take your zolpidem and
do not eat any after midnight!
We wish you the best!
- Your ___ treatment team
Followup Instructions:
___
|
19629468-DS-13
| 19,629,468 | 25,479,606 |
DS
| 13 |
2159-12-27 00:00:00
|
2159-12-27 13:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bleach
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with L infiltrating ductal carcinoma (stage pIbN0M0, grade
I, ER+/PR+/HER2-, s/p partial mastectomy and currently on XRT),
distant h/o of DVT while on OCPs, and GERD p/w chest pain since
morning of admission. Describes pain as located in upper
strenum, constant, ___, sharp with pressure, worsening over
the course of the day, started early this morning while resting
prior to breakfast, radiating to back and L shoulder. Denies
heartburn, took Prilosec as usual. Denies nausea, headache,
diaphoresis, or dyspnea at rest or on exertion. She took Ativan
but no other medications for it.
In the ED, vitals were 97.4, 82, 166/92, 18, 98% 4L. She was
given aspirin, dilaudid 1mg x2, and zofran. Labs unremarkable,
including trop neg x1. CTPA showed no evidence of pulmonary
embolus or acute aortic pathology.
On the floor, patient reports improved chest pain. No pleurisy.
Pain is reproducible. Feels anxious. No other complaints.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: s/p bilateral submammary breast augmentation at age ___: s/p implant removal, partial capsulotomies, extensive
dissection of the pectoral major muscles and submammary tissues
due to fibrosis, and subpectoral implants by Dr. ___
at ___. No problems with the implants subsequently. She has
had multiple aspirations of breast cysts. She has been having
routine mammograms at the ___ facility of ___
Radiology since the ___. Mammograms there on ___ was
unremarkable.
-___: Pt noted increased size of a right breast cyst and
pain in the lower inner quadrant.
-___: mammogram showed no lesions in the right breast, but
a 0.7-cm spiculated mass with skin retraction was seen in the
left breast, which on questioning the patient says she had noted
on self-exam for approximately six weeks. This persisted on
spot compression views. Right breast ultrasound on the same day
showed a bilobed nodule with 0.5-cm and 0.4-cm lobes at 7
o'clock, 1 cm from the nipple, consistent with a cyst with
debris or a mass. Left breast ultrasound on the same day showed
a 0.7-cm mass at ___ o'clock, 6 cm from the nipple. The
left axillary nodes were unremarkable. Bilateral
ultrasound-guided core biopsies on the same day showed the
right-sided lesion to resolve after the third pass. Pathology
revealed a cyst wall only. The left breast biopsy revealed a
grade 1 infiltrating ductal carcinoma measuring at least 0.8 cm
with a focus suspicious for LVI and ADH, ER positive, PR
positive, and HER-2
negative by FISH.
-___: Dr. ___ ultrasound-localized left
breast excision and sentinel node biopsy. Lymphoscintigraphy
showed uptake in two axillary sites. A single incision was used
for both the excision of the mass and the sentinel node biopsy.
The mass was very superficial, and an additional anterior margin
specimen was taken. Breast dissection extended to the fascia
posteriorly. Radiograph of the 5.8 x 4.5 x 1.2-cm main breast
specimen showed the marking clip placed at core biopsy and a
mass. It contained a 0.6-cm grade 1 infiltrating ductal
carcinoma without LVI or an EIC. Tumor extended to less than 1
mm of the posterior margin, 4 mm of the inferior margin, and 4.5
mm of the superior margin. The 3 x 1.5 x 1-cm anterior margin
specimen measuring contained no disease. All six recovered
axillary sentinel nodes were negative.
-___: began 33-fraction course of 4500 cGy total planned to
left breast and 6100 cGy total planned to left breast excision
site
PAST MEDICAL HISTORY: (per OMR)
Vocal cord overuse leading to surgeries performed in ___ and
___ by Dr. ___ at ___
___. DVT after oral contraceptive use when patient was in
her ___.
Social History:
___
Family History:
The patient's mother developed breast cancer at age ___ and was
treated with breast-conserving therapy. Her father developed
melanoma at age ___, of which he died. A sister had melanoma at
age ___. The patient has regular skin checks. She is of ___
ethnic descent.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98 BP 149/81 HR 72 RR 18 97% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs. left
sternum/chest wall slightly tender to palpation. erythema over
left chest, no discrete lesions
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities, 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0, 114-149/73-88, 68-76, 97-99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs. left
sternum/chest wall slightly tender to palpation but less
pronounced. erythema over left chest, no discrete lesions
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities, 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 11:50AM BLOOD WBC-9.6 RBC-4.62 Hgb-14.7 Hct-44.5 MCV-97
MCH-31.7 MCHC-32.9 RDW-12.7 Plt ___
___ 11:50AM BLOOD Glucose-98 UreaN-18 Creat-0.7 Na-135
K-5.9* Cl-97 HCO3-28 AnGap-160
___ 11:59AM BLOOD Lactate-0.9 K-3.9
___ 09:40PM BLOOD Na-135 K-3.5 Cl-97
___ 11:50AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
___ 11:50AM BLOOD CK(CPK)-165
___ 11:50AM BLOOD cTropnT-<0.01
___ 09:40PM BLOOD cTropnT-<0.01
___ CTA chest:
1. No evidence of pulmonary embolus. No evidence of acute aortic
pathology.
2. 1 cm right-sided thyroid nodule which may be further
evaluated by
nonemergent ultrasound.
Brief Hospital Course:
___ with stage I breast cancer currently on XRT p/w chest pain
since morning of admission.
# chest pain: most concerning for PE or aortic pathology, but
CTPA reassuring. ACS also concerning given history, though EKG
unchanged and trop negative x2, ruling out ACS. Symptoms most
likely secondary to costochondritis from XRT. She was given
toradol and dilaudid at first, and was converted to ibuprofen
the following morning.
# breast cancer: s/p ___ cGy of 4500 cGy total planned to left
breast and 6100 cGy total planned to left breast excision site.
She will resume radiation therapy on the afternoon of discharge,
per Dr. ___.
# GERD: home PPI was continued
# Alcohol use: patient was monitored closely for withdrawal,
defer CIWA for now
Medications on Admission:
1. Omeprazole 20 mg PO DAILY Start: In am
2. Vitamin D 1000 UNIT PO DAILY Start: In am
3. coenzyme Q10 *NF* 10 mg Oral daily
4. Vitamin B Complex w/C 1 TAB PO DAILY Start: In am
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Vitamin B Complex w/C 1 TAB PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. coenzyme Q10 *NF* 10 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
costochondritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted for chest pain, but we found that you had no evidence
of pulmonary embolism or heart injury. We believe that this
pain is most likely coming from the chest wall and may have been
induced by the radiation. We recommend anti-inflammatory
medications to help you with this pain (ibuprofen 600mg every
___ hours with meals as needed).
You will also continue with radiation therapy starting this
afternoon.
Followup Instructions:
___
|
19629953-DS-11
| 19,629,953 | 29,333,610 |
DS
| 11 |
2118-07-10 00:00:00
|
2118-07-10 22:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with recently diagnosed
Stage IVB ovarian adenocarcinoma who presents to the ED with leg
weakness and difficulty ambulating 5 days after starting
treatment with carboplatin/paclitaxel.
The patient was in her usual state of health until 3 days ago
when she noticed the gradual onset of lower extremity heaviness
and thigh pain. Over the next three days her pain worsened. She
was without fevers or chills. She had no back pain or
bowel/bladder incontinence. No Paresthesia. She then called her
oncologist's office who recommended she present to the ED for
further evaluation.
The patient went to an OSH where she underwent ___ which was
negative for DVT. She was then transferred to ___ for further
care.
In the ED, the initial vital signs were: T 97.0 Hr 65 BP 128/93
R 16 SpO2 985
Laboratory data was notable for: Normal Chem7, CK and CBC
The patient received: ___ 08:50 PO/NG Docusate Sodium 100
mg
Upon arrival to 11R, the patient states she feels much improved
after receiving IVF at the OSH. She states her strength and pain
is significantly improved.
She has no headache or vision changes. No chest pain or dyspnea.
No abd pain. No n/v/d. No back pain. No bowel or bladder
incontinence.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
Due to abdominal pain, she had a pelvic ultrasound on ___
showing uterus measuring 8.8 x 4.8 x 4.4 cm with an endometrial
stripe up to 0.9 cm. A complex cyst was seen measuring 5.8 x 6.9
x 8.3 cm with multiple septations, one of which is thick. The
left ovary measured 5.1 x 3.2 x 3.7 cm without a mass or cyst
noted. A moderate amount of free pelvic fluid was noted. CT A/P
showed no free fluid in the peritoneal cavity and the right
adnexal mass was measured to be 8.1 x 8.4 x 7.4 cm. Her lymph
nodes were normal and there were no inflammatory changes in the
mesentery. CA 125 was 106.
On ___ she underwent total abdominal hysterectomy,
bilateral salpingo-ooprectomy, right ureterolysis, removal of
anterior abdominal wall mass, cystotomy repair, total infracolic
omentectomy, bilateral pelvic lymph node sampling, plasma jet
ablation of diaphragmatic and peritoneal nodules. Intraoperative
findings were notable for an 8 to 9 cm white smooth walled right
ovarian cyst that was adherent to the right pelvic sidewall with
question of invasion into the right pelvic peritoneum adjacent
to the ureter deep to the pelvis. The right fallopian tube had a
cystic appearing bulge and was adherent to the round ligament
and anterior abdominal wall in the lower pelvic area. A 4 cm
anterior abdominal wall bulge was noted to contain tumor and the
peritoneum overlying this mass was adherent to the right cornea.
The left ovary was enlarged and cystic measuring 4-5 cm. Surface
excrencences were noted on the left diaphragm and omentum and
the anterior pelvic peritoneum and presacral space, all
approximately 2-3 mm in size. There was no evidence of disease
at the conclusion of the surgery. Cystoscopy showed a bladder
repair evident, and normal-appearing bladder mucosa.
Final pathology showed high-grade ovarian serous adenocarcinoma,
and right anterior abdominal wall mass revealed metastatic
serous adenocarcinoma. Lymph nodes, omentum, and bladder wall
biopsy were negative for malignancy. Cytology of pelvic washings
was negative.
OTHER PMH:
Ovarian CA, as above
Gastric bypass (___)
HTN (resolved after bypass)
Hyperlipidemia (resolved after bypass)
Pre-DM2 (resolved after bypass)
h/o kidney stones
laparoscopic tubal ligation
laparoscopic cholecystectomy
"varicose vein" surgery, unclear procedure
Social History:
___
Family History:
Mother possibly died of ovarian cancer in her ___
Physical Exam:
ADMISSION:
==========
VITALS: T 98.0 BP 93/69 HR 106 R 20 SpO2 96 Ra
GENERAL: NAD, lying comfortably in bed
HEENT: Clear OP without lesions. Moist membranes
EYES: PERRL, anicteric
NECK: supple
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, NTND no rebound or guarding
EXT: warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact. Sensation intact. Strength ___ UE and
___ b/l
MSK: Normal muscle bulk of ___. No pain on palpation. No pain on
palpation of spine
ACCESS: PIV
DISCHARGE:
=========
T98.3, BP 106/71, HR 75, RR 18, 100% RA
Orthos:
Lying 106/71, HR 75 -> Sitting 109/74, HR 85 -> Standing 127/69,
HR 117
GENERAL: NAD, lying comfortably in bed
HEENT: Clear OP without lesions. Moist membranes
EYES: PERRL, anicteric, EOMI
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: +BS, soft, NTND no rebound or guarding
EXT: lower ext warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact. Sensation intact. Strength ___ UE and
___ b/l
MSK: Normal muscle bulk of ___. No pain on palpation. No pain on
palpation of spine
ACCESS: PIV
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 08:39PM BLOOD WBC-9.0 RBC-4.22 Hgb-12.1 Hct-37.9 MCV-90
MCH-28.7 MCHC-31.9* RDW-12.9 RDWSD-42.5 Plt ___
___ 08:39PM BLOOD Glucose-109* UreaN-19 Creat-0.6 Na-139
K-4.4 Cl-107 HCO3-23 AnGap-9*
___ 06:15AM BLOOD ALT-12 AST-13 AlkPhos-89 TotBili-0.4
___ 06:23AM BLOOD TSH-1.8
MICRO:
======
URINE CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. 10,000-100,000 CFU/mL.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING/OTHER STUDIES:
======================
MRI Brain ___. Small area of T1 hypointense signal in the dens, could
represent a bone island, but a marrow replacing process,
including metastatic disease can't be excluded. Diffuse
intermediate T1 signal throughout the calvarium, likely
represents red marrow reconversion, although this could obscure
an underlying metastatic calvarial lesion. These findings could
be further evaluated with a CT of the head, extending through
the
C2 vertebral body if clinically indicated.
2. No intracranial evidence of metastatic disease or abnormal
enhancement after contrast administration.
LABS AT DISCHARGE:
=================
___ 06:23AM BLOOD WBC-5.7 RBC-3.68* Hgb-10.7* Hct-33.5*
MCV-91 MCH-29.1 MCHC-31.9* RDW-12.4 RDWSD-41.2 Plt ___
___ 06:23AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-140
K-4.7 Cl-103 HCO3-28 AnGap-9*
Brief Hospital Course:
___ with recently diagnosed Stage IVB ovarian adenocarcinoma who
presented to the ED with bilateral leg weakness and difficulty
ambulating 5 days after starting treatment with
carboplatin/paclitaxel.
# Lethargy/generalized weakness:
Patient presented with progressive fatigue and subjective leg
weakness. ___ at OSH prior to admission negative for DVT. Her
exam was reassuring against cord compression and therefore did
not warrant dedicated spine imaging. No major lab abnormalities.
TSH normal. Case discussed with outpatient oncologist who agreed
that symptoms most likely related to her recent chemotherapy,
particularly paclitaxel (initiated 5d prior to admission).
Orthostatics were negative by blood pressure criteria
(borderline
by HR criteria), and her initial symptoms resolved completely
with IVFs. She was asymptomatic with a normal neurologic exam at
discharge, tolerating a regular diet. Followup in ___
clinic
already scheduled for ___.
# Headache:
Endorsed new HAs ___. No other red flag symptoms, but given
known diagnosis of stage IV cancer, MRI obtained to exclude
brain
metastasis that did not identify parenchymal brain mets. There
was a question of an abnormal signal in the skull calvarium of
unclear significance. Per discussion with Dr. ___
imaging either with bone scan or dedicated CT will be determined
on follow up with Dr. ___ as outpatient.
# Ovarian Cancer:
Recently diagnosed and s/p total lap hysterectomy and b/l
salpingo-oophorectomy on ___. Started C1 of ___ 5
days prior to admission. As above, outpatient oncologist (Dr.
___ followed closely, and Ms. ___ will f/u in clinic ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. Multivitamins 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
6. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
# Fatigue secondary to recent chemotherapy and
# stage IVB Ovarian Adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a priviliege to care for you at the ___
___. You were admitted for weakness/fatigue. We
performed several tests and the most likely cause of your
symptoms is side effects from your recent chemotherapy. You were
given IV fluids for dehydration and it is now safe to be
discharged home.
Please follow up with your appointment to see Dr. ___
week.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19630335-DS-19
| 19,630,335 | 22,841,303 |
DS
| 19 |
2136-12-22 00:00:00
|
2136-12-22 21:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of EtOH cirrhosis complicated by recurrent SBP,
ascites, encephalopathy, rheumatoid arthritis, hypothyroidism,
pleural plaques of unclear etiology presents for abdominal pain
from OSH. He states that was in his usual state of health until
two days ago when he developed periumbilical abdominal pain
which woke him from sleeping. He describes the pain as ___, has
happened previously. It hurts at the site of his umbilical
hernia. He has been able to reduce the hernia. He continued to
have bowel movements with two each day, while taking lactulose.
He had no nausea/vomiting/diarrhea. He had no fevers or chills,
no chest pain dyspnea, cough, dysuria. He denies black stool,
blood, hematochezia.
Of note he had a recent hospitalization in ___ for
cough, fever, chills where he was diagnosed with pneumonia and
treated with levofloxacin. He was found to have a large right
pleural effusion which was drained. The studies were exudative.
No cultures were sent on the fluid. Further workup showed
mediastinal lymphadenopathy and bilateral pleural plaques from a
CT scan.
He was diagnosed with cirrhosis in ___ and since
then has had two episodes of SBP and is on Bactrim for
prophylaxis. He denies drinking EtOH since ___.
In the ED, initial vital signs were: 100.0 95 119/56 18 97%RA
- Exam was notable for: not documented
- Labs were notable for: WBC 10.3, H/H 9.6/27.3, plts 51. INR
2.5. AST/ALT 55/32, Bili 11.4. Na 126, BUN/Crt ___. Lactate
2.2. UA unremarkable.
- Imaging: Chest xray with small right pleural effusion. Liver
ultrasound with patent portal veins and splenomegaly. No ascites
- The patient was given: Nothing
- Consults: None
Vitals prior to transfer were: 99.5 93 101/50 16 97% RA
Upon arrival to the floor, the patient has no further
complaints.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
-EtOH cirrhosis complicated by ascites, SBP x2, hepatic
encephalopathy
-Rheumatoid arthritis (never on methotrexate due to alcohol
use)
-Hypertension
-Basal cell carcinoma, three lesions removed from his lower
eyelid on the left eye as well as chest
-Umbilical hernia
-Pancytopenia
-Alcohol dependence
-Anxiety
-Hypothyroidism after resection of the craniopharyngioma
-Craniopharyngioma status post resection and XRT in ___
-Bilateral pleural plaques and mediastinal lymphadenopathy
Social History:
___
Family History:
He has one brother and two sisters who are healthy without any
liver disease, liver cancer, colon cancer, or lung disease. His
dad died of possible pulmonary fibrosis, also had prostate
cancer. His mother had hypertension.
Physical Exam:
ADMISSION EXAM
VITALS: 98.7 102/56 91 18 98%RA
GENERAL: Pleasant, cachectic, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor,
+scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, ___ SEM.
PULMONARY: Clear to auscultation bilaterally, except for slight
decreased breath sounds on right base
ABDOMEN: Normal bowel sounds, soft, minimally distended,
+palpable spleen, +palpable liver, umbilical hernia soft and
reducible with pain on palpation just cephalad to hernia.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema, with skin changes consistent with venous stasis.
SKIN: +erythematous rash on back of scalp.
NEUROLOGIC: AAOx3, +slight asterixis vs tremor
DISCHARGE EXAM
Vitals 98.7 102-111/56 ___
General: jaundiced, somewhat cachectic, talks slowly
HEENT: scleral icterus
Heart: RRR no murmurs
Lungs: CTAB
Abdomen: soft, NTND, no varices, jaundiced skin
Extremities: no edema
Neuro: no asterixis
Pertinent Results:
ADMISSION LABS
___ 09:54PM BLOOD WBC-10.3*# RBC-2.75* Hgb-9.6* Hct-27.3*
MCV-99*# MCH-34.9* MCHC-35.2 RDW-14.1 RDWSD-50.7* Plt Ct-51*
___ 09:54PM BLOOD ___ PTT-45.9* ___
___ 09:54PM BLOOD Glucose-127* UreaN-13 Creat-1.0 Na-126*
K-3.8 Cl-95* HCO3-22 AnGap-13
___ 09:54PM BLOOD ALT-32 AST-55* AlkPhos-88 TotBili-11.4*
DirBili-3.5* IndBili-7.9
___ 09:54PM BLOOD Albumin-3.2* Calcium-9.5 Phos-3.2 Mg-1.8
___ 05:35AM BLOOD calTIBC-146* Hapto-<10* Ferritn-490*
TRF-112*
___ 06:20AM BLOOD RheuFac-29* CRP-30.9*
___ 06:20AM BLOOD IgG-1533 IgA-441* IgM-332*
___ 09:57PM BLOOD Lactate-2.2*
DISCHARGE LABS
___ 06:20AM BLOOD WBC-3.2* RBC-2.65* Hgb-9.2* Hct-26.2*
MCV-99* MCH-34.7* MCHC-35.1 RDW-14.2 RDWSD-51.0* Plt Ct-45*
___ 06:20AM BLOOD ___ PTT-44.2* ___
___ 06:20AM BLOOD Glucose-93 UreaN-14 Creat-0.9 Na-130*
K-3.5 Cl-96 HCO3-25 AnGap-13
___ 06:20AM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.4* Mg-2.0
Iron-63
MICRO
___ 9:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
BCX ___, 52 PND AT TIME OF DISCHARGE
IMAGING
RUQ US ___. Patent portal veins with normal flow direction.
2. Splenomegaly is similar to prior.
CXR ___
No acute intrathoracic process.
Brief Hospital Course:
___ yo M with ETOH cirrhosis Childs B c/b SBP x 2, ascites, HE
with last EGD sometime in last few months which only showed
small varices who presents from OSH for abdominal pain that is
likely related to known umbilical hernia. No ascites, no pleural
effusion on imaging. Currently undergoing transplant w/u with
Dr. ___ was continued in house. MELD-Na 27 on day of
discharge.
Investigations/Interventions:
1. Abdominal pain: patient reported abdominal pain related to
doing yard work and picking up bags of mulch. His pain on
presentation was located directly over site of known umbilical
hernia. This was reducible on exam. We did perform ultrasound of
abdomen to assess for ascites with plan for diagnostic
paracentesis, but ultrasound revealed no ascites. His pain
resolved in house with a few doses of tramadol. Of note, as
patient has Childs Class B cirrhosis, his 3-month post-operative
mortality risk from umbilical hernia repair would be
approximately 50%, therefore general surgery consultation/follow
up was deferred.
2. EtOH cirrhosis: Childs B c/b SBP x 2, ascites, HE with last
EGD sometime in last few months which only showed small varices
(unclear date as this occurred at OSH). In house he had no
encephalopathy or infection. No ascites or pleural effusions.
INR stable at 2.3. Home medications lactulose, rifaximin, and
Bactrim (SBP prophylaxis) continued in house. He is currently
undergoing transplant evaluation with Dr. ___ we
continued this workup while hospitalized. Follow up appointment
with Dr. ___ after discharge.
3. Pleural plaques: presence of pleural plaques noted on prior
imaging, and patient has recently seen Dr. ___ in our
pulmonary clinic. A number of rheumatologic conditions are under
consideration, and we performed a large amount of this workup in
house. Patient subjectively asymptomatic during hospitalization.
Follow up appointment with Dr. ___ in ___.
Transitional Issues
[]Patient requires continued workup of his possible pulmonary
disease; one possible disorder is short telomere, testing for
which needs to be done at a ___ as it is a
genetic disease (this was thoroughly explained to patient and
his girlfriend ___
[]Patient is on Bactrim DS 1 tab qd for SBP prophylaxis
[]Please follow up on pending BCx from date ___
[]Will need repeat CT chest per pulmonologist Dr. ___
[]Patient has follow up with hepatologist Dr. ___ on ___
and PCP ___
#CONTACT: ___ (girlfriend) ___
#CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID
2. LORazepam 0.5 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. tadalafil unknown oral unknown
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN sob
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Levothyroxine Sodium 175 mcg PO DAILY
11. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES
QID:PRN eye irritation
12. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Medications:
1. Lactulose 15 mL PO BID
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Vitamin D ___ UNIT PO 1X/WEEK (SA)
4. Spironolactone 50 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES
QID:PRN eye irritation
7. Multivitamins 1 TAB PO DAILY
8. LORazepam 0.5 mg PO BID
9. Furosemide 20 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN sob
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
EtOH cirrhosis
Reducible umbilical hernia
Secondary:
Rheumatoid arthritis
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were hospitalized with abdominal pain. We felt this was due
to your umbilical hernia and less likely related to your liver.
While you were here, we continued Dr. ___ workup
for liver transplant. You should make sure to follow up with
her on ___.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
19630335-DS-21
| 19,630,335 | 20,756,437 |
DS
| 21 |
2137-03-18 00:00:00
|
2137-03-28 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Admission from clinic for volume overload
Major Surgical or Invasive Procedure:
Ultrasound guided therapeutic paracentesis ___
History of Present Illness:
___ year old gentleman w/ PMH of alcoholic cirrhosis (MELD 30),
c/b recurrent SBP with refractory ascites, encephalopathy, as
well as rheumatoid arthritis, hypothyroidism, pleural plaques of
unknown etiology who presents from clinic for large volume
paracentesis and IV diuresis.
Mr. ___ denies that he has noticed any significant weight
change or abdominal distension- feels that his abdomen is
actually better than baseline. He states that his ankles and
feet have been swollen for the last few weeks, but that they are
actually improving. Review of past records demonstrates that his
last discharge weight on ___ was 181.88 lbs; on admission 187.4
lbs. His last LVP was last week at OSH, with report of 2.5 L
removed. At home, he was taking furosemide 40 mg qAM, which he
reports was decreased today to 20 mg daily because of
hyponatremia seen on outpatient labwork. He continues to take
spironolactone 50 mg daily. He denies any dyspnea on exertion,
orthopnea, or PND.
He overall feels well with the exception of his R inguinal
hernia, which he states hurts when he is walking. He reports
taking hydromorphone 2mg every ___ hours for pain, in addition
to tramadol. He was referred to chronic pain clinic during his
last hospitalization and has an appointment in several weeks. He
states that he has multiple soft brown bowel movements (3 in AM,
3 in ___ with his lactulose.
In the Emergency Department:
Initial Vitals: T 97.5 HR 81 BP 147/77 RR 16 SpO2 98%RA
Labs: Notable for Na 127, Cr 0.9, ALT 25, AST 59, AP 79, Tbili
8.7, Alb 2.8, INR 2.6. Hgb 9.0, Plt 47, WBC 3.5, AbsNeut 2.53.
Studies: CXR with persistent small R pleural effusion, calcified
granuloma projecting over R midlung, but otherwise clear.
Patient did not receive any medications
Vitals on transfer: T 98.2 HR 70 BP 137/80 RR 16 SpO2 99%RA
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:
Past Medical History:
1. EtOH cirrhosis complicated by ascites, SBP x2, hepatic
encephalopathy
- History of SBP with E. coli resistant to TMP/SMX and cipro, on
cefuroxime
- Hepatic encephalopathy on lactulose and rifaximin
- Last paracentesis ___ with no evidence of SBP (only 15 mL out)
2. Rheumatoid arthritis (never on methotrexate due to alcohol
use)
3. Hypertension
4. Basal cell carcinoma, three lesions removed from his lower
eyelid on the left eye as well as chest
5. Umbilical hernia
6. Pancytopenia
7. Alcohol dependence
8. Anxiety
9. Craniopharyngioma status post resection and XRT in ___
10. Hypothyroidism after resection of the craniopharyngioma
11. Bilateral pleural plaques and mediastinal lymphadenopathy
- Thoracentesis ___ at ___ in ___ with
normal differential, CL < 25, ___ 12, negative AFB stain, no
organisms or malignant cell types, amylase 10, albumin 2.3.
- He has been ruled out for TB twice already
Social History:
___
Family History:
He has one brother and two sisters who are healthy without any
liver disease, liver cancer, colon cancer, or lung disease. His
dad died of possible pulmonary fibrosis, also had prostate
cancer. His mother had hypertension.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
GENERAL: Pleasant, well-appearing, resting comfortably in no
apparent distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor.
+scleral icterus, R pupil reactive to light, L no response
(chronic).
NECK: Supple, no LAD, no thyromegaly, JVP to angle of jaw at 45
degress.
CARDIAC: RRR, normal S1/S2, ___ SEM best appreciated at ___
without radiation to carotids.
PULMONARY: Decreased BS at R lung base, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, distended, no
organomegaly. Large umbilical hernia.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Jaundice, no palmar erythema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal with exception of L
pupil no response to light, normal sensation, with strength ___
throughout. Subtle asterixis.
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: 98.2 127/83 77 16 99% RA
GENERAL: Pleasant, well-appearing, resting comfortably in no
apparent distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor.
+scleral icterus, R pupil reactive to light, L no response
(chronic).
NECK: Supple, no LAD, no thyromegaly, JVP to angle of jaw at 45
degress.
CARDIAC: RRR, normal S1/S2, ___ SEM best appreciated at ___
without radiation to carotids.
PULMONARY: Decreased BS at R lung base, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, distended, no
organomegaly. Large umbilical hernia.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Jaundice, no palmar erythema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal with exception of L
pupil no response to light, normal sensation, with strength ___
throughout. Subtle asterixis
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 04:00PM BLOOD WBC-3.5* RBC-2.46* Hgb-9.0* Hct-26.7*
MCV-109* MCH-36.6* MCHC-33.7 RDW-15.6* RDWSD-61.5* Plt Ct-47*
___ 04:00PM BLOOD Neuts-71.5* Lymphs-9.3* Monos-14.7*
Eos-3.4 Baso-0.8 Im ___ AbsNeut-2.53 AbsLymp-0.33*
AbsMono-0.52 AbsEos-0.12 AbsBaso-0.03
___ 04:00PM BLOOD ___ PTT-44.8* ___
___ 04:00PM BLOOD Glucose-120* UreaN-14 Creat-0.9 Na-127*
K-4.3 Cl-91* HCO3-28 AnGap-12
___ 04:00PM BLOOD ALT-25 AST-59* AlkPhos-79 TotBili-8.7*
___ 04:00PM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.4 Mg-1.7
PERTINENT INTERVAL RESULTS:
===========================
___ 04:00PM ASCITES WBC-101* RBC-893* Polys-11* Lymphs-30*
Monos-26* Mesothe-12* Macroph-21* Other-0
___ 04:00PM ASCITES TotPro-0.7 Albumin-0.4
LAB RESULTS ON DISCHARGE:
=========================
___ 06:44AM BLOOD WBC-3.1* RBC-2.47* Hgb-8.9* Hct-25.9*
MCV-105* MCH-36.0* MCHC-34.4 RDW-15.4 RDWSD-59.0* Plt Ct-47*
___ 06:44AM BLOOD ___ PTT-48.5* ___
___ 06:44AM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-131*
K-4.2 Cl-93* HCO3-32 AnGap-10
___ 06:44AM BLOOD ALT-24 AST-47* AlkPhos-78 TotBili-7.5*
___ 06:44AM BLOOD Albumin-2.8* Calcium-8.3* Phos-2.7 Mg-1.7
RADIOLOGY:
==========
CXR ___
-------------
Persistent small right pleural effusion.
RUQ ULTRASOUND ___
1. Coarse and nodular hepatic architecture consistent with the
patient's known cirrhosis. No concerning liver lesion
identified.
2. No portal vein thrombus. The portal vein is patent and a
recanalized
paraumbilical vein is again noted.
3. Large ascites and right pleural effusion.
PATHOLOGY (FROM LAST ADMISSION):
================================
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Colonic mucosal samples, six:
1. Cecal polyp, polypectomy:
Inflammatory-type polyp.
2. Ascending, mucosal biopsies:
Colonic mucosa with focal surface erosion and assoc
iated crypt regeneration.
3. Transverse, mucosal biopsies:
Within normal limits.
4. Descending, mucosal biopsies:
Within normal limits.
5. Sigmoid, mucosal biopsies:
Within normal limits.
6. Rectum, mucosal biopsies:
Within normal limits.
Note: The changes in the ascending colon are similar to those
seen in the setting of a focal drug-induced injury, such as can
be associated with NSAID use. Correlation with clinical data is
needed. No features of an inflammatory type colitis are seen in
any of the above samples
Brief Hospital Course:
___ year old gentleman w/ past medical history of alcoholic
cirrhosis (MELD 30) recently listed for transplant, c/b
recurrent SBP with refractory ascites, encephalopathy, as well
as rheumatoid arthritis, hypothyroidism, pleural plaques of
unknown etiology who presents from clinic for large volume
paracentesis and IV diuresis in setting of hyponatremia. He is
now s/p 3.4L LVP on ___ and diuresis with IV furosemide.
Hyponatremia improved to 131 from 127 on presentation.
# Volume overload: Last paracentesis here on ___ without
evidence of SBP, last paracentesis at OSH with 2.5 L removed. At
home he is on diuretic regimen of furosemide 20 mg PO daily and
spironolactone 50 mg PO daily. He was admitted from clinic ___
for volume overload in the setting of hyponatremia with
peripheral edema and ascites. Admission serum sodium was 127,
and admission weight was recorded as 85 kg. We initially
diuresed him with IV furosemide 20 mg on day of admission,
however this was not very successful - he only made 458 mL urine
over 24 hours and his Cr increased from 0.9 to 1.1. Hence he
went for ___ guided paracentesis on ___. Prior to procedure he
received FFP for an INR of 2.6. Removal of 3.4 L of clear
straw-colored ascitic fluid was accomplished, with infusion of
albumin 25 g post procedure. Fluid analysis ___ did not
demonstrate SBP and was consistent with portal hypertension with
SAAG of 2.1. He was subsequently given furosemide 40 mg once and
albumin 25 g. Upon discharge, a standing order was provided to
___ Radiology for weekly therapeutic paracentesis,
and no changes were made to his diuresis. Discharge weight was
78.4 kg, and discharge Cr was back to his baseline of 0.9.
# Hyponatremia: Improved from 127 -> 131 with diuresis and
albumin. Urine sodium is 21 with FeNa 0.12%. He received total
of 50g 25% albumin throughout stay
# EtOH cirrhosis (MELD-Na 30)
He is listed for transplant
1) Ascites management as above
2) SBP: Continued prophylaxis with cefpodoxime during stay as
cefuroxime is non formulary. He was continued on home cefuroxime
upon discharge. He has history of SBP with E. coli resistant to
TMP/SMX and ciprofloxacin.
3) Hepatic encephalopathy: Continued home rifaximin 550 mg PO
BID; maintain K>4; lactulose 45 mg TID titrating to ___ BM
daily. He had no evidence of portal vein thrombus on ___ RUQ
ultrasound
4) GIB/Varices: Last EGD unknown date, not in our system
5) Coagulopathy: INR 2.6, Plt 42 around baseline
6) ?Hepatopulmonary syndrome: Early bubbles seen on ___ TTE,
cannot rule out intrapulmonary shunt.
Chronic issues:
---------------
# R inguinal hernia: Was seen by chronic pain while in house
during last admission ___ - ___, placed on dilaudid
___ mg q6H PRN, tramadol 50 mg PO BID and lidocaine 5% patch. He
was then referred to ___. During this admission,
he was continued on home dilaudid 2mg q6H PRN moderate pain,
4mg q6H PRN severe pain, tramadol 50 mg BID and had no
complaints.
# Pancytopenia: Thought to be secondary to liver disease w/
known splenomegaly. Remains at baseline. On discharge Hgb 8.9
with MCV 105 (he is on levothyroxine for hypothyroidism; no
folate or B12 in our system), WBC 3.1, Plt 47.
# Hypothyroidism: Continued home levothyroxine 150 mcg qDaily
# Anxiety: Continued home lorazepam 0.5 mg qHS PRN
TRANSITIONAL ISSUES:
====================
[ ] Discharge weight was 78.4 kg, and discharge Cr at baseline
of 0.9
[ ] No changes were made to home diuretics: he is continued on
spironolactone 50 mg and furosemide 20 mg daily
[ ] Standing order to ___ for weekly large volume
paracentesis
Follow up issues from prior discharge summary dated ___:
[ ] He requires 2nd dose of Hep A vaccination in ___
[ ] He requires 3rd dose of Hep B vaccination in ___
[ ] Pathology of ___ polyps benign without evidence of
malignancy or inflammatory colitis but with changed in
aschending colon similar to those seen in setting of focal drug
induced injury (Please see results section)
# Full code
# Contact: ___ ___ (Girlfriend)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cefUROXime axetil 500 mg oral BID
2. Furosemide 20 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. Lactulose 45 mL PO BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
8. LORazepam 0.5 mg PO QHS:PRN anxiety
9. TraMADol 50 mg PO BID
10. Rifaximin 550 mg PO BID
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. cefUROXime axetil 500 mg oral BID
3. Furosemide 20 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
5. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
6. Lactulose 45 mL PO BID
7. Levothyroxine Sodium 150 mcg PO DAILY
8. LORazepam 0.5 mg PO QHS:PRN anxiety
9. Rifaximin 550 mg PO BID
10. Spironolactone 50 mg PO DAILY
11. TraMADol 50 mg PO BID
12.Therapeutic paracentesis
Standing order: Ultrasound guided therapeutic paracentesis.
Schedule: Every 1 week.
ICD-10: ___.31 Alcoholic cirrhosis of liver with ascites
Responsible provider: ___, MD ___ ___
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic cirrhosis with ascites
Secondary:
Umbilical hernia
Inguinal hernia
History of SBP
History of hepatic encephalopathy
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ from liver clinic because of concerns
that you were building up too much fluid and trying to remove
the fluid with medications was making your electrolytes
abnormal. We gave you some fluids and removed fluid from your
belly with a paracentesis. We are not making any changes to your
diuretic medications. To help keep the fluid in your belly under
control, we are going to have go to ___ once a week
for a paracentesis. Call ___ to schedule the
appointments, starting next week.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
19630335-DS-27
| 19,630,335 | 24,876,520 |
DS
| 27 |
2138-12-20 00:00:00
|
2138-12-20 16:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
levothyroxine sodium
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with alcoholic cirrhosis s/p DDLT on ___. His
postoperative course was complicated by ___'s
cardiomyopathy
and fluid overload requiring prolonged ICU stay. He has been
following up regularly with the transplant clinic, and was most
recently seen yesterday ___. He continues to make a steady
recovery. His feeding tube was removed last week. He complains
of
night sweats, left chest/upper abdominal pain and dyspnea on
exertion, all of which are stable to slightly improved since
discharge.
CXR yesterday showed improved lung volumes and resolution of
pulmonary edema in comparison to discharge. Routine labs were
notable for hyperkalemia (K:6.3) and the patient was advised to
seek medical treatment. He presented to an OSH where his K+ was
verified at 6 and he was given 2g calcium gluoncate, 6 units of
insulin, 50% dextrose injection and transferred to ___ for
further management.
On surgical evaluation, Mr. ___ is comfortable and in no acute
distress. He reports the pain and shortness of breath (as
detailed above). Review of systems is otherwise negative. He is
meeting his calorie needs with protein shakes (~4 daily) but
does
not drink water or additional fluids. He denies nausea/emesis or
change in bowel function. He denies fevers/chills. He received
an
additional
ROS:
(+) per HPI
(-) Denies pain, fevers chills, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, cough, edema, urinary frequency, urgency
Past Medical History:
1. EtOH cirrhosis (decompensated by ascites, SBP and HE)
2. Rheumatoid arthritis
3. Hypertension
4. Basal cell carcinoma
5. Umbilical hernia
6. Pancytopenia
7. Alcohol dependence
8. Anxiety
9. Craniopharyngioma status post resection and XRT in ___
10. Hypothyroidism after resection of the craniopharyngioma
11. Bilateral pleural plaques and mediastinal lymphadenopathy
Social History:
___
Family History:
He has one brother and two sisters who are healthy without any
liver disease, liver cancer, colon cancer, or lung disease.
His father died of possible pulmonary fibrosis, also had
prostate cancer. His mother had hypertension.
Physical Exam:
Physical Exam:
Vitals: T97.8 HR85 BP137/85 RR18 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, incision well-healing; large
reducible midline hernia
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Laboratory:
___ 11:50PM BLOOD WBC: 4.5 RBC: 2.57* Hgb: 8.1* Hct: 23.9*
MCV: 93 MCH: 31.5 MCHC: 33.9 RDW: 22.0* RDWSD: 74.1* Plt Ct: 85*
___ 11:50PM BLOOD Neuts: 87.3* Lymphs: 6.3* Monos: 4.0*
Eos:
0.2* Baso: 0.4 Im ___: 1.8* AbsNeut: 3.89 AbsLymp: 0.28*
AbsMono: 0.18* AbsEos: 0.01* AbsBaso: 0.02
___ 11:50PM BLOOD Glucose: 108* UreaN: 49* Creat: 1.3* Na:
131* K: 6.2* Cl: 96 HCO3: 22 AnGap: 13
___ 11:50PM BLOOD ALT: 40 AST: 25 AlkPhos: 178* TotBili:
1.0
___ 11:57PM BLOOD K: 5.9*
Imaging:
CXR ___:
1. Interval resolution of pulmonary edema with improvement in
vascular congestion, now mild and perihilar.
2. Interval decrease in loculated right pleural effusion, now
small.
EKG
Pertinent Results:
___ 10:30AM BLOOD WBC-5.3 RBC-3.13* Hgb-9.7* Hct-30.1*
MCV-96 MCH-31.0 MCHC-32.2 RDW-22.5* RDWSD-77.5* Plt ___
___ 05:41AM BLOOD WBC-4.2 RBC-2.83* Hgb-8.7* Hct-27.1*
MCV-96 MCH-30.7 MCHC-32.1 RDW-21.7* RDWSD-76.0* Plt Ct-82*
___ 11:50PM BLOOD ___ PTT-26.1 ___
___ 05:41AM BLOOD ___ PTT-28.0 ___
___ 10:30AM BLOOD UreaN-51* Creat-1.4* Na-134* K-6.3*
Cl-94* HCO3-24 AnGap-16
___ 11:50PM BLOOD Glucose-108* UreaN-49* Creat-1.3* Na-131*
K-6.2* Cl-96 HCO3-22 AnGap-13
___ 01:25PM BLOOD Glucose-172* UreaN-44* Creat-1.4* Na-131*
K-5.5* Cl-94* HCO3-19* AnGap-18
___ 05:41AM BLOOD Glucose-99 UreaN-39* Creat-1.3* Na-138
K-5.7* Cl-100 HCO3-24 AnGap-14
___ 05:41AM BLOOD Glucose-117* UreaN-32* Creat-1.2 Na-136
K-5.5* Cl-99 HCO3-20* AnGap-17
___ 10:30AM BLOOD ALT-46* AST-30 AlkPhos-215* TotBili-1.1
___ 11:50PM BLOOD ALT-40 AST-25 AlkPhos-178* TotBili-1.0
___ 05:55AM BLOOD ALT-105* AST-63* AlkPhos-595* TotBili-1.1
___ 06:47AM BLOOD ALT-71* AST-29 AlkPhos-434* TotBili-1.0
___ 05:41AM BLOOD ALT-58* AST-20 AlkPhos-362* TotBili-1.0
___ 05:41AM BLOOD ALT-45* AST-17 AlkPhos-292* Amylase-29
TotBili-0.9
___ 05:41AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1
___ 05:41AM BLOOD TSH-4.9*
___ 05:41AM BLOOD Free T4-0.9*
___ 10:30AM BLOOD tacroFK-11.7
___ 04:24AM BLOOD tacroFK-13.5
___ 05:55AM BLOOD tacroFK-8.8
___ 06:47AM BLOOD tacroFK-4.4*
___ 05:41AM BLOOD tacroFK-5.8
___ 12:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ y.o. male with a history of alcoholic cirrhosis s/p DDLT on
___ presented with hyperkalemia and ___, likely due to
dehydration. Hyperkalemia was treated at the OSH and ___ ED.
He had no acute symptoms associated with electrolyte
abnormalities and EKG was stable. Elevated Cr was in the setting
of poor PO intake and he was resuscitated with fluids.
Creatinine was 1.4 on hospital day 2. Fluconazole and Valcyte
doses were renally dosed. Potassium decreased from 6.3 to 5.9
then 5.7 after dextrose, insulin and kayexalate (had multiple
BMs)and repeat potassium was 5.0. Diet was ordered for 2 gram
potassium restriction. Nutrition recommended Ensure Clears or
Nepro for supplements tid. Bactrim was briefly switched to
atovaquone on ___ then Bactrim was resumed. Due to persistent
potassium elevation back up to 5.7 requiring treatment, Bactrim
was discontinued on ___ and atovaquone started. Of note, G6PD
was normal, but wbc ranged between 4.9-4.1. Florinef (0.1mg
every other day)was started on ___. He was given kayexalate
30gram on ___ and was instructed to repeat kayexalate that
evening after discharge.
Labs were notable for anemia of unclear origin; admission hct
was 30.1 that decreased to 23.9 later in the day likely from
IVF. Repeat HCT was 26.2. He was
hemodynamically stable, stool was guaiac negative and HCT
remained stable.
LFTs were normal on admission and increased the next day with
alt up to 63 from 25, ast 105 from 41, alk phos 595 from 182 and
t.bili 1.1 from 1.0. Liver duplex was wnl. LFTs decreased each
day until an ERCP was performed on ___ with removal of the
previously placed stent as ducts were patent without
stricture/stenosis. He tolerated this procedure well and LFTs
continued to decrease. Amylase/lipase were wnl. Diet was
resumed.
He continued to have left chest/subclavian area/rib clicking
sensation. Chest CT was performed noting new mild sclerosis of
the right 8 costal junction that could represent subacute
nondisplaced fracture. No fractures of the left ribs were noted.
Patient was given a lidocaine patch to the area without
improvement. This was not ordered for home.
Immunosuppression was notable for Prednisone decrease to 10mg on
___. Cellcept was well tolerated. Admission Tacrolimus level
was elevated at 11.2. Tacrolimus trough was 13.5 the next day
and dose was decreased to 1mg twice daily. Daily troughs and
dose adjustements were made as follows:
___ FK3/3(5.8)****Fluconazole was d/c'd on ___ after am
dose. Qtc were 488-___
___ FK ___
___ FK ___ FK ___
Next lab draw was scheduled for ___.
He was started on Amlodipine for sbp in 130s to 150s and because
Florinef was started for hyperkalemia.
He was tolerating regular food (2gram K restriction). He was
encouraged to continue to drink 3 nutritional supplements (Nepro
or Ensure Clear)per day. Weight was 65kg on ___. He was
ambulating independently and was ready for discharge to home on
___. Previous ___ services resumed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluconazole 400 mg PO Q24H
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Synthroid (levothyroxine) 150 mcg oral DAILY
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
5. Mycophenolate Mofetil 1000 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. PredniSONE 12.5 mg PO DAILY
8. Sertraline 25 mg PO DAILY
9. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 1.5 mg PO Q12H
12. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
13. TraZODone 25 mg PO QHS:PRN insomnia
14. ValGANCIclovir 900 mg PO Q24H
15. Calcium Carbonate 500 mg PO ASDIR
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Magnesium Oxide 400 mg PO DAILY
18. Mens Daily (multivit with min-FA-lycopene) 0.4-600 mg-mcg
oral DAILY
19. Senna 8.6 mg PO BID:PRN Constipation
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
do not take more than 2000mg per day
2. amLODIPine 5 mg PO DAILY elevated BP
HOLD for sbp <110
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
3. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Disp #*300
Milliliter Refills:*11
4. Fludrocortisone Acetate 0.1 mg PO Q48H hyperkalemia
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth every other day
Disp #*30 Tablet Refills:*3
5. Levothyroxine Sodium (levothyroxine) 150 mcg oral DAILY
6. PredniSONE 10 mg PO DAILY Duration: 7 Days
follow scheduled taper, decrease to 7.5mg next ___
7. Sodium Polystyrene Sulfonate 15 gm PO ONCE elevated
potassium of 5.5 Duration: 1 Dose
take when you get home today
8. Tacrolimus 3 mg PO Q12H
9. ValGANCIclovir 450 mg PO Q24H
10. Docusate Sodium 100 mg PO BID:PRN constipation
Discontinue use for diarrhea or more than 2 bowel movements
daily
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. LORazepam 0.5 mg PO DAILY:PRN anxiety
13. Mens Daily (multivit with min-FA-lycopene) 0.4-600 mg-mcg
oral DAILY
14. Mycophenolate Mofetil 1000 mg PO BID
15. Pantoprazole 40 mg PO Q24H
16. Senna 8.6 mg PO BID:PRN Constipation
17. Sertraline 25 mg PO DAILY
18.Nepro Supplements
Supply: 90 cans
Refill: 2
Diagnosis: Malnutrition
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyperkalemia
history of liver transplant
___
Malnutrition, moderate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ arranged to follow you at home
T: ___
F: ___
Please call the transplant clinic at ___ for fever of
101 or greater, chills, nausea, vomiting, diarrhea,
constipation, inability to tolerate food, fluids or medications,
yellowing of skin or eyes, increased abdominal pain, incisional
redness, drainage or bleeding, dizziness or weakness, decreased
urine output or dark, cloudy urine, swelling of abdomen or
ankles, weight gain of 3 pounds in a day or any other concerning
symptoms.
.
Bring your pill box and list of current medications to every
clinic visit.
.
You will need to have STAT labs drawn at ___,
___ Office Building Lab on ___ then have
labwork drawn twice weekly as arranged by the transplant clinic,
with results to the transplant clinic (Fax ___ . CBC,
Chem 10, AST, T Bili, Trough Tacro level, Urinalysis.
.
*** On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacrolimus with
you so you may take your medication as soon as your labwork has
been drawn.
.
Follow your medication card as there have been several changes
to your medications. Keep it updated with any dosage changes,
and always bring your card with you to any clinic or hospital
visits.
No driving if taking narcotic pain medications
.
Avoid direct sun exposure. Wear protective clothing and a hat,
and always wear sunscreen with SPF 30 or higher when you go
outdoors.
.
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like Ensure CLEAR or Nepro.
(which are lower in potassium)Continue to follow low potassium
diet
.
Check your blood pressure at home. Report consistently elevated
systolic BP values above 160 or less than 110 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
Followup Instructions:
___
|
19630515-DS-21
| 19,630,515 | 28,795,483 |
DS
| 21 |
2180-07-05 00:00:00
|
2180-07-14 13:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial droop, vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o positive PPD in ___ for the last 5 months now
p/w Facial droop, vertigo.
She was in her USOH until ___ when she developed a
gradual-onset vertex headache that built over the day,
eventually
becoming quite severe (not the worst headache ever). It started
whiel at work (bank) and resolved later in the day when she was
at the gym. However, the same headache recurred the following
day. Again, it abated in the evening. On the third day, she got
a
headache again which resolved. It was a pounding headache and
when she touched her temples, they hurt. It did not radiate down
the neck and there was no back or neck stiffness. There was no
sensitivity to light or sound. The gym seemed to help; she did
not take any medicine. There were no obvious provoking or
exacerbating factors. There were no associated complaints. She
is
not a headache sufferer and has never had anything along these
lines before.
The next day (___), the headache did not recur - but she
did
develop dizziness which seems most like a mix of internal
movement (not the world spinning around her) and
light-headedness. She started noticing this at work and it
worsened over the following few days. There is no illusion of
the
world moving and there is no sensation of instability beneath
the
feet. This has persisted virtually unchanged.
She saw a doctor on ___ in ___ who diagnosed
with with labyrinthitis (though the hearing was unaffected,
tinnitus, or fullness) and gave her "beta-histina bluepharma".
At
that time, she noticed that she had diplopia (horizontal) on
right lateral gaze (she had noticed this earlier that day while
driving).
This past ___, almost 2 weeks after vertigo started)
her cousin came over and asked what was wrong with her face. She
felt like the right side of the mouth was off when she was
brushing her teeth - not numb (poor control). Since this began,
it has not changed.
ROS positive: When she squeezes her fingers, it hurts more than
normal. Otherwise positive per HPI. No cognitive complaints
aside
from forgetting her father's birthday recently.
ROS negative: headache, neck/back pain, nausea/vomiting, gait
difficulty, diplopia/oscillopsia/blurred vision, field cuts,
facial numbness or tingling, dysphonia, dysphagia, hearing
changes, weakness, numbness, tremors, clumsiness, bowel/bladder
complaints, fevers, chills, diaphoresis, weight changes, EENT
issues, chest pain, dyspnea, cough, abdominal pain, N/V/C/D,
rashes, myalgias.
No tick exposure. + Mosquito exposure. Was sneezing a lot at
work
(so was everyone else) but she feels well now.
Past Medical History:
- positive PPD with negative chest x-ray (before college, on ABx
for ___ months)
- hepatitis A positive antibody
- positive H. pylori status post treatment in ___
- hyperhidrosis of the hands and feet since childhood
- history of depression
- Bartholin cyst
- subclinical hypothyroidism
- rectal bleeding
Social History:
___
Family History:
Positive for hypertension, diabetes, dyslipidemia. No history of
neurologic problems (MS, NMO) or autoimmune problems (sarcoid,
lupus, Sjogren's).
Physical Exam:
ON ADMISSION:
VITALS: 98.2 71 115/73 16 100% RA
GEN: NAD NT ND
HEENT: While there is some asymmetry to the palpebrae, there is
no convincing ptosis in reference to the ___.
NECK: No meningism, supple, full ROM (painless). No pain on
percussion.
CARD: RRR no m/r/g
PULM: CTAB no r/r/w
ABD: Soft NT ND NABS
EXTREM: + acral hyperhidrosis. WWP no c/c/e
NEUROLOGIC
- MS: A&Ox3. Very alert despite the time (2am). Registers ___,
recalls ___ spontaneously and the ___ with a category cue. DOWIR
done normally and promptly. Fluent, names normally.
Comprehension
intact. Repetition nl. Follows complex commands without
left-right confusion.
- CN: 6-> 3 ___. Eyes are conjugate in primary position. There
is
no nystagmus in primary position until either eye is occluded
with a bright light in the opposite - at that point, a left
beating, torsional nystagmus is seen. On left gaze, there is no
diplopia but there is a left beating, torsional nystagmus. On
right gaze, diplopia is elicited and it appears that the left
eye
adducts better than the right eye abducts - there is higher
amplitude nystagmus beating to the right. Patient cannot say
which eye yields the false image. There is no truly vertical
nystagmus though the direction changing, torsional nystagmus is
seen. Right face is attenuated with no lagophthalmos but weak
eye
closure and diminished forehead excursion. Audition is equal
bilaterally. The RIGHT palate appears to elevate better than the
left thought it is suble. Tongue is midline vis a vis the nose.
- MOTOR: Normal tone. Full strength. No orbiting. Finger
tapping
is normal. Neither ___ nor Babinski.
- SENSORY: Intact to temperature, touch, direction of skin
deviation, direction of hallux movement throughout. No Romberg.
- REFLEXES: Brisk throughout but the adductors barely cross and
there are no pectoralis reflexes.
- CEREBELLAR: No rebound, mirroring deficits, dysmetria or
action tremor on FNF or heel/shin abnormalities. There is no
truncal ataxia at the bedside (eyes closed, arms crossed) or
walking.
- GAIT: Base is narrow and normal. Initiation prompt. Stride
length, arm swing are normal. Turns normally. Nl tandem, heel,
toe walking.
ON DISCHARGE:
Her R eye gaze is unchanged with right ___ palsy. Her palate
elevates midline. Facial droop is improved but not resolved.
Direction changing nystagmus is improved but not resolved.
Pertinent Results:
Labs:
___ 08:57PM BLOOD WBC-8.5 RBC-4.09* Hgb-13.1 Hct-39.2
MCV-96 MCH-32.1* MCHC-33.5 RDW-12.7 Plt ___
___ 08:57PM BLOOD Neuts-49.4* ___ Monos-6.4 Eos-2.2
Baso-1.1
___ 05:48AM BLOOD ESR-5
___ 08:57PM BLOOD Glucose-80 UreaN-10 Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
___ 05:48AM BLOOD HCG-<5
___ 05:48AM BLOOD ___
___ 05:48AM BLOOD CRP-0.3
___ 04:00PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-0 Polys-0
___ ___ 04:00PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-75
CSF Send Outs Labs:
___ 16:00 CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR - NOT
DETECTED
___ 16:00 COCCIDIOIDES ANTIBODY - <1:1
___ 16:00 ANGIOTENSIN 1 CONVERTING ENZYME - 4 (ref
<=15 U/L)
___ 16:00 BLASTOMYCES QUANTITATIVE ANTIGEN - None
Detected
___ 16:00 VDRL - Non-Reactive
___ 16:00 TB - PCR - Not Detected
___ 16:00 HERPES SIMPLEX VIRUS PCR - Negative
___ 16:00 BORRELIA BURG___ ANTIBODY INDEX FOR CNS
INFECTION - <1.0 (Test not performed)
___ 16:00 ___ VIRUS, QUAL TO QUANT, PCR - Not
Detected
___ 16:00 MULTIPLE SCLEROSIS (MS) PROFILE
MULTIPLE SCLEROSIS (MS) PROFILE
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Multiple Sclerosis Profile
CSF Bands 4 bands
CSF Olig Bands AB 4 bands
<4
Interpretation
--------------
The oligoclonal band assay detected 4 or more IgG bands in the
CSF, which
are not detected in the serum. This is a POSITIVE result.
Microbiology:
___ Blood (EBV) ___ VIRUS:
___ 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.
___ Blood (CMV AB) CMV IgG ANTIBODY
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
50 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
___ SEROLOGY/BLOOD LYME SEROLOGY - NO ANTIBODY
TO B. BURGDORFERI DETECTED BY EIA
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
NO MYCOBACTERIA ISOLATED.
___ CSF;SPINAL FLUID CRYPTOCOCCAL
ANTIGEN-CRYPTOCOCCAL ANTIGEN NOT DETECTED
Imaging:
CTA Head/Neck ___:
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, masses, mass
effect, or
infarction. The ventricles and sulci are normal in caliber and
configuration.
No fractures are identified.
Head and neck CTA: The carotid and vertebral arteries and their
major branches
are patent with no evidence of stenoses. The distal cervical
internal carotid
arteries measure 4 mm in diameter on the left and 4 mm in
diameter on the
right. There is no evidence of aneurysm formation or other
vascular
abnormality.
IMPRESSION:
Significant abnormalities are seen on CT angiography of the head
and neck. No
evidence of occlussion stenosis or dissection. No evidence of
aneurysm greater
than 3 mm in size.
MRI W/ and W/out contrast ___:
1. Compared to ___, there are multiple new small T2
hyperintense
lesions in the supratentorial white matter, which are
nonspecific. In a
patient of this age, diagnostic considerations include
demyelinating disease,
Lyme disease, sarcoidosis, vasculitis, and other inflammatory/
post
inflammatory etiologies. Please correlate clinically.
2. No evidence for brainstem lesions.
CXR ___: No evidence of intrathoracic lymphadenopathy.
Cytology:
CSF: NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with no neurologic history who
presented with headache, unsteadiness, diplopia, and right
facial palsy found to have dysfunction of multiple cranial
nerves (R ___, R ___, ?L ___ and direction changing nystagus.
Her MRI shows multiple non-specific white matter lesions,
including a small brainstem lesion which is likely the etiology
of her current cranial nerve symptoms. Her presentation is most
consistent with clinically isolated syndrome as this is her
first clinically apparent demyelinating event and she may
develop multiple sclerosis in the future. She was treated with a
5 day course of steroids and noted improvement in her facial
droop and dysequilibrium.
# Clinically Isolated Syndrome: This is her first clinically
apparent demyelinating event and has caused cranial
neuropathies. She completed 5 days of methylprednisone (1 g
daily). Her CSF studies were significant for oligoclonal bands,
which returned after her discharge. Given that this is
clinically isolated syndrome, she may never have another
demyelinating event or she may progress to multiple sclerosis.
Given the risks of prolonged treatment with immune modulating
medications, particularly in women of childbearing age, we
decided to not start long term therapy. This can be reconsidered
if she has another demyelinating event and thus a diagnosis of
MS. ___ was counseled about other symptoms of MS and to notify
her doctor or come to the ED if she experiences neurological
deficits. She will follow up in neurology clinic and this will
be coordinated prior to her return home to ___.
TRANSITIONAL ISSUES:
- full code
- she lives mostly in ___ which may complicate follow up
care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. betahistine (bulk) 100 % PO as directed
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
clinically isolated syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you during your recent
hospitalization. You came to the hospital with dizziness, double
vision and a facial droop. We found some abnormalities in your
eye movements on exam. You brain MRI showed a small
demyelinating area in your brainstem that explains your
symptoms. This is usually caused by inflammation and you were
treated with steroids. If you have another episode of
neurological symptoms (like numbness, tingling, dizziness,
difficulty walking, incontinence, blurry vision, weakness,
double vision), it is very important that you tell you
neurologist or get evaluated in the ED because you may need more
long term medications.
On discharge, you should follow up in neurology clinic. Please
call to make an appointment with ___. If you are unable to schedule an appointment with them,
please call to schedule one with ___ or
___ at ___.
At your appointment, please ask for your discharge summary and
we can print it out for you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19630573-DS-18
| 19,630,573 | 24,784,646 |
DS
| 18 |
2125-04-08 00:00:00
|
2125-04-09 07:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers and chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ gentleman with BPH (on Flomax),
and a history of Babesiosis and malaria, who presented with
fevers and chills and is admitted for workup of new
thrombocytopenia and neutropenic fever.
The patient was in his usual state of health until ___
evening when he returned from a ___nd started to
develop chills. He went to urgent care a ___ where
he had a flu test that was negative. Labs were sent including
babesia, ehrlichia, anaplasma, were negative. He was sent home
with Tylenol and instructed to hydrate. His symptoms continued
to persist with temps up to ___ so he returned to clinic on
___ where he was found to be neutropenic and thrombocytopenic
so he was sent to the ___ Ed for further management and
evaluation.
In the ED, initial VS were: T102.8 93 115/73 19 96% RA
Exam notable for: RRR. CTAB. NTND abd. No meningismus or neck
tenderness. No c/c/e. No rash. Alert and warm to the touch. No
lymphadenopathy
Labs showed: UA Sm blood, parasite smear neg, WBC 1.7/990 PMNs,
6% bands, 2% atypicals, INR 1.2, ALT/AST ___, LDH 386,
Tbili 0.4, Alb 3.3, Na 133, BUN/Cr ___, uric acid 4.1, INR
1.2, fibrinogen 540, lac 1.3
Imaging showed: CXR w/RLL opacity
Consults:
ID: "hepatitis and tick borne illness labs, start empiric
doxycycline, blood cultures."
Patient received: Cefepime 2g, Vanc 1500mg, 1L NS, Doxy 100mg
PO,
Flomax 0.4mg
On arrival to the floor, patient reports that he has experienced
multiple tick-borne illnesses before including babesiosis a
couple of years ago. He has recent travel to ___ and ___
___ and has felt normal since his return mid ___. He also
notes that he pulled a tick off of his back the week prior to
the onset of symptoms. He denies any chest pain, cough, LAD,
diarrhea, constipation, dysuria.
Past Medical History:
Positive PPD
Osteoporosis
Plantar fasciitis
HEMORRHOIDS
Impingement syndrome, shoulder
CME (cystoid macular edema)
Partial tear of rotator cuff
History of left total knee replacement (___)
Vitreous detachment
Irritable bowel syndrome (IBS)
Advance directive discussed with patient
___
Greater tuberosity of humerus fracture
Elevated PSA
Social History:
___
Family History:
Lung Cancer, Colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VS: ___ 0139 Temp: 98.5 PO BP: 117/66 HR: 81 RR: 18 O2 sat:
94% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: coarse lung sounds, with rhonchi RL lung fields,
breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, 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: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
======================
24 HR Data (last updated ___ @ 525)
Temp: 98.0 (Tm 98.7), BP: 110/67 (103-115/64-76), HR: 64
(54-64), RR: 16 (___), O2 sat: 97% (97-98), O2 delivery: Ra
GENERAL: flushed, mildly diaphoretic, reclined in bed, in no
acute distress
HEENT: AT/NC, anicteric sclera, MMM
HEART: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: +BS, nondistended, nontender, no hepatosplenomegaly
EXTREMITIES: no edema, 2+ ___ pulses b/l
NEURO: answering questions appropriately, moving all 4
extremities with purpose
SKIN: warm and well perfused, no rashes
Pertinent Results:
PERTINENT ADMISSION LABS
======================
___ 07:50PM BLOOD WBC-1.7* RBC-4.66 Hgb-14.5 Hct-41.6
MCV-89 MCH-31.1 MCHC-34.9 RDW-13.5 RDWSD-44.8 Plt Ct-30*
___ 07:50PM BLOOD Neuts-52 Bands-6* ___ Monos-14*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-0.99*
AbsLymp-0.48* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 07:50PM BLOOD ALT-205* AST-201* LD(LDH)-386*
AlkPhos-115 TotBili-0.4
___ 07:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
PERTINENT INTERVAL LABS
=====================
___ 06:33AM BLOOD calTIBC-194* VitB12-562 Folate-17
Ferritn-1778* TRF-149*
PERTINENT DISCHARGE LABS
======================
___ 08:12AM BLOOD WBC-3.7* RBC-4.35* Hgb-13.4* Hct-39.1*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.5 RDWSD-47.9* Plt ___
___ 08:12AM BLOOD ALT-192* AST-151* LD(LDH)-295*
AlkPhos-101 TotBili-0.4
___ 08:12AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.2
IMAGING/STUDIES
==============
CXR ___
IMPRESSION:
Streaky right lower lobe opacity, which given the clinical
history, is
concerning for developing pneumonia.
Brief Hospital Course:
Mr ___ is a ___ gentleman with BPH (on Flomax),
and a history of babesiosis (in ___, ehrlichiosis, and malaria
(in the 1970s), who presented with acute fevers and chills,
found to have leukopenia, thrombocytopenia, and transaminitis in
the setting of recent tick-exposure, most concerning for
anaplasmosis.
ACUTE ISSUES
============
#Leukopenia and thrombocytopenia
#Transaminitis
#Presumed Anaplasmosis
Mr. ___ presented with several days of acute-onset
fevers and chills after a recent tick exposure, found to be
febrile with a leukopenia/neutropenia, thrombocytopenia, and
transaminitis. His initial work-up for tick-borne illnesses
(babesiosis, anaplasmosis, and Lyme disease) on ___ at his
PCP's office was negative, but it is common for anaplasmosis
antibodies to be negative early in the course of this infection.
Anaplasmosis antibodies as well as PCR labs were redrawn on
___, and these results are pending. Mr. ___ was
started empirically on doxycycline (100 mg BID for ___ay 1 = ___. By the day of discharge (___), Mr.
___ white blood cell count had improved to 3.7,
neutrophil count to 2.1, and platelet count to 156. We suspect
he has anaplasmosis based on his clinical improvement with
treatment.
#Positive hepatitis B core antibody:
Mr. ___ was found to have a positive hepatitis B core
antibody with negative hepatitis B surface antigen and surface
antibody. A repeat hepatitis B screening panel was still
positive. This most likely reflects a resolved infection, but
can also represent a low level chronic infection or a resolving
acute infection. Per his PCP's records, he was vaccinated
against hepatitis B in ___. We checked a hep B IgM level and
viral load, which are pending, to rule out a low level chronic
or acute resolving infection.
#Right lower lobe opacity:
#Neutropenic fever:
A streaky right lower lobe opacity was seen on CXR in the ED,
which can indicate a developing pneumonia. He did not have any
preceding respiratory symptoms (no cough, no sputum production,
no difficulty breathing). He was started empirically on
vancomycin and cefepime on ___ given his neutropenia;
vancomycin was stopped on ___, and cefepime on ___. His last
fever was to 101.0 at ___ on ___. His neutropenia had resolved
by ___.
CHRONIC ISSUES
==============
#Benign prostatic hypertrophy: Continued on his home Floxmax.
TRANSITIONAL ISSUES
===================
- Doxycycline to complete a 10d course (___)
- Pending lab results for PCP: anaplasmosis antibodies and PCR,
Lyme antibodies, CMV, EBV, blood cultures, hepatitis B IgM
antibody and viral load
- At follow up with primary care doctor in 1 week, would
recommend repeat CBC w/ diff and LFTs to confirm they are
normalizing.
- Pending results hepatitis B tests, should determine whether
further work-up, treatment, or re-vaccination is indicated.
#CODE: Full (presumed)
#CONTACT: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO BID
2. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
Take twice a day for a 10-day course (day 1 = ___, last day =
___.
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Twice a day
Disp #*15 Tablet Refills:*0
2. Loratadine 10 mg PO DAILY:PRN allergies
3. Tamsulosin 0.4 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Anaplasmosis (suspected)
Neutropenic fever
SECONDARY DIAGNOSIS
==================
Positive hepatitis B core antibody
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
WHY WERE YOU HERE?
You were admitted to the hospital because you had fevers and
chills, and your white blood cell and platelet counts were low.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- While you were in the hospital you were started on antibiotics
(doxycycline, vancomycin, and cefepime) because of concern you
have an infection, anaplasmosis, as well as a possible
pneumonia, and were found to have a very low white cell count
which makes you vulnerable to more dangerous infections.
- Your cell counts normalized with treatment of your infection,
and the vancomycin and cefepime were stopped as they are not
needed to treat anaplasmosis. We think it is unlikely you have a
true pneumonia.
- You underwent several blood tests during your stay to diagnose
your infection, the results of which are pending and will be
communicated to your PCP once they result.
WHAT SHOULD YOU DO WHEN YOU GET HOME?
1) Please follow up with your primary care doctor ___ below).
2) Please take your medications as prescribed. The new
medication we began is doxycycline 100 mg twice per day, which
you should take for 10 days. (Day 1 was ___, so your last
day will be ___ Note that doxycycline causes sensitivity
to the sun, so please take care to wear clothing that covers
your skin and sunscreen.
WHAT ARE REASONS TO RETURN TO THE HOSPITAL?
- Fevers or chills
- Abdominal pain
- Any other symptoms that concern you
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19631047-DS-12
| 19,631,047 | 24,054,330 |
DS
| 12 |
2131-12-11 00:00:00
|
2132-01-02 00:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female with a PMHx ___
s/p prior resections, known cervical and thoracic lesions who
now presents with worsening pain, difficulty ambulating.
Regarding her ___ she has undergone schwannoma
resections of right sciatic nerve ___ and left retroperitoneal
in ___. Most recent MRI in ___ showed numerous cervical
and thoracic spinal lesions. She has been following with Drs.
___ and ___. She now presents with
uncontrolled, worsening pain despite increasing doses of her
gabapentin. She has visited multiple urgent care clinics where
plains films and renal ultrasounds were read as normal before
presenting to ___ ED where recommendation was made for
outpatient MRI, which she brought today showing evidence of
L1-L2 intramedullary lesion consistent with schwannomma.
Pain began in ___ in her coccyx and upper left lower
extremity. The pain has worsened progressively without
particular trauma or stress beyonf lifting grandkids and working
in laundromat. Pain is now bilateral but LLE > RLE. The pain is
dull-ache in quality baseline ___ and at worst ___. The pain
is sometimes stabbing, shooting down leg to knee. She has
associated paresthesias down anterior ___ below L knee as well as
her R ankle. Worse with sitting/lying down. Relief with
standing. She now regularly uses a cane and had to stop working
for last week, and stands for 15 hours per day to avoid sitting.
Gabapentin and advil have provided minimal relief. No recent
trauma, falls.
She denies loss of motor function or balance but she is afraid
her legs will give out and uses a cane. No loss of sensation. No
back pain above coccyx, no saddle anesthesia, urinary hesitancy
but otherwise no change in bowel or urinary frequency nor
continence.
In the ED, initial vitals were: T: 99.7 HR:88 BP:126/82 RR:
20 SO2: 100% RA. Exam notable for no focal neurological
deficits.
Labs notable for no leukocytosis, chem 7 wnl. No repeat imaging
performed. Patient received oxycodone 5mg PO, IV morphine
sulfate 4mg x2, IV Ketorolac 30 mg.
Patient was seen by neurosurgery in the ED, and they recommended
outpatient neurosurgery ___ as well as possible admission
for pain management with repeat imaging with neurosurgery
consult service following. Patient was also seen by neurology,
they recommended medicine admission for pain control. Decision
was made to admit for pain control.
Vitals notable for T: 97.6 PO BP: 117 / 88 HR: 70 RR: 20
SO2: 100 ra. On the floor, added lidocaine patch, continued PRN
pain regimen.
Past Medical History:
___ (Extramedullary enhancing lesions at the C7-T1,
T9-T10, T10 and L1 levels, compatible with nerve sheath tumors/
A partially visualized left axillary T2 hyperintense mass is
also noted, presumably representing a nerve sheath tumor.)
RT Static nerve schwanomma s/p resection in ___ by Dr. ___
___ buttock lipoma s/p excision.
LT retroperitoneal schwannomma s/p resection in ___
LT knee arthroscopy
DJD
Last mammography more than ___ years ago, no h/o colonoscopy
Social History:
___
Family History:
Mother and brothers: ___
Father potentially: stomach cancer and lip cancer
Daughter: Severe ___ s/p multiple
surgicalinterventions to remove spinal massess.
Son: ?___ aunt: colon cancer
___ grandfather: lung cancer
___ grandmother: died of breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.6 PO BP:117 / 88 (L Standing) HR: 70 RR: 20 SO2: 100 ra
wt 58.3 kg
Gen: AAOx3, NAD, appears stated age
HEENT: NC/AT, no thyromegaly, no cervical adenopathy
CV: RRR, +s1s2 no m/r/g
Pulm: CTAB, resonant to percussion
Abd: normoactive BS, no tenderness to palpation, no
organomegaly, no CVA tenderness
Ext: no point tenderness in either lower extremity
Skin: no rashes
Neuro: AAOx3, concentration recall intact, follows three step
commands crossing midline, no pronator drift
CN2:12 intact
Motor: ___ UE and ___ bilaterally
Sensory: mild decreased fine touch, pain and temperature in LLE
Reflexes: brachioradialis, bicep, patellar 3+
Cerebellar: no dysdiadochokinesia, no tremor
No dysmetria on FNF or HKS bilaterally.
Gait: deferred
Provocative tests: SLR negative
Psych: full affect, denies depressed mood, anhedonia, no formal
thought disorder
DISCHARGE PHYSICAL EXAM
==================================
VS: 97.9 PO 99 / 68 70 18 97 RA
Gen: AAOx3, NAD
HEENT: NC/AT, PERRL, EOM intact
CV: RRR, +s1s2 no m/r/g
Pulm: CTAB, resonant to percussion
Abd: normoactive BS, no tenderness to palpation, no
organomegaly, no CVA tenderness
Ext: no point tenderness in either lower extremity
Skin: no rashes
Neuro: AAOx3, concentration intact, language fluent,
comprehension intact (follows three step commands crossing
midline), no pronator drift
CN2:12 intact
Motor: ___ upper extremity and lower extremity bilaterally
Sensory: mild decreased fine touch, pain and temperature in LLE
Reflexes: brachioradialis, bicep, patellar 3+
Cerebellar: no dysdiadochokinesia, no tremor
Pertinent Results:
ADMISISON LABS
=============================
___ 10:27AM BLOOD WBC-8.4 RBC-4.65 Hgb-13.3 Hct-40.7 MCV-88
MCH-28.6 MCHC-32.7 RDW-12.7 RDWSD-40.3 Plt ___
___ 10:27AM BLOOD Neuts-75.3* Lymphs-17.4* Monos-6.1
Eos-0.4* Baso-0.4 Im ___ AbsNeut-6.34* AbsLymp-1.46
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03
___ 10:27AM BLOOD Glucose-90 UreaN-18 Creat-0.7 Na-139
K-4.9 Cl-102 HCO3-22 AnGap-20
___ 02:47PM BLOOD K-3.6
IMAGING RESULTS
=============================
MRI cervical thoracic lumbar spine: 1. Multiple enhancing
lesions throughout the cervical, thoracic, and lumbar spine, are
unchanged compared to the prior exams from ___ and ___, likely secondary to nerve sheath tumors, with the
largest in the region of the L2 vertebral body measuring up to
2.3 cm.
2. Incidental 3.4 cm large T2 hyperintense mass within the left
axillary region, is incompletely evaluated on this exam. An MRI
of the left axilla is recommended for further evaluation.
DISCHARGE LABS
=============================
___ 06:10AM BLOOD WBC-3.8*# RBC-4.23 Hgb-12.0 Hct-37.2
MCV-88 MCH-28.4 MCHC-32.3 RDW-12.3 RDWSD-39.3 Plt ___
___ 06:10AM BLOOD Glucose-91 UreaN-21* Creat-0.6 Na-139
K-4.1 Cl-102 ___ AnGap-15
Brief Hospital Course:
This is a ___ year old female with past medical history of
___ requiring prior surgical resections secondary to
pain, referred for admission with worsening back and leg pain,
MRI without causative etiology, with notable incidental finding,
able to be discharged home.
# Lower back and leg pain / ___ - Patient admitted
with new lower back and left leg pain, worse with ambulation and
ADLs. She was comfortable at rest. On exam, symptoms did not
conform to single dermatome. She was seen by the neurosurgery
service due to her history of ___, and underwent an
MRI that did not show any new masses or lesions compared to
recent prior--their service did not recommend any acute surgical
interventions. She was seen by the chronic pain service, who
recommended initial of amitryptiline. If pain persisted as
outpatient, they recommended consideration of MRI left lower
extremity to rule out peripiheral scitatic impingement. Ms.
___ plans to ___ with Dr. ___ neurosurgery as an
outpatient, and is consider pain clinic ___ as well.
# Incidental mass in the left axilla - MRI of the torso
incidentally detected a 3x2cm mass in the left axilla.
Radiology recommended an MRI of the left axilla for further
evaluation.
TRANSITIONAL ISSUES:
[] the patient was started on amitriptyline 25mg QHS. Can
consider increasing by 25mg every 3 days up to 150mg with total
trial of 6 to 8 wks.
[] neurosurgery ___ with Dr. ___ as an outpatient
[] pain recommended standing tramadol for pain control however
due to significant interaction between it and the amitriptyline,
we felt that it wasn't safe for her to be discharged on that
regimen. Therefore we discharged her on a limited supply of
oxycodone for severe pain with recommendation to follow up with
the pain clinic as an outpatient.
[] MRI of the torso done during her admission detected a 3x2cm
mass in the left axilla. An MRI of the left axilla is
recommended for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO QID
2. Ibuprofen 400-600 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
2. Amitriptyline 50 mg PO QHS Duration: 3 Days
please take this medication from ___ till ___. on the
___ the dose will be higher.
RX *amitriptyline 50 mg 1 tablet(s) by mouth at bedtime Disp #*3
Tablet Refills:*0
3. Amitriptyline 75 mg PO QHS Duration: 3 Days
please take this medication from ___ till ___. On ___ your dose will be higher
RX *amitriptyline 75 mg 1 tablet(s) by mouth qsh Disp #*3 Tablet
Refills:*0
4. Amitriptyline 100 mg PO QHS Duration: 3 Doses
please take this dose from ___ till ___.
RX *amitriptyline 100 mg 1 tablet(s) by mouth at bedtime Disp
#*3 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth three times a
day Disp #*12 Tablet Refills:*0
6. Gabapentin 600 mg PO Q6H
RX *gabapentin 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*56 Tablet Refills:*0
7. Ibuprofen 400-600 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Left Leg Pain
___
Left axillary Mass
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 ___,
You were admitted to the hospital because you had worsening leg
pain. We gave you medications to help your pain and consulted
our chronic pain team. We also repeated a MRI which did not show
a change in the schwannomas in your spine. We also found an
incidental mass in the left axilla which is new and requires
further imaging as an outpatient with your primary care provider
or neurosurgeon. The pain service evaluate your pain and
recommended outpatient follow up. The cause of the pain is
unclear and might be related to one of the nerves in your lower
back/pelvis being irritated. You will require further imaging
with an MRI to fully exclude this possibility. You were started
on a medication called amitriptyline which should help with the
pain. the dose of the medication will be increased gradually
every 3 days. the following is the timetable for recommended
increase.
You will be taking a 50mg amitriptyline tablet from ___
till ___. THEN You will be taking a 75mg amitriptyline
tablet from ___ till ___. THEN You will be taking a
100mg amitriptyline tablet from ___ till ___. By the
___ you should have seen your primary care provider who will
continue to go up on the medication every 3 days until you reach
a maximum dose.
IMPORTANT: do not take more than one tablet of amitriptyline on
a given day. If you do please report to an MD as soon as
possible.
You should ___ with Dr. ___ in ___
clinic within two weeks, ___. also please call your
primary care provider and the pain clinic to arrange for follow
up. the contact information of Dr. ___ primary care
provider and the pain clinic are provided below.
It was a pleasure caring for you,
-Your ___ care team
Followup Instructions:
___
|
19631398-DS-15
| 19,631,398 | 25,399,840 |
DS
| 15 |
2141-02-02 00:00:00
|
2141-02-03 12:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac Arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization showing single vessel disease with 80%
culprit lesion in Left Anterior Descending Artery with placement
of Drug Eluting Stent.
History of Present Illness:
___ male with no sign pmh who presented to OSH after
sustaining cardiac arrest, specifically vfib arrest. Sister
reports that pt was at his ___ home with non specific complaints
of not feeling well during his lunch break from work. ___ was
returning to work when ___ decided to come back to the home and
___ complained of CP - took two baby ASA. ___ subsequently had a
witnessed arrest (eyes rolled backwards), bystander CPR was
started, EMS called, and the pt recieved 4 shocks, 6 rounds of
epi, and amio 300 - 15 min period for ACLS - ROSC acheived.
Taken to OSH where ___ was stable, EKG reportedly unremarkable,
HS stable. ___ transferred to ___. EMS reported
movements of upper extremitiy that were non purposeful at the
OSH, Versed/Fentanyl was used for sedation.On arrival to ___,
pt continued to show non-purposeful movements, agitated, and
thus restarted sedation. ___ began the coooling process. Head CT
w/o acute bleed. CXR unremarkable. VSS. Transferred up to CCU
where ___ is sedated and intubated.
Past Medical History:
None
Social History:
___
Family History:
Father: CAD, CABG, Pacemaker - occurred in his older years
No SCD in the family
Physical Exam:
Admission Exam:
===============
VS: 95.2 80 151/102 24 97% intubated
Gen: Intubated, sedated, comfortable
HEENT: pink conj, anicteric
NECK: Difficult to appreciate JVD
CV: S1S2 RRR no m/g/c/r
LUNGS: CTAB anteriorly
ABD: Soft, slightly distended, NT, no r/g, no organomegaly
EXT: No c/c/e, cool to touch in the s/o being cooled
PULSES: 2+ radial/dp
SKIN: No rashes
NEURO: Sedated in the s/o cooling
Discharge Exam:
===============
Pertinent Results:
LABS
___ 04:58AM BLOOD WBC-7.6 RBC-4.15* Hgb-13.3* Hct-39.3*
MCV-95 MCH-32.0 MCHC-33.8 RDW-13.5 RDWSD-46.9* Plt ___
___ 05:49PM BLOOD WBC-11.3* RBC-4.01* Hgb-13.1* Hct-39.6*
MCV-99* MCH-32.7* MCHC-33.1 RDW-13.4 RDWSD-48.7* Plt ___
___ 04:58AM BLOOD ___ PTT-27.6 ___
___ 04:58AM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-23 AnGap-17
___ 05:49PM BLOOD UreaN-13 Creat-0.9
___ 11:28PM BLOOD ALT-208* AST-227* LD(LDH)-499*
CK(CPK)-1541* AlkPhos-60 TotBili-0.3
___ 05:49PM BLOOD CK-MB-22* MB Indx-5.2
___ 05:49PM BLOOD cTropnT-0.79*
___ 11:28PM BLOOD CK-MB-91* MB Indx-5.9 cTropnT-1.39*
___ 06:07AM BLOOD CK-MB-102* MB Indx-5.2 cTropnT-0.87*
___ 12:56PM BLOOD cTropnT-0.46*
___ 10:00PM BLOOD cTropnT-0.32*
___ 06:07AM BLOOD Triglyc-35 HDL-76 CHOL/HD-1.9 LDLcalc-63
___ 06:29AM BLOOD %HbA1c-5.8 eAG-120
___ 04:30AM BLOOD HCV Ab-POSITIVE*
IMAGING
TTE
___ Normal biventricular cavity size and global/regional
systolic function. Diastolic parameters indeterminate to assess
diastolic function. LVEF>55%
PROCEDURES
Left heart catheterization with PCI and DES to LAD
Brief Hospital Course:
___ y/o male with no sign pmh who presented to OSH after
sustaining cardiac arrest, specifically vfib arrest.
#VFIB ARREST#
On arrival to ___, pt continued to show non-purposeful
movements, agitated, and thus restarted sedation. ___ began the
coooling process. Head CT w/o acute bleed. CXR unremarkable.
VSS. Transferred up to CCU where ___ is sedated and intubated.
Cooling protocol was initiated- 34 degrees for 24 hours with
continuous EEG, PCO2 35-45, sat 94 or greater, and HOB 30
degrees. ___ was briefly put on vancomycin and zosyn given
elevated lactate. ___ underwent left heart cardiac
catheterization the following day (___) where single vessel
disease of LAD was found (80% stenosis) with PCI and placement
of DES. ASA 81 mg and Ticagrelor 90mg BID were started for
minimum of ___ year. ___ was also started on Metoprolol tartrate
25mg Q6H and Atorvastatin 80mg. On discharge, ___ was
hemodynamically stable with appropriate follow-up as detailed
below.
#DYSPHAGIA#
Following rewarming, patient failed speech and swallow but was
clinically improved. It was suspected that dysphagia was
related to cardiac arrest and resolving encephalopathy. Patient
improved and tolerated crushed/whole meds. ___ was cleared to
resume regular PO intake following subsequent speech and swallow
evaluation prior to discharge.
#HYPERTENSION#
The patient was on no medications prior to this hospital stay.
It is likely his elevated blood pressures has been untreated.
The patient was started on metoprolol tartrate 25 mg PO Q6h and
lisinopril 5 mg PO daily, both of which ___ was instructed to
continue on discharge.
#TOXIC METABOLIC ENCEPHALOPATHY#
Upon rewarming, patient demonstrated significant short term
memory loss- likely component of ICU delirium, metabolic
encephalopathy, and cardiac arrest. His mental status gradually
improved during his hospital course and ___ was appropriately
interactive and mentating well on discharge.
#HEMATURIA#
Patient developed hematuria on ___, likely secondary to trauma
from foley insertion and foley manipulation. Bladder scan was
negative, foley was discontinued, and ___ had no more episodes of
hematuria.
#HYPODENSE INTRACRANIAL LESION#
CT head on admission showed hypodensity read as infarct vs.
artifact. Per rad, this could have represented small pontine
infarct w/o associated bleed. Repeat CT head was ordered and
without concerning features.
#ACUTE LIVER INJURY#
Likely from cardiac arrest. LFTs were monitored and
downtrending. Hepatitis panel was ordered and patient was now
found to be HepB negative but HCV+. HCV viral load was ordered
and still pending at discharge. The patient was given
instructions to follow up with his primary care physician
regarding this issue. ___ will also need to follow up regarding
hepatitis B vaccination as ___ was HBsAg and HBsAb negative.
#TRANSITIONAL ISSUES#
-Medication changes: Patient was started on ASA 81 PO mg
indefinitiely, and Ticagrelor 90mg PO BID which will need to be
continued for a minimum ___ year. ___ was also started on
Metoprolol tartrate 25mg PO Q6H, Lisinopril 5mg PO daily for BP
control, and Atorvastatin 80mg PO daily. ___ will also need
cardiac rehab.
-Hypodense intracranial lesion: CT head on admission showed an
intracranial hypodensity read as infarct vs. artifact. Radiology
felt that this could be a small pontine infarct w/o associated
bleed. Repeat CT head was ordered and was limited but did not
identify any concerning features, suggesting this more likely to
be artifact.
-Acute Liver Injury. Patient found to have a transaminitis on
admission likely ___ poor perfusion. Hepatitis studies were
sent, showing that Mr. ___ was HCV ___ positive. Viral load
324,000 IU/mL. Needs follow up with hepatology. Needs hepatitis
B vaccine
- Patient is currently on metop 25mg Q6hr which can be converted
to 100mg daily if patient not having lightheadedness with
ambulation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO Q6H
6. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Coronary artery disease
-Subendocardial Myocardial Infarction
-Cardiac Arrest
-Toxic Metabolic Encephalopathy
-Hypertension
-Hepatitis C
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted due to a cardiac arrest. You were treated
with a cooling protocol and you underwent a cardiac
catheterization where you were found to have coronary artery
disease. This is likely the cause of your cardiac arrest.
During the catheterization, a stent was placed to open the
narrowed vessel in your heart. You will need to take aspirin
forever and Ticagrelor for at least one year and follow up with
a cardiologist. It is very important that you take these
medications every day as missing a dose puts you at risk for a
severe heart attack. You will also need to take metoprolol,
lisinopril, and atorvastatin. We also found that you have an
infection called hepatitis C. You will need to followup with a
liver specialist for this.
It was a pleasure to take care of you at ___,
Your ___ Team
Followup Instructions:
___
|
19631414-DS-4
| 19,631,414 | 20,088,323 |
DS
| 4 |
2180-03-28 00:00:00
|
2180-03-30 21:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bone pain, metastatic nonsmall cell lung cancer
Major Surgical or Invasive Procedure:
Fine needle aspiration
Radiation therapy
History of Present Illness:
___ with history of HTN, HLD, Depression admitted for pain
control with MRI/CT highly suggestive of metastatic disease,
etiology unknown. MRI of spine done at OSH on ___
revealed multiple lesions c/w mets. Patient also has severe
cutaneous and sub-cutaneous nodules suspicious for malignancy.
Lesions are located over RUQ of abdomen, lower left back, right
inner thigh - states she was told they are lipomas.
Non-painful, non-purulent. + history of subjective fevers and
weight loss. + headaches, + weakness in lower extremities - no
bowel or bladder incontinence or falls. No chest pain,
palpitations, SOB, cough, abdominal pain, N/V/D,
dysuria/hematuria. Regarding health screening, no colonoscopy,
last mammogram in ___.
.
In the ED, VS 98.5 123 167/91 20 98%, pain 6. Given morphine and
ativan. Chem 7, LFTs, CBC WNL except for WBC of 12.0 (N:81.2
L:11.3 M:5.0 E:1.5 Bas:0.9). Lactate 1.4. CT chest/abd/pelvis
performed just prior to arrival to the floor, negative for PE -
previous concerning bony/abdominal wall lesions noted.
.
On the floor, patient triggered for sustained HR in 130's,
asymptommatic, VSS. Pain ___ located in lower back.
Otherwise no complaints. On O2, no subjective SOB.
Past Medical History:
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia
New diagnosis of nonsmall cell lung cancer with mets to the skin
and bone (this admission)
Social History:
___
Family History:
dad with metastatic prostate cancer, grandmother with breast
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.5 BP: 154/82 P: 132 R: 20 O2: 94%3L
General: Alert, oriented, appears anxious, thin
HEENT: dry MM, no OP lesions
Neck: supple, JVP not elevated, no LAD
Lungs: poor inspiratory effort, decresed BS at left lower base,
minimal crakle at right posterior base. no rhonchi.
CV: tachycardic, regular rhythm. no m/g/r.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 1.5 cm elevated hard, indurated, non-supporative,
non-painful lesion on right upper quadrant of abdomen with
minimal surrounding erythema (appears chronic, not acute).
Hard, irregular subcutaneous nodule in lower left back and right
medial thigh. no other rash.
Neuro: anxious, CN II-XII grossly intact. strength ___ in all
4 extremities. no sensation deficits appreciated. no nystagmus.
Discharge Exam:
Vitals: Tm/c: 98.5 BP: 110/60, 69 22 96% 1L
General: Alert, oriented, more cooperative this morning, thin
HEENT: MMM, no OP lesions
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB. Breathing comfortably.
CV: RRR no m/g/r. Chest wall and sternum TTP
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Skin: 1.5 cm elevated pupuric, hard, indurated,
non-supporative, non-painful lesion on right upper quadrant of
abdomen with minimal surrounding erythema, biopsy clean and not
bleeding. Hard, irregular subcutaneous nodule in lower left
back, LUQ, and right medial thigh. no rash.
Neuro: anxious, CN II-XII grossly intact. strength ___ in all
4 extremities. no sensation deficits appreciated.
Pertinent Results:
ADMISSION LABS:
___ 03:10PM WBC-12.0* RBC-4.79 HGB-14.8 HCT-43.8 MCV-92
MCH-30.8 MCHC-33.6 RDW-13.7
___ 03:10PM NEUTS-81.2* LYMPHS-11.3* MONOS-5.0 EOS-1.5
BASOS-0.9
___ 03:10PM PLT COUNT-353#
___ 03:10PM GLUCOSE-88 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-17
___ 03:10PM ALT(SGPT)-10 AST(SGOT)-25 ALK PHOS-100 TOT
BILI-0.3
___ 03:10PM LIPASE-17
___ 03:10PM ALBUMIN-4.1 CALCIUM-10.3 PHOSPHATE-3.2
MAGNESIUM-1.9
___ 03:10PM TSH-4.8*
___ 03:26PM LACTATE-1.4
___ 03:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 03:10PM URINE RBC-5* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-4
.
DISCHARGE LABS:
___ 07:00AM BLOOD Glucose-91 UreaN-14 Creat-0.5 Na-136
K-4.5 Cl-95* HCO3-33* AnGap-13
___ 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
.
Imaging:
___ CTA TORSO:
CHEST: There is no evidence of pulmonary embolus. There is no
aortic
dissection. In the superior portion of the left lower lobe,
there is a
heterogeneously enhancing spiculated mass measuring 4.2 x 5.3 cm
in AP and
transverse ___, respectively. The bulk of the mass is
nodular and
centered within the lung parenchyma; however, there is medial
linear extension which courses along the descending thoracic
aorta approximately 8.7 cm in craniocaudal dimension. There is
mild post-obstructive pneumonitis (5:51). The mass causes
narrowing of the coursing pulmonary arteries without evidence of
pulmonary embolus. There is mass effect on the lower lobe
bronchi with occlusion of the inferomedial bronchi (___).
6-mm right upper lobe pulmonary nodule is evident (2:27). There
is a 1-2 mm right lower lobe pulmonary nodule (5:41). Peripheral
ground-glass opacity in the right upper lobe, just superior to
the major fissure (2:32) is nonspecific. There is no pleural
effusion.
Extensive coronary artery and aortic atherosclerotic
calcifications are
evident. There appears to be mild irregularity/ulceration of the
left lateral margin of the aortic arch (5A:12). The ascending
aorta measures 3.1 cm. Left hilar and subcarinal adenopathy is
evident; measuring 1.5 cm in the left hilum and 1.1 cm in the
subcarinal region. There is no right hilar or axillary
adenopathy. The right atrium is enlarged.
Also at the right base, there is nodular opacity at the
periphery with
associated linear atelectasis (5a:72) which may represent
rounded atelectasis with attention on followup recommended.
ABDOMEN: Ill-defined 5-mm hypodensity in hepatic segment II
(5B:87) is too
small to accurately characterize. No additional liver lesions
are identified. The portal and hepatic veins are patent. The
spleen, pancreas and gallbladder are within normal limits.
Bilateral adrenal nodules which are heterogeneous in appearance
are evident. Nodule in the left adrenal gland measures 9 mm
(5B:85). The remainder of the left adrenal gland is thickened.
In the right adrenal gland, there is a hypodense 1.3-cm nodule
(5B:86).
There are bilateral hypodense renal lesions. The largest is in
the
mid-to-lower pole of the left kidney measuring slightly higher
than water
density in ___ units and 4.7 cm. This likely represents a
cyst with
possible hemorrhagic or proteinaceous debris. In the interpolar
region of the right kidney, there is an 8-mm hypodense lesion
which measures 97 in
___ units. Non-contrast imaging through the kidneys was
not performed to confirm enhancement. The kidneys demonstrate
symmetric uptake and excretion of contrast.
There is extensive atherosclerotic calcification within the
normal caliber
abdominal aorta. There is no obvious mesenteric or
retroperitoneal
adenopathy. Visualized bowel loops are grossly unremarkable.
Multiple enhancing subcutaneous nodules are evident; for
example, measuring
1.9 cm overlying the lateral right lower ribs, measuring 1.4 cm
in the left
flank and measuring 1.3 cm in the mid left anterior abdominal
wall. These are suspicious for subcutaneous metastases.
PELVIS: The bladder and rectum are grossly unremarkable. The
uterus is not
identified, possibly surgically absent. The ovaries are also not
identified. There is no pelvic adenopathy or free fluid.
OSSEOUS STRUCTURES: Multiple lytic osseous metastases are
identified in the
left tip of the scapula, T11 vertebral body, posterior ninth rib
on the right, left posterior iliac bone, right anterior iliac
bone, and sternum. In addition, there are multiple osseous
sclerotic lesions in the posterior left rib, left iliac bone
surrounding the lytic lesions, and left sacral ala.
IMPRESSION:
1. No pulmonary embolism.
2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x
7.7 cm,
concerning for a primary lung malignancy. The spiculated mass
runs along the descending thoracic aorta with its linear medial
component approximately 8.7 cm in craniocaudal dimension. There
are two small right pulmonary nodules, possibly representing
metastases measuring 6 and 2 mm.
3. Osseous metastatic disease with mixed lytic and sclerotic
lesions.
4. Enhancing subcutaneous nodules concerning for metastases.
5. Bilateral adrenal nodules, likely metastases.
6. 8mm inter-polar right renal lesion is incompletely evaluated
on this
examination. This does not measure fluid density. When
clinically
appropriate, further characterization with ultrasound may be
beneficial.
Additional simple left renal cyst and too small to characterize
lesions.
7. Significant aortic atherosclerotic disease and extensive
coronary artery
calcifications.
.
___ MRI head: There is a 20 x 11 mm measuring oval right
temporal-occipital calvarium lesion, which likely represents a
bone metastasis and is pushing on the dura without evidence of
adjacent FLAIR signal abnormality or involvement of the
intra-axial space. Additional osseous metastases are not
identified in the imaged volume.
A briskly enhancing 12 (AP) x 9 (TRV) x 15 (SI) left
parasagittal frontal
lesion appears to be extra-axial and is exerting mass effect on
the adjacent sulcus. There is no associated parenchymal FLAIR
signal abnormality and the lesion most likely corresponds to a
parafalcine meningioma. There is no evidence of intra-axial
metastatic lesions. Extensive periventricular, subcortical and
deep white matter FLAIR/T2 signal abnormalities are in keeping
with sequela of small vessel ischemic disease. Flow voids of the
major intracranial vessels are preserved. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Right occipital calvarium lesion, likely representing bony
metastasis.
2. Left frontal parasagittal mass, most likely representing a
meningioma.
3. There is no evidence of intraparenchymal metastatic disease
and no acute findings, such as hemorrhage or infarct.
.
___ L tib/fib XRAY
TWO VIEWS OF THE TIBIA AND FIBULA: No definitive lytic or
sclerotic lesions
are seen, however there is an area of trabecular rarefaction
within the distal fibula. While this may be projectional, please
correlate clinically and consider dedicated ankle radiographs.
.
___ CYTOLOGY
FNA, Right abdominal lesion:
POSITIVE FOR MALIGNANT CELLS,
consistent with a poorly differentiated non-small cell
carcinoma; see note.
.
___ PATHOLOGY
Cell block, right abdominal lesion, FNA:
Positive for malignant cells, consistent with a
poorly-differentiated non-small cell carcinoma; Note: By
immunohistochemistry, the tumor cells are positive for
cytokeratin cocktail (keratin AE1/AE3, Cam 5.2), CK7, and TTF-1
and are negative for CK20, CDX-2, S-100, and desmin. Smooth
muscle actin highlights background stromal cells. The histologic
and immunohistochemical findings are compatible with a tumor of
lung origin. Correlation with clinical and radiographic findings
is recommended.
Brief Hospital Course:
___ with history of anxiety and hypertension admitted with
worsening back pain in setting of concerning lesions on MRI/CT
for metastases. Hospital course was notable for diagnosis of
metastatic nonsmall cell carcinoma of the lung and radiation
therapy to metastatic bone lesions.
.
#Metastasic nonsmall cell lung cancer: Presented with widely
metastatic cancer with lesions in the lung, adrenals, skin as
well as diffuse bony disease. FNA of the RUQ subcutaneous nodule
demonstrated poorly differentiated non-small cell lung cancer.
Hematology oncology was consulted who recommended outpatient
oncology follow up which has been scheduled for ___. During this admission, she underwent mapping and
palliative XRT to the rib/sternum and L fibula/ilium. MRI of the
brain showed mets to the skulls, a meningioma, without
intraparenchymal disease.
.
# Bone Pain: From metastatic disease. She was started on
standing oxycontin and acetaminophen as well as prn oxycodone
and ibuprofen for pain control. She was additionally given a
lidocaine patch for her sternal pain. Her pain medications were
titrated until she was no longer requesting all of her prns and
was sleeping comfortably through the night. She appeared
comfortable on daily examinations and would only say her pain
was not well controlled if directly asked. She was discharged on
oral and topical pain control and advised to contact her PCP
___ Oncologist should she require adjustments to her home
pain medication regimen.
.
# Hypoxia: On admission, she was noted to be hypoxic, likely
related to her baseline decreased lung function (chronic
smoker), NSCLC with possible associated atelectesis, and
possibly decreased inspiratory volumes ___ sternum and rib pain
(bony metastasis). Physical therapy worked with the patient and
noted she was 84% on room air when sitting. She was discharged
on home oxygen ___ at rest.
.
# Tachycardia - She had sinus tachycardia on admission. CTA did
not show PE. Her tachycardia was believed to be from pain and
anxiety, possible hypermetabolic state ___ cancer. She was
started on pain control as above and her lisinopril was switched
to propanolol TID both for pain control and possibly better
control of her anxiety symptoms.
.
# Social Issues/Depression: The patient and brother are having a
very difficult time dealing with her new diagnosis and reduced
functional status. The patient has been nervous about being
discharged home, but physical therapy felt that she did not
require rehab and she has been arranged to have services at home
(she will be staying with a family friend). ___, her
brother has been staying at a local hotel and they have been
resistant to her going there. She lives in ___ but
was not interested in having her care in ME. Lastly, Ms.
___ was given the number for psychiatry as she is having a
difficult time coping with her diagnosis and speaking to someone
or starting on antidepressants may help her.
.
CHRONIC ISSUES:
.
# Hypothyroidism - Stable continued synthroid.
.
# Anxiety - Continued ativan prn, restarted celexa. Propranolol
started as above.
.
# Hypertension - Lisinopril switched to propanolol.
.
Transitional Issues:
- Has follow up with heme-onc on ___ as well as with her
PCP on the same day.
Medications on Admission:
Fluticasone daily
Anaprox DS 550 mg q12 h prn back pain
synthroid ___ mcg daily
Lisinopril 10 mg daily
Ativan 1 mg TID
Vicodin 7.5/325 q4h prn pain
zofran prn
Discharge Medications:
1. fluticasone Nasal
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain: Please do not take if you are feeling tired
or confused. Do not operate heavy machinery or drive while on
this medication.
Disp:*90 Tablet(s)* Refills:*0*
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*160 Tablet(s)* Refills:*0*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. propranolol 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
12. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: Do not operate
heavy machinery or drive while on this medication.
Disp:*20 Tablet Extended Release 12 hr(s)* Refills:*0*
13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
Disp:*30 packets* Refills:*0*
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
patch to area of most significant pain (i.e. sternum). Leave
leave patch on for 12 hours only. Remove patch, and reapply 12
hours later.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for constipation.
Disp:*1 bottle* Refills:*0*
16. Supplemental Oxygen
___ continuous pulse dose for portability
Dx: metastatic nonsmall cell lung cancer
RA sat 84%
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Metastatic lung cancer
Secondary Diagonsis:
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ you for coming to the ___.
You were in the hospital because of your pain and skin lesions
that were concerning for cancer. We performed a biopsy which
showed that you have metastatic lung cancer. You started
radiation therapy to help with your pain. You will need to
follow up with a lung cancer specialist to discuss further
treatment options. We started you on oxycontin (long acting
oxycodone), oxycodone, tylenol, and a lidocaine patch for pain.
You should continue to take ativan and citalopram for anxiety.
You were also noticed to need supplemental oxygen when walking
around, which is being provided to you. You have been feeling
weak throughout the admission, however physical therapy has
evaluated you several times and feel that you are safe for
discharge. It is important that you continue to drink water and
eat food to keep your nutrition status up.
.
Medication Recommendations:
Please START:
-Supplemental oxygen at ___
-Oxycontin 30 mg twice daily
-Oxycodone ___ tabs) every 4 hours as needed for pain.
If you are feeling drowsy or confused, it is possible you are
taking too much of this medication. Please avoid this medication
until you are feeling back to normal.
-Zofran (ondansetron) ___ mg three times per day as needed for
nausea
-Ibuprofen 600 mg every 8 hours as needed for pain
-Acetaminophen 1000 mg every 6 hours for pain
-Senna 8.6 mg twice daily as needed for constipation
-Docusate 100 mg twice daily for constipation
-Milk of magnesia as needed for constipation
-Miralax 1 packet daily as needed for constipation
-Citalopram 20 mg daily
-Propanolol 20 mg every 8 hours
It is important you continue to have regular bowel movements as
the prescribed pain medications frequently cause constipation in
patients. Please take colace daily and senna, miralax and milk
of magnesia as needed so that you are having a bowel movement a
day.
.
Please STOP lisinopril.
Followup Instructions:
___
|
19631414-DS-5
| 19,631,414 | 26,220,780 |
DS
| 5 |
2180-03-31 00:00:00
|
2180-04-02 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a history of metastatic lung
cancer (bone) with chronic rib pain who presents with
uncontrolled pain and concern for low oxygen saturations. She
had radiation therapy 4 days ago and starting experiencing
increasing pleuritic pain about three days ago. Today had
episode of light-headedness and nausea while standing. She
denies any chest pain at rest, syncope, fever, chills, vomiting,
dyspnea, wheezing, stridor. She was noted by ___ to have labored
breathing and subsequently called EMS.
In the ED her initial VS were 97.8 36 133/68 19 91% on 3L. She
was triggered in triage for bradycardia to 36 (en route to the
ED) and upon arrival was found to be in intermittent bigeminy. A
CXR showed a visible mass with no changes c/w infectious
process. Her O2 sats went down to 90% on 4L for a while but
after changing the pulsox they were 98-99% on 3L.
Per discussion with the inpatient team that discharged her
yesterday she had reluctantly left after the inpatient team felt
that she no longer required an inpatient level of care. During
her hospital course she had been tachycardic and so was
apparently started on propranalol. A PE workup was negative. She
was told to stop taking the propranalol on discharge however she
continued to take it. She was discharged to a hotel because she
and her brother (with whom she is currently staying) do not yet
have a permanent residence in ___ (they have a home in ___
and another one in ___.
Past Medical History:
Metastatic lung cancer w/ bony mets
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia
Social History:
___
Family History:
dad with metastatic prostate cancer, grandmother with breast
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.3po 80 128/78 20 99% 3L nc
GENERAL - Alert, interactive, somewhat ill-appearing, in obvious
discomfort
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - scattered crackles at RLL, slightly diminished breath
sounds bilaterally
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - notable for subcutaneous nodules and 1 quarter sized
purpuric lesion on RUQ
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
DISCHARGE PHYSICAL EXAM
O2 95% on 1L, breathing comfortably, afebrile, HR 85, BP 121/68
General: Alert, oriented, more cooperative this morning, thin
HEENT: MMM, no OP lesions
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB. Breathing comfortably.
CV: RRR no m/g/r. Chest wall and sternum TTP
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Skin: 1.5 cm elevated pupuric, hard, indurated,
non-supporative, non-painful lesion on right upper quadrant of
abdomen with minimal surrounding erythema, biopsy clean and not
bleeding. Hard, irregular subcutaneous nodule in lower left
back, LUQ, and right medial thigh. no rash.
Neuro: anxious, CN II-XII grossly intact. strength ___ in all
4 extremities. no sensation deficits appreciated.
Pertinent Results:
ADMIS___ LABS
___ 05:05PM BLOOD WBC-14.6*# RBC-4.75 Hgb-14.9 Hct-44.0
MCV-93 MCH-31.3 MCHC-33.8 RDW-13.3 Plt ___
___ 05:05PM BLOOD Neuts-86.6* Lymphs-6.1* Monos-4.1 Eos-2.1
Baso-1.2
___ 05:54PM BLOOD ___ PTT-29.7 ___
___ 07:00AM BLOOD Glucose-91 UreaN-14 Creat-0.5 Na-136
K-4.5 Cl-95* HCO3-33* AnGap-13
___ 07:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
Discharge labs:
___ 06:30AM BLOOD WBC-13.6* RBC-4.38 Hgb-14.0 Hct-40.5
MCV-92 MCH-31.9 MCHC-34.5 RDW-13.3 Plt ___
___ 06:30AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-135
K-4.4 Cl-95* HCO3-31 AnGap-13
___ 06:30AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
Urine studies:
___ 07:50PM URINE Color-Straw Appear-Clear Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 07:50PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
___ 05:34PM URINE Hours-RANDOM UreaN-813 Na-25 K-72 Cl-59
Phos-116.7
___ 05:34PM URINE Osmolal-634
Micro:
___ urine culture negative
___ blood cultures pending
Imaging:
___ CXR: Frontal and lateral radiographs of the chest were
acquired. There is minimal atelectasis or scarring in the
lingula as well as evidence of emphysema. A large rounded left
infrahilar opacity corresponds to a left lower lobe mass, better
assessed on recent CT from ___. The lungs are
otherwise clear. There are no pleural effusions. No pneumothorax
is seen. The heart size is normal. The mediastinal contours are
normal.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Left lower lobe lung mass, better evaluated on recent CT from
___ ECG: rate 83, Normal sinus rhythm with ventricular premature
complexes in a bigeminal
pattern. Marked left axis deviation which probably reflects a
combination of left anterior hemiblock and inferior wall
myocardial infarction of indeterminate age. Delayed R wave
progression in the precordial leads which may be due to lead
position or prior anteroseptal myocardial infarction. Compared
to the previous tracing supraventricular tachycardia has
resolved, but
ventricular ectopy is new.
___ ECG: rate 77, Ectopic atrial rhythm. Leftward axis.
Possible old anteroseptal myocardial
infarction. Possible old inferior myocardial infarction.
Compared to the previous tracing of ___ ventricular ectopy
has resolved. P waves are now inverted in the inferior leads.
___ ECG: rate 90, Sinus rhythm with frequent ventricular
premature beats, usually in a bigeminal
pattern. Leftward axis. Probable old anteroseptal myocardial
infarction. Possible old inferior myocardial infarction.
Compared to tracing #1 ventricular ectopy has returned. P waves
are again upright in the inferior leads.
Brief Hospital Course:
This is a ___ year old woman with new diagnosis of metastatic
lung cancer discharged yesterday who is presenting with ongoing
pain related to bony metastases and ___ concern for low O2 sats.
# Pain Control: There has been no acute change from her prior
hospitalization. The patient was maintained on a similar pain
regimen, however her oxycontin was titrated up to 40mg BID and
it was recommended she take NSAIDs for additional treatment of
her pain. It was unclear whether the lidocaine patch was
effective for her. She was instructed to use this is it was
affordable to her and if she felt it helped her pain. She was
continued on a bowel regimen, given her opiate use.
# Hypoxia: The patient has known hypoxia on room air at rest, in
the mid-low ___, for which she was discharged with home oxygen
___. She refused to wear this and was subsequently brought to
the hospital for hypoxia on room air. During her admission, she
noted she felt better wearing the nasal cannula and has agreed
to wear supplemental oxygen in the outpatient setting.
# Leukocytosis: WBC elevated to 13.6, without bands, on
admission. No fever, cough, diarrhea, abdominal pain or dysuria.
CXR without evidence of infection. UA not impressive (although
not entirely bland) and pt denies any specific UTI symptoms. Not
on steroids. Likely leukomoid reaction related to malignancy and
recent radiation therapy.
# Bradycardia/arrhythmias: She was briefly noted to be
bradycardic to 36 en route to the ED. According to the record in
the ED she went in and out of bigeminy and bradycardia with
PVCs. She was monitored on telemetry on the floor and the
patient was noted to have bouts of asymptomatic ventricular
tachycardia and supraventricular tachycardia in house, likely
due to pulmonary issues related to her cancer. Her propanolol
was stopped, however, as it was felt to contribute to
bradycardia and her BP was well controlled off that medication.
Her intermittent SVT (not Afib) is likely related to pulmonary
disease causing ectopic atrial pacemaker and perhaps MAT. She
also has occasional sinus tachycardia. Both these were noted to
worsen with emotional stress or discomfort.
# Hyponatremia: Presented with Na 131, which improved to 135
after fluid restriction. She appeared euvolemic and BUN/Cr ratio
also did not suggest prerenal etiology. Urine osm >600 and
urine Na+ 25, suggesting SIADH in the context of malignancy with
possible element of dehydration as she has not had significant
PO intake.
Transitional Issues at discharge include:
-She will need to follow up with hematology/oncology to decide
on treatment of her metastatic non small cell lung cancer.
-She will likely need further titration of her analgesic regimen
as pain is expected to improve after radiation has full effect
but may worsen with increased activity.
-Blood pressure should be followed off therapy to make sure she
does not become hypertensive
-She had a leukocytosis without band forms or localizing sources
of infection. Likely due to leukemoid reaction related to
cancer and radiation therapy. This should be followed as an
outpatient.
Additionally, the patient is having a difficult time coping with
her new diagnosis and would benefit from therapy and
psychosocial support. On the last admission, she was given the
phone number for the psychiatry department counseled that she
should seek out support if she felt this might benefit her.
Medications on Admission:
Fluticasone daily
Anaprox DS 550 mg q12 h prn back pain
synthroid ___ mcg daily
Lisinopril 10 mg daily
Ativan 1 mg TID
Vicodin 7.5/325 q4h prn pain
zofran prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
8. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for anxiety.
11. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: ___ tablets
Injection Q8H (every 8 hours) as needed for nausea.
12. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
13. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: To be taken with
your 30mg tablets BID, for a total of 40mg per dose.
Disp:*10 Tablet Extended Release 12 hr(s)* Refills:*0*
14. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: 12 hours on, 12 hours off.
Apply to sternum.
16. supplemental Oxygen
___ supplemental oxygen, where all the time.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hypoxia
Secondary Diagnosis: metastatic lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came back to the hospital for shortness of breath in the
context of not wearing your home oxygen. You were observed
overnight and your pain medications were changed to allow for
better pain control. You are safe to be discharged back to your
hotel.
Please make sure you are always wearing your oxygen.
Please also make sure to continue eating and drinking water to
keep your energy up.
Medication changes:
Ibuprofen 800mg by mouth every 8 hours
Oxycodone SR (OxyconTIN) 40 mg by mouth twice daily. You were
prescribed an additional 10mg oxycontin, which you should take
with your previously prescribed 30mg pills. You're prescription
is ready and waiting for you at the ___ on ___.
*Please purchase Zantac 150mg tablets over the counter at a
local pharmacy and take 1 tablet daily.
STOP:
propranolol
Followup Instructions:
___
|
19631540-DS-14
| 19,631,540 | 28,205,868 |
DS
| 14 |
2116-12-24 00:00:00
|
2116-12-24 09:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
cyclobenzaprine / cetirizine / hydrochlorothiazide / cephalexin
/ lisinopril / Influenza Virus Vaccines
Attending: ___
Chief Complaint:
Rapid, irregular heart beat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with history of HTN, HLD, DM1 and s/p CABGx3 on
___. Post-op course complicated by 6 hrs of afib 120's and
was started on amiodarone and Lopressor dose was adjusted. He
converted to SB 50's with stable hemodynamics. In light of
slower HR amiodarone was discontinued prior to discharge to
home.
Coumadin was also not indicated at the time due to the brevity
of the afib. Patient was discharged to home on ___. He
called today to report his heart was "trashing in his chest".
According to his home monitor, his HR was 123, BP 138/75 and he
otherwise felt well. He was instructed to come to ___ for
admission to cardiac surgery for management of presumed RAF.
Past Medical History:
CAD
Hypertension
Hyperlipidemia
Diabetes Mellitustype 1
Blepharitis
Chalazion
Cataract
Ptosis
Myopia with astigmatism and presbyopia
Right rotator cuff tear
Colon Adenomas
Sleep apnea
Lung nodule
Abnormal thyroid test
Right foot surgery ___
femur fx with hip pinning
Social History:
___
Family History:
mother deceased ___ breast cancer
father MI at ___ deceased from brain tumor at ___
Physical Exam:
98.6 HR 65BPM BP 124/84 RR 16 O2 sat: 95% RA
Height:75" Weight:94.4 kg
General: No acute distress, sitting comfortably on edge of bed
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: diminished in bases L>R
Heart: RRR [x] no murmur noted
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema ___ plus bilat
w/chronic PVD color changes
Neuro: A&O x3, MAE, non-focal exam
Radial Right: 2+ Left: 2+
___ 1+ 1+
Carotid Bruit: none appreciated
Pertinent Results:
___ 08:45AM BLOOD WBC-10.3* RBC-3.41* Hgb-9.8* Hct-31.1*
MCV-91 MCH-28.7 MCHC-31.5* RDW-12.1 RDWSD-39.8 Plt ___
___ 08:45AM BLOOD Glucose-152* UreaN-11 Creat-1.2 Na-133
K-5.2* Cl-96 HCO3-24 AnGap-18
___ CXR
1. Increase in small left pleural effusion with left basilar
opacity likely representing combination of compressive
atelectasis and pleural fluid
Superimposed infection cannot be excluded
2.Stable trace right pleural effusion
3.Stable mild cardiomegaly
4.No pulmonary edema
.
Brief Hospital Course:
___ year old male POD# ___ s/p CABG presented from home with
irregular heart rhythm, RAF by EKG in ED. Had converted to SR
rate 65 by time he arrived on floor. Lopressor was increased and
Pradaxa was started after discussion with Dr. ___. He remained
in sinus rhythm for the remainder of his hospital course and was
discharged home on HD2 with follow up appointments advised.
Medications on Admission:
Zinc Sulfate 50 mg PO DAILY
Vitamin D ___ UNIT PO DAILY
magnesium 30 mg oral BID
Loratadine 10 mg PO DAILY
Glargine 19 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
amLODIPine 10 mg PO DAILY
ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
Oxycodone ___ q4 hrs prn pain
Lopressor 50mg po tid
Colace 100 mg bid
senna 2 tabs bid prn
Lasix 40mg po daily x 5 days (1 day remaining)
Potassium 20meq po daily x 5 days ( 1 day remaining)
ASA 81mg po daily
Atorvastatin 80 daily
Plavix - last dose: none
Allergies:
flexeril - dizziness
cetirizine - cough
dairy - shortness of breath
hctz - hyponatremia
Keflex - diarrhea nausea and vomiting
lisinopril dizziness
strawberries - rash
flu shot
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*1
2. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
3. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
4. Glargine 19 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
5. Metoprolol Tartrate 75 mg PO TID
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
6. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
7. amLODIPine 10 mg PO DAILY
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN
dryness
9. Aspirin EC 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Docusate Sodium 100 mg PO BID
12. Loratadine 10 mg PO DAILY
13. magnesium 30 mg oral BID
14. Milk of Magnesia 30 mL PO DAILY
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
17. Senna 8.6 mg PO BID Duration: 1 Week
hold for loose stool
18. Vitamin D ___ UNIT PO DAILY
19. Zinc Sulfate 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Post op rapid atrial fibrillation
Hypertension
Hyperlipidemia
Diabetes Mellitus type 1
Blepharitis
Chalazion
Cataract
Ptosis
Myopia with astigmatism and presbyopia
Right rotator cuff tear
Colon Adenomas
Sleep apnea
Lung nodule
Abnormal thyroid test
Right foot surgery ___
femur fx with hip pinning
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
___ lower extremity Edema with chronic venous stasis changes
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19631540-DS-15
| 19,631,540 | 22,081,365 |
DS
| 15 |
2117-01-08 00:00:00
|
2117-01-08 21:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cyclobenzaprine / cetirizine / hydrochlorothiazide / cephalexin
/ lisinopril / Influenza Virus Vaccines
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with PMHx HTN, HLD, ___ s/p CABGx3 on ___ s/p
inferior STEMI with recent diagnosis postoperative atrial
fibrillation on pradaxa who presents with acute 5 pound weight
gain (206.5lbs ___ & 212lbs ___ in the setting of orthopnea
and dyspnea on exertion for last week.
Patient hospitalized from ___ - ___ for inferior
STEMI s/p CABG on ___. Originally transfer from OSH with
STEMI s/p ___ coronary angiogram that revealed significant CAD
with subtotal RCA and severe diagonal/LAD disease. Underwent
relook cath on ___ here for consideration of PCI to RCA
which revealed LAD 80% stenosis and RCA 80% stenosis. Patient
underwent CABG x 3 (left internal mammary artery > LAD,
saphenous vein graft > PDA, saphenous vein graft > diagonal).
Patient developed postoperative atrial fibrillation with RVR and
was started on amiodarone, with conversion and stable
hemodynamics, not discharged home on AC. Patient then
readmitted from ___ to ___ with afib with RVR, however
spontaneously converted. His beta blocker was increased and
Pradaxa was started. Patient has been taking furosemide 40mg PO
daily since discharge on ___ with his last dose written
for ___.
He & his wife report that he has been taking Lasix up until
___. Since ___ patient has been calling cardiac
surgery physician line daily reporting insomnia, dry mouth,
restless legs, and shortness of breath. Advised to come to ED
on ___ given recent weight gain and orthopnea. He denies
fever, chills, URI symptoms, cough, abdominal pain, chest pain,
pleuritic chest pain, calf pain, drainage from sternotomy wound.
Weight Trend:
___ lbs
___ lbs
___ lbs in ED
___ lbs on admission to floors s/p IV Lasix 40mg
In the ED initial vitals were: T98.0 HR60 BP127/73 RR18 98% RA
EKG: HR67 sinus rhythm inferior infarct; no acute ST/T changes
Labs/studies notable for: ___ 12553, Cr 1.0, BMP wnl, CBC
stable/increased Hbg/Hct, Trop .07 --> .06
CXR moderate left pleural effusion and small right pleural
effusion are increased
Patient was given:
___ 07:54 IV Furosemide 40 mg
___ 13:53 SC Insulin 8 UNIT
Vitals on transfer: T98.0 HR69 BP164/78 RR16 98% RA
On the floor patient endorses HPI as above. He states since
getting IV Lasix in the emergency room, he is able to now
recline at a 45 degree angle. He endorses 5 pillow orthopnea
since most recent discharge, unable to sleep secondary to
orthopnea and sensation of choking when attempting to lie down
to sleep. Unclear if PND as patient states he has not slept. He
does endorse "seconds" of chest tightness when he forcefully
blows into his incentive spirometer which he has been using
regularly at home. He denies current chest pain or dyspnea at
rest.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea (he states he has not gotten to
sleep), palpitations, syncope, or presyncope. On further review
of systems, denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. Denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- IDDM (TYPE I)
- Dyslipidemia
- HTN
2. CARDIAC HISTORY
- CABG: ___ CABG x3 (Left internal mammary
artery > left anterior descending, Saphenous vein graft >
posterior descending artery, Saphenous vein graft > diagonal)
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- CORONARY ANGIOGRAMS: ___ IABP placement; ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- CATARACTS
- MYOPIA WITH ASTIGMATISM & PRESBYOPIA
- RIGHT ROTATOR CUFF TEAR
- OSA NOT ON CPAP
- COLON ADENOMAS
- LUNG NODULE
- ABNORMAL THYROID TEST
- RIGHT FOOT SURGERY ___
- HX FEMUR FRACTURE S/P HIP PINNING
Social History:
___
Family History:
Father MI at age ___, deceased brain tumor age ___
Mother breast cancer deceased age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T98.0 BP 175/84 (manual recheck 140s/80s) HR 58 RR 18 97% RA
Pulsus check ___
Weight on admission: 96.1kg (212 lbs)
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate. Not in acute respiratory distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. MMM.
NECK: Supple with JVD just above the clavicle
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. irreguarlly irregular rhthym . No murmurs/rubs/gallops.
LUNGS: +sternotomy site and wires c/d/i, no erthyma; Resp were
unlabored, no accessory muscle use. Decreased BS bilaterally at
bases. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP. 2+ pitting edema bilaterally up to knees
SKIN: venous statis changes; scab R neck & healing graft harvest
site on R calf & scab over R groin cath site
PULSES: 2+ Femoral pulses; DP & ___ pulses difficlut to
appreciate given edema but warm feet
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T98.0 HR62-63 BP109-142/61-69 RR16 98RA
Weight: 88.9kg (196 lbs)
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate. Not in acute respiratory distress. Sitting up in
bed eating breakfast. HEENT: NCAT. Sclera anicteric. PERRL,
EOMI. Conjunctiva pink. MMM.
NECK: Supple with JVD just above the clavicle
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. No murmurs/rubs/gallops.
LUNGS: +sternotomy site and wires c/d/i, no erethyma; Resp were
unlabored, no accessory muscle use. CTAB. No crackles, wheezes
or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP. trace edema up to mid shin R leg, 1+ edema up
to mid shin L leg.
SKIN: venous stasis changes; scab R neck & healing graft harvest
site on R calf & scab over R groin cath site
PULSES: 2+ Femoral pulses; DP & ___ 2+
Pertinent Results:
ADMISSION LABS:
==============
___ 06:20AM BLOOD WBC-7.1 RBC-3.68* Hgb-10.5* Hct-33.7*
MCV-92 MCH-28.5 MCHC-31.2* RDW-13.2 RDWSD-42.7 Plt ___
___ 06:20AM BLOOD Neuts-67.6 Lymphs-17.1* Monos-12.6
Eos-1.3 Baso-0.8 Im ___ AbsNeut-4.78 AbsLymp-1.21
AbsMono-0.89* AbsEos-0.09 AbsBaso-0.06
___ 06:20AM BLOOD ___ PTT-44.9* ___
___ 06:20AM BLOOD Glucose-128* UreaN-16 Creat-1.1 Na-135
K-4.6 Cl-99 HCO3-22 AnGap-19
___ 09:30PM BLOOD CK(CPK)-34*
___ 06:20AM BLOOD CK-MB-2 ___
___ 06:20AM BLOOD cTropnT-0.06*
___ 06:45AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
INTERVAL LABS:
=============
___ 12:07PM BLOOD cTropnT-0.07*
___ 09:30PM BLOOD CK-MB-2 cTropnT-0.07*
___ 06:45AM BLOOD CK-MB-1 cTropnT-0.06*
___ 07:15AM BLOOD WBC-6.5 RBC-3.77* Hgb-10.7* Hct-33.6*
MCV-89 MCH-28.4 MCHC-31.8* RDW-13.3 RDWSD-43.0 Plt ___
___ 07:15AM BLOOD ___ PTT-40.1* ___
DISCHARGE LABS:
==============
___ 05:57AM BLOOD Glucose-150* UreaN-23* Creat-1.1 Na-138
K-3.8 Cl-98 HCO3-26 AnGap-18
___ 05:57AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.3
STUDIES/REPORTS:
===============
___ CXR
Moderate left pleural effusion and small right pleural effusion
are increased in size from chest radiograph ___.
Bibasilar atelectasis is noted. There is no pneumothorax or
evidence of pulmonary edema. Evaluation of the
cardiomediastinal silhouette is limited by left-sided pleural
effusion. Sternotomy wires and surgical clips overlying the
upper mediastinum are again noted.
___ TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. 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 borderline dilated. There is mild to
moderate regional left ventricular systolic dysfunction with
near akinesis of the basal ___ of the inferior wall and
hypokinesis of the inferior septum and inferolateral walls. The
remaining segments contract normally. Quantitative (biplane)
LVEF = 52 %. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is a prominent left pleural effusion.
IMPRESSION: Borderline leftventricular cavity dilation with
regional systolic dysfunction most c/w CAD (PDA distribution).
Right ventricular cavity dilation with low normal free wall
motion. Moderate mitral regurgitation. Borderline pulmonary
artery systolic hypertension. Compared with the prior study
(images reviewed) of ___, the left ventricular cavity is
now borderline dilated and the severity of mitral regurgitation
has increased. A prominent left pleural effusion is also now
seen and the right ventricular cavity is now dilated.
___ CXR
Mild left pleural effusion has decreased since prior exam.
Decreased left basilar opacity. Small right pleural effusion is
similar. Decreased right basilar opacity. Increased heart
size. Normal pulmonary vascularity. Sternotomy. Chronic
fracture left clavicle.
MICRO:
======
___ BCX - PENDING
Brief Hospital Course:
___ PMHx HTN, HLD, ___ s/p CABGx3 on ___ s/p inferior
STEMI with recent diagnosis postoperative afib on pradaxa
admitted with acute exacerbation of systolic and diastolic heart
failure. Patient with 5 pound weight gain (206.5lbs ___ to
212lbs ___ with one week of orthopnea and DOE. Etiology of
heart failure exacerbation hypertension, increase in severity of
MR (___), and discontinuation of short course of oral lasix
started after CABG. Patient denied anginal symptoms and troponin
still downtrending since STEMI (during prior admission)
reflecting continued clearance of troponin. During this
admission, no acute cardiac enzyme rise or fall. Did not suspect
early graft closure/failure. Patient was diuresed initially with
IV Lasix, with improvement in weight, and was discharged home on
Torsemide 40mg daily. Hospital course also complicated by afib
with RVR, on pradaxa. Metoprolol regimen was changed to
Metoprolol Succinate 100mg BID on discharge.
# CORONARIES: s/p CABG x 3
# PUMP: EF 52% TTE ___
# RHYTHM: paroxysmal afib
****TRANSITIONAL ISSUES****
Discharge Weight: 88.9kg
Discharge Cr: 1.1
- Patient with a self reported history of myalgias to
simvastatin, and reports restless legs/insomnia to atorvastatin.
He was started on 20mg rosuvastatin QPM during this
hospitalization. If tolerates, please increase dosage to 40mg
QPM.
- Patient with a diagnosis of OSA, has only completed first part
of sleep study. Please follow up on to ensure completion of
second part of sleep study.
- NEW MEDICATIONS: Torsemide 40mg QD, Rosuvastatin 20mg QPM,
Metoprolol Succinate XL 100mg BID, Losartan 100mg QD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
2. amLODIPine 10 mg PO DAILY
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dryness
4. Aspirin EC 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 75 mg PO TID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
8. Vitamin D ___ UNIT PO DAILY
9. Zinc Sulfate 50 mg PO DAILY
10. Dabigatran Etexilate 150 mg PO BID
11. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN
dryness
7. Aspirin EC 81 mg PO DAILY
8. Dabigatran Etexilate 150 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
12. Vitamin D ___ UNIT PO DAILY
13. Zinc Sulfate 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis:
Acute Exacerbation of Systolic and Diastolic Heart Failure
Afib with RVR
Secondary Diagnosis:
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the cardiology service because you had
trouble breathing and couldn't lay flat in bed when trying to
sleep. We gave you medication through your IV initially to help
you remove fluid from your lungs, which helped your breathing
and improved your lower leg swelling. This medication was
called Lasix. You were discharged home on torsemide (similar to
Lasix, a "water pill").
You had an ultrasound of your heart which shows that your heart
has some dysfunction in "pumping" since your heart attack.
YOUR HEART MEDICATIONS:
Aspirin 81mg daily
Dabigatran 150mg twice per day
Torsemide 40mg daily (fluid pill)
Rosuvastatin 20mg daily at night
Metoprolol Succinate XL 100mg twice per day
Losartan 100mg daily
You weighed 88.9kg (196 lbs) on discharge. Please weigh
yourself daily after urinating bathroom in the morning on a good
quality scale in lightweight clothing. Call your cardiologist
___, MD ___ if your weight increases by
more than 3 lbs in one day or more than 5 lbs in three days.
Please follow up with your cardiac surgeon Dr. ___ on ___ @
1pm, your cardiologist Dr. ___ ___ @ 2:20pm.
Please call your primary care doctor Dr. ___ ___
___ to schedule a follow up appointment in one week.
It was a pleasure taking care of you,
Your ___ Cardiac Care Team
Followup Instructions:
___
|
19631540-DS-16
| 19,631,540 | 25,568,984 |
DS
| 16 |
2117-04-19 00:00:00
|
2117-04-25 17:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cyclobenzaprine / cetirizine / hydrochlorothiazide / cephalexin
/ lisinopril / Influenza Virus Vaccines
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis ___
Placement of PICC line ___
History of Present Illness:
___ yo man with h/o type 1 diabetes mellitus, CAD with H/O MI now
s/p CABG in ___ (with post-operative transient atrial
fibrillation) and CHF presenting with right neck to shoulder
pain since the previous night. In the ED, he reported pain as
___ with deep inspiration and ___ with normal breaths. The
pain radiated to the shoulder with deep breaths. There was also
a little bit of pain under his right breast. He also reported a
bit of a dry cough as well. Of note, he was hyperglycemic this
morning and this did not respond to insulin as usual.
Of note patient had 3V CABG ___ complicated by transient
post-operative atrial fibrillation. He was admitted ___ for
atrial fibrillation with a rapid ventricular rate (RVR) and was
put on metoprolol and dabigatran. In ___, his dabigatran was
stopped given no overt further episodes of atrial fibrillation.
In ED initially he had no shortness of breath, no pressure on
chest, no palpitations. He reported no headache, visual changes,
neurological symptoms, abdominal pain, diarrhea. In the ED,
initial vitals were: T 100.0 pulse 77 BP 143/67 RR 18 SaO2 98%
on RA. Lung exam notable for mild crackles at bases. Labs
notable for WBC 12.1, NT-Pro-BNP 5079, two negative troponins.
CXR showed small bilateral pleural effusions with minimal right
basilar atelectasis; hyperinflated lungs compatible with COPD.
Patient was given aspirin, metoprolol succinate 100 mg,
rosuvastatin 5 mg, furosemide 40 mg IV and insulin 14 units.
Later in the ED, at ~ 130 am, patient then stood up and felt
palpitations. EKG showed atrial fibrillation with RVR to 112. He
was given diltiazem 10 mg IV and admitted to cardiology. He had
CTA to screen for pulmonary embolus which showed a pericardial
abscess tracking to the sternotomy. Cardiac surgery was
consulted who felt this was not an abscess or infection and
recommended admission to cardiology for treatment atrial
fibrillation. During wait for bed patient received an additional
2 doses of diltiazem 10 IV mg.
Upon arrival to the cardiology ward, patient appeared well. He
reported that his sole complaint was feeling a pain over his
right upper chest when he breathed in, feeling as though it
"moved" from his neck/right upper chest to his lower chest as he
walked. He also reported a fever coming into the ED which
resolved with acetaminophen.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD RISK FACTORS
- IDDM (TYPE I)
- Dyslipidemia
- Hypertension
2. CARDIAC HISTORY
- CABG: ___ CABG x3 (LIMA-LAD, SVG-PDA, SVG-diagonal)
- Percutaneous coronary interventions: None
- Coronary angiograms: ___ with IABP placement; ___
- Pacing/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Cataracts
- Myopia with astigmatism & presbyopia
- Right rotator cuff tear
- OSA, not on cpap
- Colon adenomas
- Lung nodule
- Abnormal thyroid test
- S/P right foot surgery ___
- S/P hip pinning for femur fracture
Social History:
___
Family History:
Father passed away from pneumonia after diagnosis of brain
cancer, mother passed away from lung cancer after smoking.
Physical Exam:
On admission
GENERAL - middle aged white man in NAD, well appearing
VITAL SIGNS T 98.3 BP 94/66 HR 101 RR 20 SaO2 96% on RA
HEENT - no frontal/maxillary sinus tenderness
NECK - JVP at clavicle at 45 degrees
CARDIAC - tachycardic, irregular, ___ systolic murmuer at RUSB
LUNGS - CTAB over anterior chest, very slight bibasilar crackles
ABDOMEN - non-tender, not distended
EXTREMITIES - No edema
NEUROLOGIC - ___ strength both UE and ___
SKIN - sternotomy site clean, dry and intact; well healing
At discharge
GENERAL: in NAD, well appearing
VS: T 98.3 BP 128-164/65-80 HR 57-67 RR 18 SaO2 96-100% in RA
Weight: 88.3 kg -> 88.8 kg -> 90.0
HEENT - EOMI, mucous membranes moist
NECK - JVP not elevated at 90 degree
CARDIAC - RRR; no murmurs, rubs or gallops
LUNGS - CTAB - no adventitious breath sounds
ABDOMEN - non-tender, not distended
EXTREMITIES - Cool, trace edema bilaterally
NEUROLOGIC - ___ strength both UE and ___
SKIN - sternotomy site clean, dry and intact; well healing; L
PICC clean, dry and intact
Pertinent Results:
___ 05:16PM BLOOD WBC-12.1* RBC-5.03 Hgb-13.9 Hct-43.2
MCV-86 MCH-27.6 MCHC-32.2 RDW-13.9 RDWSD-42.8 Plt ___
___ 05:16PM BLOOD Neuts-83.6* Lymphs-5.2* Monos-10.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.12*# AbsLymp-0.63*
AbsMono-1.27* AbsEos-0.01* AbsBaso-0.04
___ 05:16PM BLOOD ___ PTT-30.9 ___
___ 05:16PM BLOOD Glucose-205* UreaN-12 Creat-1.1 Na-136
K-4.1 Cl-94* HCO3-26 AnGap-20
___ 05:16PM BLOOD proBNP-5079*
___ 05:16PM BLOOD Calcium-9.8 Phos-3.2 Mg-1.9
___ 09:49PM BLOOD D-Dimer-489
___ 06:33AM BLOOD Vanco-23.3*
___ 05:24PM BLOOD Lactate-1.6
___ 09:16AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:16AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-150 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:16AM URINE RBC-7* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
___ 06:00AM BLOOD ALT-17 AST-13 LD(LDH)-167 CK(CPK)-36*
AlkPhos-98 TotBili-2.5* DirBili-0.3 IndBili-2.2
___ 05:42AM BLOOD CRP-140.2*
___ 10:45AM OTHER BODY FLUID WBC-286* RBC-83* Polys-88
___ Monos-0 Eos-1
___ 11:24AM BLOOD WBC-7.4 RBC-4.16* Hgb-11.4* Hct-35.8*
MCV-86 MCH-27.4 MCHC-31.8* RDW-13.4 RDWSD-42.1 Plt ___
___ 11:24AM BLOOD Neuts-71.8* Lymphs-13.6* Monos-8.3
Eos-5.0 Baso-0.8 Im ___ AbsNeut-5.33 AbsLymp-1.01*
AbsMono-0.62 AbsEos-0.37 AbsBaso-0.06
___ 11:24AM BLOOD Glucose-259* UreaN-17 Creat-1.4* Na-136
K-5.3* Cl-98 HCO3-24 AnGap-19
___ 11:24AM BLOOD ALT-11 AST-12 LD(LDH)-218 AlkPhos-89
TotBili-0.7
___ 11:24AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.4
___ 07:45PM BLOOD Vanco-24.2*
Microbiology
___ ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
INDEX VALUE 0.14 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
___ B-GLUCAN
Test Result Reference
Range/Units
FUNGITELL(R) (___) B D 84 H pg/mL
GLUCAN ASSAY
INTERPRETATION POSITIVE
___ ESR 38 mm/h H
___ 6:00 am BLOOD CULTURE: NO GROWTH.
___ 9:16 am URINE CULTURE: NO GROWTH.
___ 9:15 am BLOOD CULTURE: NO GROWTH.
___ 6:33 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Final ___: NO MYCOBACTERIA ISOLATED.
___ 6:33 am BLOOD CULTURE: NO GROWTH.
___ 3:32 pm FLUID,OTHER Source: mediastinal fluid.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Final ___: NO MYCOBACTERIA ISOLATED.
NOCARDIA CULTURE (Final ___: NO NOCARDIA ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
___ 5:15 pm SEROLOGY/BLOOD
CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN
NOT DETECTED.
___ B-GLUCAN
Test Result Reference
Range/Units
FUNGITELL(R) (___) B D 57 pg/mL
GLUCAN ASSAY
INTERPRETATION NEGATIVE
___ HISTOPLASMA ANTIGEN
Test Result Reference
Range/Units
HISTOPLASMA GALACTOMANNAN <0.5 ng/mL
ANTIGEN, URINE
REFERENCE RANGE: <0.5 ng/mL
CXR ___
Patient is status post median sternotomy and CABG. Heart size is
mildly enlarged but unchanged. The mediastinal and hilar
contours are within normal limits. Pulmonary vasculature is not
engorged. Lungs are hyperinflated without focal consolidation.
Minimal atelectasis is seen within the right lung base. Blunting
of the costophrenic angles posteriorly on the lateral view
suggests trace bilateral pleural effusions. No pneumothorax is
seen. There are mild degenerative changes noted in the thoracic
spine.
IMPRESSION:
Small bilateral pleural effusions with minimal right basilar
atelectasis. Hyperinflated lungs compatible with COPD.
CTA chest ___
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the subsegmental level without filling defect to indicate a
pulmonary embolus. The thoracic aorta is normal in caliber
without evidence of dissection or intramural hematoma. Fluid
collection with rim enhancement is identified at the the right
pericardial space measuring 6.8 x 3.7 x 5.9 cm. The fluid tracks
anteriorly to the sternotomy. The fluid collection effaces the
lateral wall of right atrium.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Right pleural effusion is small.
LUNGS/AIRWAYS: Atelectasis is mild in right lower lobe. The
airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the upper abdomen is notable for 7
mm hypodense lesion in the spleen which is unchanged.
BONES: Sternotomy wires are intact. No suspicious osseous
abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Fluid collection with rim enhancement is identified at the
the right pericardial space measuring 6.8 x 3.7 x 5.9 cm. The
fluid tracks anteriorly to the sternotomy. Findings may reflect
pericardial abscess.
2. No evidence of pulmonary embolism or aortic abnormality.
Echocardiogram ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with akinesis of the inferior and inferolateral
walls. Diastolic function could not be assessed. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Moderate (2+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is a moderate sized pericardial effusion. The effusion has
an area of echo density, consistent with blood, inflammation or
other cellular elements. The effusion appears loculated and is
adjacent to the right atrium, best seen in the subcostal views.
There are no echocardiographic signs of tamponade.
IMPRESSION: Loculated pericardial effusion adjacent to the right
atrium measuring 4.8 x 2.8 cm with solid echodensity within the
fluid-filled cavity measuring 1.5 x 1.6 cm. Moderate left
ventricular cavity dilatation with mild to moderate regional
systolic dysfunction. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
the collection adjacent to the right atrium is new. The left
ventricular cavity is more dilated. Pleural effusions have
resolved.
CT guided aspiration of pericardial collection ___
TECHNIQUE: The risks, benefits, and alternatives of the
procedure were explained to the patient. After a detailed
discussion, informed written consent was obtained. A
pre-procedure timeout using three patient identifiers was
performed per ___ protocol.
The patient was placed in a supine position on the CT scan
table. Limited preprocedure CT scan was performed to localize
the collection. Based on the CT findings an appropriate skin
entry site for the FNA was chosen. The site was marked. Local
anesthesia was administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___
needle was inserted into the collection. Approximately 28 cc of
serous fluid was aspirated with a sample sent for microbiology
and cytology evaluation. Postprocedure scan demonstrated that
the pericardial collection has essentially resolved.
Attempt was made to access a second small collection just deep
to the inferiorsternum, but no fluid could be aspirated.
The procedure was tolerated well, and there were no immediate
post-procedural complications.
Echocardiogram ___
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal with moderate global free
wall hypokinesis. There is a small pericardial effusion. The
effusion appears loculated, subtending the right atrium.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion appears smaller.
CXR ___
Interval placement of a left PICC line, with its tip
projecting over the cavoatrial junction.
No focal consolidation, pleural effusion or pneumothorax is
identified. The size of the cardiac silhouette is enlarged but
unchanged. The patient is status post prior median sternotomy
and CABG. The sternotomy wires are intact.
IMPRESSION:
The tip of a new left PICC line projects over the cavoatrial
junction.
Brief Hospital Course:
___ yo man with h/o type 1 diabetes mellitus, CAD with H/O MI now
s/p CABG ___ with transient post-operative atrial
fibrillation and systolic CHF presented with pleuritic chest
pain and slight cough as well as recurrence of paroxysmal atrial
fibrillation with a rapid ventricular rate. CTA showed no
evidence of pulmonary embolism but had concerning pericardial
fluid collection worrisome for abscess. This was drained by
Interventional Radiology on ___. There was concern about an
indolent infection (high inflammatory markers) vs.
post-cardiotomy syndrome. Several cultures were obtained,
including aerobic/anerobic, AFB, nocardia, all returned
negative. On advice of Infectious Disease, patient was started
on vancomycin and Zosyn and transitioned to vancomycin and
cefepime. PICC line was placed on ___. Beta glucan returned
positive 1 day prior to discharge though there was no plan to
add fungal coverage until follow-up values returned (ultimately
this was negative).
# Chest pain: Patient presented with pleuritic chest pain
starting at the right side of the neck and radiating downward to
the right clavicle. Troponins and CXR were negative. Patient had
a CTA performed to rule out pulmonary embolism, though this
revealed a large pericardial effusion with similar density
material tracking up to the site of his sternotomy, as below.
His pain seemed to be referred from to the shoulder from the
effusion, possibly through a referral through the phrenic nerve.
# Rim enhancing lesion near pericardium/possible pericardial
abscess: Noted on CTA as above. It was unclear if he had a
surgical site abscess versus fluid collection or post operative
inflammation. An echocardiogram demonstrated a right sided
loculated effusion abutting the right atrium. It was thought
that post-cardiotomy syndrome would not typically be associated
with a located effusion, so antibiotics were started to cover
possible abscess (vancomycin + Zosyn, transitioned to vancomycin
+ cefepime). An ___ drainage of the collection was
performed on ___. Drainage of the anterior collection was
attempted, but was unsuccessful. Patient was continued on
empiric antibiotics. Follow-up was established with infectious
disease.
# Paroxysmal atrial fibrillation: Patient had a history of
atrial fibrillation 10 days post-CABG and was started on
dabigatran at that time. He had since stopped the NOAC after
seeing cardiology as outpatient as he had no overt recurrence of
atrial fibrillation. He developed atrial fibrillation with rapid
ventricular rate while in the ED and continued to go in and out
of sinus rhythm on telemetry. Patient's metoprolol was changed
to carvedilol for improved blood pressure control. He was
restarted on dabigatran 150 mg bid.
# HFrEF: Patient with known CHF after his STEMI and largely
preserved LVEF (52 %). He did not appear floridly overloaded per
imaging, however NT-Pro-BNP elevated at 5079; no baseline
NT-Pro-BNP when dry, last NT-Pro-BNP when had CHF exacerbation
was ~ ___. LVEF on echocardiogram this admission ___.
Patient received furosemide 40 mg IV in ED but did not receive
further diuresis after arriving on the medical floor; oral
torsemide dose resumed at discharge. His beta-blocker was
switched to carvedilol. ___ held due to ___ as below.
# ___: Likely ___ osmotic diuresis and poor PO intake in setting
of transiently higher sugars on ___. Held ___ at time of
discharge.
# Hypertension
- Held ___ in setting ___ as above
- Transitioned metoprolol to carvedilol 12.5 mg BID for better
BP control
# Possible COPD: CXR findings on admission were suggestive of
hyperinflation. Patient had a dry cough on admission. Patient
may benefit from outpatient PFTs.
# CAD: S/p CABG in ___. Continued home rosuvastatin, aspirin
with change in beta-blocker as above.
# T1DM - Some issues with hyperglycemia throughout admission. We
requested that his antibiotics be reformulated in non-D5W to
reduce dextrose exposure and increased his sliding scale as
necessary. Discharged on Glargine 20 Units qHS with ISS.
TRANSITIONAL ISSUES:
- Losartan held for ___, please restart as tolerated
- Torsemide restarted on discharge. Patient instructed to take
extra dose and call doctor if weight increased by 3 lbs.
- Patient's metoprolol was changed to carvedilol for improved
blood pressure control. He was restarted on dabigatran 150 mg
bid. An effort was made to explore options to assist him in
obtaining the latter at low cost.
- Patient was discharged with PICC line in place and continued
vancomycin+cefepime with ID follow-up in ___ weeks to make
further decisions about his antibiotics
- Patient will need follow-up CT and echocardiography in ___
weeks to evaluate whether pericardial effusion has recurred.
- Please consider need outpatient evaluation for primary
prevention ICD in the setting of systolic dysfunction.
# CODE: FULL, presumed
# CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Rosuvastatin Calcium 5 mg PO QPM
6. Torsemide 20 mg PO EVERY OTHER DAY
7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
2. CefePIME 2 g IV Q8H
RX *cefepime [Maxipime] 2 gram 1 dose IV Every 8 hours Disp #*42
Vial Refills:*1
3. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*2
4. Vancomycin 750 mg IV Q 12H
RX *vancomycin 750 mg 1 dose IV twice a day Disp #*28 Vial
Refills:*2
5. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
8. Aspirin 81 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO QPM
10. Torsemide 20 mg PO EVERY OTHER DAY
11. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your kidney
function improves
12.Outpatient Lab Work
Please draw weekly CBC with differential, BUN, Cr, Vancomycin
trough, ESR, CRP
ICD10: ___.1
Please fax to:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Loculated pericardial effusion, possibly infected
-Atrial fibrillation with rapid ventricular rate
-Type 1 Diabetes Mellitus with hyperglycemia
-Acute systolic congestive heart failure
-Coronary artery disease with prior bypass graft surgery
-Hypertension
-Acute kidney injury
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 when you developed chest pain.
You were evaluated with blood work and imaging which
demonstrated you were having no signs of a blood clot or heart
attack, but demonstrated you had a fluid collection around your
heart. There was concern this was a fluid collection called an
abscess, so we prepared you for a drainage procedure that took
place on ___. You were started on antibiotics which we
recommend you continue taking through the ___ line that was
placed on ___. You will need to follow-up with
infectious disease in ___ weeks to follow-up on culture data.
Because of your atrial fibrillation we have restarted your
anticoagulation medication called pradaxa.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs and take and extra dose of torsemide.
It was a pleasure to be involved with your care at ___,
-Your ___ Care Team
Followup Instructions:
___
|
19631540-DS-17
| 19,631,540 | 27,012,034 |
DS
| 17 |
2118-03-12 00:00:00
|
2118-03-12 18:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
cyclobenzaprine / cetirizine / hydrochlorothiazide / cephalexin
/ lisinopril / Influenza Virus Vaccines
Attending: ___
Chief Complaint:
Transient word-finding difficulty//Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed man with history notable
for coronary disease complicated by STEMI status post
three-vessel CABG, type 1 diabetes mellitus, hypertension,
hyperlipidemia, and paroxysmal atrial fibrillation on ___
transferred from ___ following an episode of
transient word finding difficulty.
Mr. ___ was in his usual state of health until yesterday
morning, at which time he woke up with a bifrontal headache
without associated photo- or phonophobia. His wife noted that
his systolic blood pressure was in the 200s at that time. He
subsequently had an episode of unexpected nausea and vomiting
after which he returned to bed. While asleep, his wife was
surprised to hear him saying "hi" along with some additional
unintelligible speech. When attempting to wake him, she noted
that his right hand was held in flexion with flexion of the
wrist, that struck her as being unusual. Upon waking, he
continued to have systolic blood pressures in the 190s. His
wife
felt that he had not yet returned to his baseline (though
describing this as a "sleepiness" in his eyes), prompting
evaluation at ___. There, Mr. ___ was noted to
have difficulty recalling the names of his grandchildren,
prompting evaluation with a noncontrast head CT that was
reportedly unremarkable. He also reported feeling disoriented
regarding where he was and what was happening. He was
subsequently transferred to
___ for further neurologic evaluation.
On neurologic review of systems, Mr. ___ denies prior history
of
headaches, recent lightheadedness, difficulty with producing or
comprehending speech, loss of vision, diplopia, vertigo, hearing
difficulty, or focal muscle weakness or numbness. He denies
bowel
or bladder incontinence or retention. Of note, he does note
worsening dysphagia over the past several months, but ascribes
this in part to removal of several teeth due to his diabetes.
Past Medical History:
Coronary disease complicated by STEMI s/p 3vCABG
Type 1 diabetes mellitus
Hypertension
Hyperlipidemia
Paroxysmal atrial fibrillation on apixaban
Provoked seizure i/s/o hyponatremia on HCTZ
Social History:
___
Family History:
Father passed away from pneumonia after diagnosis of brain
cancer, mother passed away from lung cancer after smoking.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
============================
Vitals: T: 98.0 P: 56 R: 15 BP: 155/65 SaO2: 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: No tachypnea or increased WOB
Cardiac: Warm, well-perfused
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. 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. Able to register 3 objects and recall ___
at 3 minutes ___ on MC). There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___. Slight bilateral ptosis
(ascribed to remote brown recluse spider bite on forehead). EOMI
without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS. +Romberg.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor or dysmetria on FNF or HKS
bilaterally.
-Gait: Narrow-based and steady albeit with unsteady tandem gait.
.
.
==============
DISCHARGE EXAM
==============
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Able to name
both
high and low frequency objects. Able to read without
difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm ___. Slight bilateral ptosis.
EOMI
without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk in the hand intrinsics. Normal tone
throughout. No pronator drift bilaterally. No adventitious
movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastr EDB
L 5 ___ ___ 5 5 5 4+ 5 4
R 5 ___ ___ 5 5 5 4+ 5 4
High arches.
-Sensory: No deficits to light touch or pinprick throughout.
Decreased joint position sense in the left more than right great
toe. No
extinction to DSS. +Romberg.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was complicated by withdrawal bilaterally.
-Coordination: No intention tremor or dysmetria on FNF or HKS
bilaterally.
-Gait: Narrow-based and steady albeit with unsteady tandem gait.
Pertinent Results:
===============
ADMISSION LABS AND WORKUP
==============
___ 12:50AM BLOOD WBC-7.6 RBC-4.13* Hgb-12.2* Hct-35.4*
MCV-86 MCH-29.5 MCHC-34.5 RDW-11.7 RDWSD-36.7 Plt ___
___ 12:50AM BLOOD Neuts-67.4 ___ Monos-9.7 Eos-2.4
Baso-0.8 Im ___ AbsNeut-5.10 AbsLymp-1.46 AbsMono-0.73
AbsEos-0.18 AbsBaso-0.06
___ 12:50AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-192* UreaN-20 Creat-1.4* Na-140
K-4.1 Cl-100 HCO3-27 AnGap-13
___ 12:50AM BLOOD cTropnT-<0.01
___ 06:17AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 Cholest-177
___ 06:17AM BLOOD %HbA1c-6.9* eAG-151*
___ 06:17AM BLOOD Triglyc-228* HDL-28* CHOL/HD-6.3
LDLcalc-103
___ 06:17AM BLOOD TSH-2.4
___ 12:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:45AM URINE Color-Straw Appear-Clear Sp ___
___ 02:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
.
.
===============
IMAGES
===============
MRI BRAIN ___ WITH MRA HEAD AND NECK
1. No intracranial hemorrhage, mass or infarct.
2. Mild realized cerebral atrophy with ex vacuo dilatation of
the ventricular
system.
3. Mild white matter microangiopathic changes.
4. The intracranial arteries are patent and demonstrate multiple
mild-to-moderate areas of narrowing which is most likely related
to
atherosclerotic disease. No arterial occlusion or aneurysm
formation.
5. Time-of-flight MRA neck demonstrates patent neck vessels.
Suspected mild
narrowing of the carotid bulbs bilateral. MRA neck with contrast
or CTA neck
may be performed for quantification.
6. Moderate paranasal sinus disease.
.
OHS NCHCT UNREMARKABLE ON OUR REVIEW
Brief Hospital Course:
___ right-handed man with history notable for coronary
disease complicated by STEMI status post three-vessel CABG, type
1 diabetes mellitus, hypertension,
hyperlipidemia, and paroxysmal atrial fibrillation on ___
transferred from ___ following an episode of
transient word finding difficulty.
On further interview, it sounded more like
confusion/disorientation in setting of hypertension SBP 200s and
throbbing headache- more consistent with hypertensive
encephalopathy. Neuro exam with no focal findings.
MRI Brain showed no stroke or acute findings, MRA with no
significant large vessel stenosis.
Because of the episode of clenching his arms when sleeping, the
confusion after awakening, and history of one prior seizure, we
ordered outpatient EEG to any focal epileptiform activity.
Stroke risk factors were sent (LDL 103, Chol 177; HbA1C 6.9%,
TSH 2.4) but because this was unlikely to represent TIA, no
change were made to his medications. He is already on both ASA
and Apixaban.
His short stay was notable for higher blood pressure but all of
his blood pressure medications had been held for permissive HTN.
His BPs improved with resuming his home medications. He will
need to follow up with his primary care provider for BP checks.
.
.
Transitional issues:
- Neurology Follow up
- Outpt EEG
- PCP follow up for blood pressure management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
2. Apixaban 5 mg PO BID
3. Carvedilol 25 mg PO BID
4. Diltiazem Extended-Release 120 mg PO DAILY:PRN palpitations
5. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Losartan Potassium 50 mg PO DAILY
7. Rosuvastatin Calcium 5 mg PO QPM
8. Torsemide 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Glargine 19 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. ProAir HFA (albuterol sulfate) 2 puff inhalation Q6H:PRN SOB
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Diltiazem Extended-Release 120 mg PO DAILY:PRN palpitations
7. Losartan Potassium 50 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO QPM
9. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to symptoms of confusion and difficult
remembering the names of your grandchildren in the setting of
high blood pressure. We feel that the most likely cause of these
symptoms was something called hypertensive encephalopathy. This
is when you get confused because of high blood pressure.
You were admitted for MRI due to possibility of a TIA - however,
the story does not sound consistent with this and the MRI Brain
was negative for stroke.
Because of the clenching of your arms when you were sleeping,
the confusion after awakening, and history of one prior seizure,
we will order outpatient EEG to evaluate any signs of increased
risk for seizure.
You will need to follow up with neurology and should be
contacted regarding an appointment. If you do not hear back,
please call ___ to schedule with Dr ___.
Followup Instructions:
___
|
19631559-DS-10
| 19,631,559 | 23,321,451 |
DS
| 10 |
2159-08-11 00:00:00
|
2159-08-12 06:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hematemesis/UGIB
Major Surgical or Invasive Procedure:
Intubated ___
EGD ___
History of Present Illness:
___ with self-reported history of ?cirrhosis, PUD, IDDM and
dCHF, presenting as a transfer from ___ with chief
complaint of UGI bleed. Per ___, the patient complained of
two days of extreme fatigue. There he womited BRB with clots,
about 200-300cc. He had a similar episode with EMS. His exam at
___ was notable for Guaiac(+) brown stool. There he was
started on IV protonix, octreotide gtt and received 2 units of
PRBCs. He was transferred to ___ for GI evaluation, as there
is no GI, anesthesia or MICU availability at ___. While
awaiting transfer he had another episode of 1400cc hematemesis.
His Hgb downtrending from 10.9 to 7.9 (baseline Hct 10.7), VSS:
BP 113/67, HR 85, afebrile, 90% RA. Has 2 18 PIV.
In the ___, initial vitals: 97.0 89 142/85 20 98% NC. He was
described as pale and lethargic, though mentating.
GI was consulted with plan to scope later this morning and he
was started on empric ceftriaxone. Per patient, no history of
esophageal varices. He is rate-controlled on atenolol. NGT
placed, bloody clots suctioned.
On transfer, vitals were: 97.6 89 124/61 28 97% NC.
On arrival to the MICU, the patient is sleepy but can engage in
a coherent conversation. He has no complaints.
Past Medical History:
- Cirrhosis, anti Sm positive
- IDDM
- Peptic ulcer disease
- Diastolic congestive heart failure
- Anemia
- Bipolar disorder
- COPD
- Chronic venous stasis disease
- OSA
Social History:
___
Family History:
(Per chart review, unable to obtain from patient given
confusion/intubation)
Father healthy at ___
Mother died at ___ because of "weak muscles in her heart"
No siblings
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 97.8 BP 120-130s/60 HR ___ 93-96% on 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry
LUNGS: Clear to auscultation bilaterally in anterior fields
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: ___ ___ edema b/l with significant venous stasis changes
DISCHARGE PHYSICAL EXAM
========================
VITALS: 98.8 132/56 65 18 96% 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 but diminished
throughout, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, obese, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
___ edema with venous stasis changes
SKIN: Extensive seborrheic keratosis noted
NEURO: Some asterixis
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:55AM BLOOD WBC-5.3# RBC-2.94* Hgb-8.2* Hct-27.3*
MCV-93 MCH-27.9 MCHC-30.0* RDW-14.1 RDWSD-47.9* Plt ___
___ 04:55AM BLOOD Glucose-294* UreaN-26* Creat-1.2 Na-137
K-4.9 Cl-101 HCO3-28 AnGap-13
___ 04:55AM BLOOD ALT-39 AST-25 AlkPhos-116 TotBili-0.5
==============
PERTINENT LABS
==============
___ 10:45AM BLOOD IgG-1130 IgA-252 IgM-253*
___ 10:45AM BLOOD ___
___ 10:45AM BLOOD AMA-NEGATIVE Smooth-PND
___ 05:13AM BLOOD HAV Ab-Positive*
___ 07:30AM BLOOD HBcAb-Positive*
___ 10:45AM BLOOD HBsAg-Negative HBsAb-Positive
___ 10:45AM BLOOD HCV Ab-Negative
___ 05:13AM BLOOD calTIBC-355 Ferritn-25* TRF-273
___ 05:26PM BLOOD %HbA1c-9.6* eAG-229*
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CULTURES x 2 ___: PENDING.
BLOOD CULTURES x 2 ___: PENDING.
=======
IMAGING
=======
___ RUQ U/S
----------------
1. Technically limited evaluation due to body habitus and
limited sonographic windows. Within that limitation the liver
appears abnormal in echotexture and echogenicity. No focal
liver lesions are identified.
2. Splenomegaly.
___ CXR
----------
The endotracheal tube terminates 3 cm above the carina.
The enteric tube extends into the stomach with tip out of view.
___ EGD
-------------
Findings:
Esophagus:
Protruding Lesions 3 cords of varices were seen in the lower
third of the esophagus. The varices were not bleeding. There
were high risk stigmata, and 3 bands were placed. 3 bands were
successfully placed with hemostasis achieved.
Stomach:
Contents: Blood clot was seen in the fundus of the stomach.
Entire fundus was not visualized. Rest of stomach was filled
with blood but no other lesions noted.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Varices at the lower third of the esophagus
(ligation)
Blood in the stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Contact interventional radiology if has
recurrent bleed to look for gastric varices.
Continue PPI and start Carafate once extubated and tolerating
orals.
___ CT ABDOMEN/PELVIS WITH AND WITHOUT CONTRAST
1. Cirrhosis with the sequela of portal hypertension including
splenomegaly, and an increased number and size of lymph nodes in
the upper abdomen, likely reactive.
2. No lesions are seen that are concerning for HCC. There are a
few tiny sub centimeter scattered hypodensities in the liver
which are nonspecific and too small to be characterized by any
imaging modality. Further attention to these areas on follow-up
imaging can be performed.
3. The common bile duct measures up to 1.3 cm. Correlate with
LFTs.
==============
DISCHARGE LABS
==============
___ 05:39AM BLOOD WBC-4.7 RBC-2.76* Hgb-7.6* Hct-25.0*
MCV-91 MCH-27.5 MCHC-30.4* RDW-14.9 RDWSD-48.4* Plt ___
___ 05:39AM BLOOD ___ PTT-34.5 ___
___ 05:39AM BLOOD Glucose-222* UreaN-19 Creat-1.3* Na-136
K-3.8 Cl-96 HCO3-29 AnGap-15
___ 05:39AM BLOOD ALT-27 AST-19 AlkPhos-120 TotBili-0.7
___ 05:39AM BLOOD Albumin-4.2 Calcium-8.4 Phos-3.7 Mg-1.9
***ANTI-SM MM AB POSITIVE
Brief Hospital Course:
___ with new diagnosis of NASH/?autoimmune cirrhosis, poorly
controlled IDDM, ___ who was admitted for management of
hematemesis/UGIB, found to have esophageal varices s/p banding
___ discharged hemodynamically stable w/stable h/h.
# Upper GI bleed: Patient intially presented to ___ after
vomiting 200-300 mL of blood. He had a similar episode en route
to hospital, witness by EMS. His exam at ___ was notable for
Guaiac(+) brown stool. Initiated on treatment, but subsequently
transferred to ___ for further GI evaluation and intervention.
Upon arrival, patient had interval history of recurrent episode
of hematemesis. EGD (with difficult airway) revealed 3 cords of
non-bleeding esophageal varices that were successfully banded.
Complete evaluation of fundus was thwarted by presence of
adherent clot.
He had no further episodes of bleeding after EGD. Following
standard post variceal bleeding protocol he remained stable. He
was started on nadolol 20 mg qPM on ___.
Discharge Hgb was 7.6. He will require re-evaluation of varices
with EGD under MAC in three weeks, and follow up with Dr.
___ in ___ clinic in one month.
# Cirrhosis (MELD-Na 13, MELD 10, Child A/6)
Abnormal echotexture of liver seen on his RUQ ultrasound
___, cirrhosis with the sequela of portal hypertension
including splenomegaly on CT abdomen/pelvis ___, in setting
of known esophageal varices on ___ EGD.
Previous etiology thought entirely due to ___. Subsequent
workup below, but most notable for autoimmune hepatitis
(Anti-Smooth positive 1:40)
Work up:
- Anti-Smooth positive 1:40. However, IgG not elevated, no
significant transaminitis.
- HBVsAg negative, HBsAb positive, HBcAb positive, HBV viral
load negative, HCV Ab negative
- Hepatitis A Antibody was sent to determine whether he would
require vaccination and was positive
- ___ negative, AMA negative.
- Iron panel without evidence of hemochromatosis
- Considered alpha-1 antitrypsin in setting of COPD though less
likely given he is already ___ years old and it was felt it would
be low yield
2) Varices: 3 cords of esophageal varices with high risk
stigmata s/p banding. Management as above. Started nadolol 20 mg
qPM on ___ SBP/Ascites: No known history of ascites and none seen on ___
RUQ ultrasound; difficult to assess on exam due to body habitus.
No current indication for SBP prophylaxis.
4) HE: Mr. ___ had a few beats of asterixis on exam ___ and
was started on lactulose 30 mL q2H; subsequently cleared.
Lactulose was decreased to 30 mL TID on ___, titrating to ___ BM
daily
5) HCC screening: Triphasic CT without evidence of HCC on
___
6) Hepatitis vaccination: Patient is HBsAb positive and HAV Ab
positive
# IDDM: Patient on significant insulin requirement at home; was
on U-500 with reported BG 300s post meals. Hgb A1c was 9.6 on
___. He reports that there are significant barriers-
including inability to afford insulin ___ had previously
provided him with free U-500 supply but he is running out), and
a diet that is described as "best case scenario ___. He
lives with his significant other who likes to cook burgers and
doesn't like him cooking. ___ was consulted for diabetes
management.
Discharged on glargine 55 U qAM, glargine 58 U qPM, Humalog 33 U
with each meal, and sliding scale humalog with blood glucoses in
200s on this regimen. He will require follow up with Dr. ___
___.
# dCHF: Last echocardiogram ___ with mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function. Right ventricle not well seen but limited
views suggest reasonably preserved systolic function (see
above). At least mild tricuspid regurgitation. Moderate
pulmonary hypertension with possible RV pressure/volume
overload. At home he is on torsemide 40 mg daily. Initially held
due to GI bleed as above, received 1 dose furosemide IV 40 mg on
___ due to volume overload with increased O2 requirement after
pRBC transfusion, with subsuquent orthostasis; furosemide was
held again. We restarted home torsemide on ___ which resulted in
Cr bump from 1.1 to 1.3 which resolved with albumin, torsemide
held. Then restarted again on ___, with Cr bump to 1.3 but
stable. We held his home losartan on discharge due to ___.
Discharge weight is 145.24 kg, still with significant lower
extremity edema.
TRANSITIONAL ISSUES:
====================
Cirrhosis:
[ ] Patient is anti-Smooth positive (1:40) but without
significant transaminitis or elevation in IgG. He will require
follow up with Dr. ___ four weeks of discharge,
scheduled for ___.
[ ] Discharge Hgb is 7.6, Hct 25.0.
[ ] Regarding his varices, patient will require follow up
endoscopy within three weeks of discharge. He was also started
on nadolol 20 mg with discharge HR 65-71, can consider
uptitrating in future (but he was complaining of lightheadedness
thus we held off).
[ ] He was started on lactulose 30 mL q4H, please titrate to ___
bowel movements daily.
[ ] Discharge weight 145.24 kg, still with significant lower
extremity edema.
[ ] Discharge Cr is 1.3. He was restarted on home torsemide on
___.
dCHF:
[ ] Discharge Cr is 1.3. He was restarted on home torsemide on
___.
[ ] He will require repeat labs: Chem 7 to be drawn within one
week (___) to follow up on his Cr.
[ ] We held his home losartan ___ slight, but stable Cr. bump.
Please consider restarting it within ___ weeks if his Cr
continues to remain stable.
Diabetes:
[ ] Insulin regimen adjusted to glargine 55 U qAM, glargine 58 U
qPM, Humalog 33 U with each meal, and sliding scale humalog with
blood glucoses in 200s on this regimen.
[ ] Patient will require assistance with resources to afford his
insulin
[ ] Patient will require assistance with healthy meals
(diabetic, 2g sodium restriction) in terms of nutrition
education and question of meals on wheels (he lives in ___,
supplied by ___)
Miscellaenous:
[ ] Omeprazole increased to 40 mg PO BID from 20 mg daily
[ ] Gallbladder with stones and non-obstructed, but dilated CBD
(1.3cm). If were to become jaundiced please consider.
[ ] Patient will require follow up with PCP for his ___ thigh
numbness.
# Code: Full
# Name of health care proxy: ___ (Daughter)
# Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Torsemide 40 mg PO DAILY
3. RisperiDONE 1 mg PO BID
4. Potassium Chloride (Powder) 20 mEq PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Aspirin 81 mg PO DAILY
11. Humulin-R Insulin (U-500) 750 UNIT SC ONCE
Discharge Medications:
1. Lactulose 30 mL PO Q4H
2. Nadolol 20 mg PO QHS
3. Simethicone 40-80 mg PO QID:PRN gas pain
4. Glargine 55 Units Breakfast
Glargine 58 Units Bedtime
Humalog 33 Units Breakfast
Humalog 33 Units Lunch
Humalog 33 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Omeprazole 40 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K >5
11. RisperiDONE 1 mg PO BID
12. Torsemide 40 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until your PCP says
to restart it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Upper GI Bleed
Cirrhosis, presumed NASH, c/b portal hypertension
Insulin dependent diabetes
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 ___
because you vomited up blood.
While you were here, we performed an EGD which discovered that
you have something called esophageal varices. These usually
develop when blood flow to the liver is blocked, such was when
you have scarring of the liver (cirrhosis). We were able to band
these varices to help prevent them from bleeding in the future.
We also started you on a medication called nadolol to help
prevent you from vomiting up blood again. Unfortunately varices
can recur, so you will need to get a repeat EGD in 3 weeks.
We also looked for a cause of your cirrhosis and tried to manage
the complications from it, which can include bleeding from
varices, confusion because your liver cannot clear toxins very
well anymore, fluid accumulation in your belly, and even liver
cancer. Your cirrhosis is most likely from fatty liver (NASH) at
this time with a possible component of autoimmune disease which
can damage the liver as well. We are starting you on a new
medication called lactulose to help you have multiple bowel
movements ___ daily) to clear up toxins that might otherwise
make you confused. On the imaging that we did, we DID NOT see
extra fluid in your abdomen (ascites), but it is important to
eat a low salt diet to prevent this from happening. Fluid in
your belly is not only uncomfortable, it can get infected and
make you very sick. We also DID NOT find any evidence of liver
cancer, but you will need to follow up with a liver doctor and
get regular scans.
Regarding your diabetes, we consulted ___ to help us manage
your blood sugars. You told us that U-500 is very expensive, and
we put you on an alternate insulin called glargine. Dr. ___
is aware of these changes and you will follow up with him.
Regarding food after you go home, you should eat a low salt and
diabetic friendly diet; the nutritionists have given you
instructions on this.
It is very important that you take your medications, eat a low
salt diet, and keep your appointments as below.
Please weigh yourself daily and if it increases by 3 pounds in a
day or 5 pounds over any period of time call your doctor.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19631559-DS-11
| 19,631,559 | 21,807,674 |
DS
| 11 |
2159-10-07 00:00:00
|
2159-10-11 09:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Anemia ISO Recent Variceal Bleed
Major Surgical or Invasive Procedure:
Endoscopy on ___
History of Present Illness:
Mr ___ is a ___ ___ gentleman with
history of cirrhosis with previous variceal bleeding, peptic
ulcer disease, diabetes, congestive heart failure who is
admitted for a falling hematocrit due to presumed upper GI
bleeding.
He was recently hospitalized at ___ from (___) with
hematemesis, where an EGD (with difficult airway) revealed 3
cords of
non-bleeding esophageal varices (with high-risk stigmata) that
were successfully banded. He was discharged after several days
of hemodynamic stability with a Hb of 7.6 on nadolol and
torsemide. He was subsequently seen in liver clinic at the end
of ___, where his Hb and creatine were at baseline. However,
he reported to urgent care on ___ with c/o dyspnea where he
was found to be volume overloaded. Torsemide at that time was
increased to 60mg daily.
Over the last week, Mr ___ had been experiencing multiple
episodes of belligerent and unusual behavior which resulted in
him being brought to ___ under ___. Patient was
felt to be lucid at ___, but labs noted an incidental drop in
his Hb to 6.6. At no point prior to BI-M or during that ED
visit, did he endorse hematemesis, BRBPR, or melena. He did
endorse some vague abdominal complaints ongoing for a week.
ED COURSE
- Initial vitals: 98.2 91 125/62 26 96% RA
- Exam: CTAB, b/l ___ edema and erythema, brown stool heme +
- Labs: H/H 6.0/21.9 BUN/Cr: 40/1.5 Plt 143, INR pending
- Pt was given PPI bolus and CTX 1g
- Liver was not consulted in the ED
- Vitals prior to transfer: 104 139/51 22 98%
ROS: Per HPI
Past Medical History:
- Cirrhosis (Child A/___) (___ vs autoimmune)
- Peptic ulcer disease
- IDDM
- diastolic congestive heart failure
- Anemia
- Bipolar disorder
- COPD
- Chronic venous stasis disease
- OSA on CPAP (non-compliant)
Social History:
___
Family History:
(Per chart review, unable to obtain from patient given
confusion/intubation)
Father healthy at ___
Mother died at ___ because of "weak muscles in her heart"
No siblings
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Reviewed in MetaVision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
RECTAL: brown stool, heme positive, no melena.
EXT: WWP, 2+ pulses, no clubbing or cyanosis. 2+ peripheral
edema with weeping.
SKIN: no rashes lesions. neg spider angiomata, palmar erythema.
b/l ___ chronic venous stasis changes.
NEURO: AAOx3, CN II-XII intact. Motor and sensation grossly
preserved to b/l ___. No asterixis
PSYCH: Mood and affect appropriate, no AH/VH
DISCHARGE PHYSICAL EXAM:
VS: 98.3 133 / 75 78 18 97 RA
I/O: 1000/500 +500 on ___
WEIGHT: 132 kg (admit 151.1 kg)
GENERAL: Sitting in chair comfortably
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI.
NECK: Difficult to assess JVP due to body habitus
CARDIAC: bradycardia with irregular rhythm, normal S1/S2, ___
systolic murmur at LUSB
PULMONARY: Clear to auscultation
ABDOMEN: Abdomen obese, soft, distended, non-tender to
palpation in all four quadrants. Hyperactive bowel sounds.
Abdominal wall edema
EXTREMITIES: Markedly swollen legs/feet w/ chronic venous stasis
changes.
NEUROLOGIC: Alert, oriented to self, date, location, attention
intact. No asterixis. Ambulatory
Pertinent Results:
ADMISSION LABS:
___ 12:06AM BLOOD WBC-5.1 RBC-2.62* Hgb-6.0* Hct-21.9*
MCV-84 MCH-22.9*# MCHC-27.4*# RDW-16.5* RDWSD-50.3* Plt ___
___ 12:06AM BLOOD Neuts-63.6 ___ Monos-11.8 Eos-1.6
Baso-0.4 NRBC-0.4* Im ___ AbsNeut-3.25 AbsLymp-1.12*
AbsMono-0.60 AbsEos-0.08 AbsBaso-0.02
___ 12:06AM BLOOD Plt ___
___ 12:06AM BLOOD Glucose-133* UreaN-40* Creat-1.5* Na-139
K-4.4 Cl-100 HCO3-27 AnGap-16
___ 12:06AM BLOOD ALT-15 AST-10 LD(LDH)-226 AlkPhos-123
TotBili-0.4
___ 12:06AM BLOOD Albumin-3.4* Iron-22*
___ 01:43PM BLOOD Calcium-8.6 Phos-5.4* Mg-2.2
___ 12:06AM BLOOD calTIBC-390 Ferritn-13* TRF-300
___ 07:33AM BLOOD ___ pO2-84* pCO2-70* pH-7.25*
calTCO2-32* Base XS-0 Comment-GREEN TOP
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-4.5 RBC-3.50* Hgb-8.3* Hct-28.0*
MCV-80* MCH-23.7* MCHC-29.6* RDW-17.1* RDWSD-49.5* Plt ___
___ 06:18AM BLOOD ___ PTT-35.5 ___
___ 06:18AM BLOOD Glucose-276* UreaN-34* Creat-1.3* Na-135
K-4.3 Cl-94* HCO3-29 AnGap-16
___ 06:18AM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.9* Mg-2.1
STUDIES/IMAGING:
CXR (___): "New multifocal pneumonia superimposed on bilateral
vascular congestion and new moderate right pleural effusion."
-US LIVER (___): "No ascites is visualized in the abdomen."
-ECHO (___): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The right
ventricle is not well seen; limited views suggest systolic
function may be borderline. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Physiologic mitral regurgitation is seen (within
normal limits). The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Suboptimal image quality. Compared with the prior study (images
reviewed) of ___, left ventricular function may be
similar; limited views suggest right ventricular function may be
borderline normal in the current study.
- EGD (___): Esophageal varices
Mosaic appearance in the fundus and stomach body compatible with
Mild portal gastropathy
No gastric varices seen
Otherwise normal EGD to third part of the duode
Brief Hospital Course:
___ is a ___ male with history of cirrhosis (NASH
vs. autoimmune) with previous variceal bleeding, peptic ulcer
disease, diabetes, severe decompensated congestive heart failure
who is admitted for a falling hematocrit due to presumed upper
GI bleeding. During hospitalization patient was diuresed for
chronic decompensated heart failure and has an episode of
dizziness and was found to have high-degree heart block with
bradycardia as well as intermittent tachycardia in the setting
of atrial flutter.
#Anemia
Mr. ___ presented with vague abdominal symptoms and new
anemia. He received 2 units of pRBCs during admission and
hemoglobin remained stable. He has a history of varices with
high-risk stigmata (banding x3 in ___ and history of peptic
ulcer disease. He received ceftriaxone for five days for SBP
prophylaxis. When patient's heart failure stabilized he was able
to undergo an GD on ___ with nonbleeding varices, no
intervention was performed. He was given Pantoprazole 40mg PO
BID while inpatient and will be discharged on his home
Omeprazole 40mg BID. Beta blockers were held due to bradycardia
and heart block.
#Atrial flutter, high degree AV block
Patient was found to have Atrial Flutter, high degree AV block,
asymptomatic bradycardia to ___, with rare ___ second pauses
on telemetry while sleeping. Initially patient became dizzy
while walking and EKG. Cardiology/EP consulted. Felt to be
nadolol effect (discontinued). Ischemic event was ruled out with
negative troponins. Ablation of adherent pathways was determined
to be the best management for A Flutter in this patient, who
will likely require beta blockade in the future because of
portal hypertension. Given his varices, he would not be able to
safely be on anticoagulation. He was counseled on risks/benefits
of procedure. Despite increased risk for strokes, bradycardia
and other arrhythmias, patient refused the ablation procedure.
He will follow up with electrophysiology after discharge.
#HFpEF
On admission patient was volume overloaded with weeping
peripheral edema and bilateral lung crackles with history of
HFpEF. He was unable to tolerate lying flat. Last discharge wt
145.24 kg, but was still significantly volume overloaded at that
time. He was diuresed with IV Lasix drip with significant
improvement in volume status. He was able to lie flat for EGD on
___. His dry weight is 134kg.
# NASH/Autoimmune Cirrhosis:
Patient with history of NASH/Autoimmune cirrhosis, Childs B.
Known sequela of portal HTN including splenomegaly, varices,
beta blocker held at time of discharge given heart block. EGD on
___ varices present and banded, repeat EGD ___ with
non-bleeding varices. No known history of ascites or SBP. RUQUS
negative for ascites. Mild HE in the past, on lactulose though
unclear compliance. Continued on Lactulose at the time of
discharge.
___
Admitted with Cr 1.5, most likely combination pre-renal from
GIB, aggressive diuresis and cardiorenal physiology. Baseline
1.0-1.1. At time of discharge patient had a Cr of 1.3.
# IDDM: Patient on significant insulin requirement; previously
treated with U-500. Hgb A1c 9.6 on ___. Poor
medication/dietary compliance with additional cost barriers.
Changed to Glargine/Humalog at last admission. Initially there
was concern for hypoglycemia at time of admission. Discharged on
home regimen of U500 with insulin sliding scale. Patient will
follow with ___.
#Multifocal Pneumonia due to gram neg bacteria:
Opacities in the right mid lung and left mid lung on CXR
consistent with multifocal PNA. Patient received Ceftriaxone
(___) and Azithromycin (___) for Community acquired
pneumonia.. Negative legionella and mycoplasma.
#Complicated UTI:
Patient with urine culture positive for resistant Klebsiella.
Asymptomatic. Given comorbidities patient was treated with
Meropenem 500 mg IV Q6H (___) for ___gitation Episodes, ?Bipolar D/O:
Patient was initially transferred from ___ on ___
due to agitation in setting of bipolar disorder. Unclear
precipitant, likely underlying hepatic/cardiac issues-most
likely HE, possible component of hypoglycemia, & toxic
encephalopathy due to multifocal PN. Psych evaluated patient on
admission and he did not meet criteria for ___. He was
kept on Risperidone, Lactulose and Rifaxmin throughout
admission.
# HLD:
Continued on home atorvastatin.
# OSA:
Patient not compliant with CPAP at home. Refused CPAP during
hospitalization.
====================
TRANSITIONAL ISSUES
====================
GENERAL
Discharge Weight: 132.27 kg
Discharge Cr: 1.3
Discharge Hgb: 8.3
ANEMIA
[ ] Monitor CBC
ATRIAL FLUTTER/HIGH DEGREE HEART BLOCK
[ ] Patient will require follow up with Electrophysiology as he
refused ablation procedure while inpatient. Can continue
discussion regarding ablation as an outpatient.
[ ] Holding all beta blockers pending normalization of heart
rate and clearance by EP
CONGESTIVE HEART FAILURE WITH PRESERVED EJECTION FRACTION
[ ] Continued on home Torsemide 60mg prior to discharge, was
slightly net positive each day. If he appears volume overloaded
he may require up-titration of his diuretics.
[ ] Started Spironolactone 50mg daily
[ ] Please obtain follow-up Chem-10 to assess need for potassium
chloride supplements. He was started on Spironolactone 50mg
during hospitalization and was not being actively diuresed at
discharge so potassium supplementation was held at discharge.
[ ] Holding all beta blockers
DIABETES MELLITUS
[ ] Discharged on home regimen of U500 insulin with scale
provided by Dr. ___ on ___. Please monitor for
hypoglycemia and assess patient compliance.
PSYCHIATRY
[ ] Continue outpatient Psychiatry follow up with Dr. ___.
[ ] Left home home Risperidone dosing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Omeprazole 40 mg PO BID
3. Torsemide 60 mg PO DAILY
4. RisperiDONE 1 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Lactulose 30 mL PO Q4H
7. Nadolol 20 mg PO QHS
8. Simethicone 40-80 mg PO QID:PRN gas pain
9. Aspirin 81 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
13. Potassium Chloride (Powder) 20 mEq PO DAILY
14. Glargine 55 Units Breakfast
Glargine 58 Units Bedtime
Humalog 33 Units Breakfast
Humalog 33 Units Lunch
Humalog 33 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Spironolactone 50 mg PO DAILY
RX *spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily
___ #*30 Tablet Refills:*0
2. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth Three times daily
Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily ___ #*30 Tablet Refills:*0
4. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day ___ #*30
Tablet Refills:*0
5. U-500 Conc 10 Units Breakfast
U-500 Conc 10 Units Lunch
U-500 Conc 10 Units Dinner
RX *insulin regular hum U-500 conc [Humulin R U-500
(Concentrated)] 500 unit/mL (Concentrated) AS DIR inject
subcutaneously as directed by ___ clinic up to 750units/day
per ___ #*2 Vial Refills:*0
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
RX *metformin [Glucophage XR] 500 mg 2 tablet(s) by mouth daily
___ #*60 Tablet Refills:*0
7. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice daily ___ #*60
Capsule Refills:*0
8. RisperiDONE 2 mg PO QHS
RX *risperidone 2 mg 1 tablet(s) by mouth every night ___ #*30
Tablet Refills:*0
9. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone [Gas Relief 80] 80 mg 1 by mouth Daily as needed
___ #*30 Tablet Refills:*0
10. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily ___ #*90 Tablet
Refills:*0
11. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily ___ #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute exacerbation of diastolic heart failure
Secondary Diagnosis: Atrial Flutter, High degree heart block,
Nonbleeding esophageal varices, Microcytic anemia, NASH
Cirrhosis, hyperlipidemia, urinary tract infection, multifocal
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were vomiting blood. We
did an endoscopy, which showed there was not bleeding in your
esophagus. You do have outpouched veins (varices) in your
esophagus, but these were not bleeding at time of the procedure.
You received a blood transfusion when you first came into the
hospital, but your blood counts have been stable for several
days.
Your heart was beating abnormally during your admission (called
Atrial Flutter). We advised you to get a procedure with the
Cardiology team called an "ablation" in order to normalize your
heart rhythm and decrease your long term risk of stroke. You
decided to forego this procedure during your hospitalzation. You
will follow up with the electrophysiology cardiology team as an
outpatient to continue the discussion about the procedure. You
will not be able to take your Nadolol without having the
procedure.
You were also confused when you came into the hospital. This may
have been because of your liver disease. We kept you on
medications (lactulose and rifaximin) that help with confusion.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19631559-DS-9
| 19,631,559 | 27,777,427 |
DS
| 9 |
2158-08-12 00:00:00
|
2158-08-14 07:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Bronchoscopy
History of Present Illness:
This patient is a ___ with unclear PMHx (possible hx of COPD on
home O2, ?CHF, ?fatty liver and DM) who is being transferred
from ___ with septic shock.
The patient presented to ___ by EMS with 3 days of
worsening mental status. In the field bp 190-200/100s, pulse
90-100, SaO2 75%. On arrival, he was found to be combative and
agitated and in acute respiratory distress (RR ___, pCO2 71) and
was intubated. His initial labs at ___ were notable for a
WBC of 10.8, H/H 10.9/34.9, ABG ___, alkphos 245, Cr
1.2, Trop 0.04 ___s a lactate of 3.4. He was given
cefepime and vancomycin and had a right IJ CVL and left radial
a-line placed prior to transfer.
Per ED sign-out, the patient received 1L IVF at ___ and
had his 2nd bag hanging on arrival to ___. He arrived on 3
pressors; Norepinephrine, Vasopressin, and Dobutamine. Since
arrival in the ED, his Norepinephrine has been downtitrated to
0.3 and his dobutamine is down to 1.5 with BP stable around
120/70. He is being sedated with fentanyl and midazolam. He has
had minimal UOP, per report. Of note, while he was with
MedFlight, he was given Hydrocortisone 100mg x 1 ___s
albuterol MDIs.
In the ___ ED, his initial vital signs were notable for HR 70,
BP 120/70 and SaO2 100% with FiO2 60% and PEEP of 8. His labs
were notable for a leukocytosis (___ 12.1), normocytic anemia
(Hgb 9.4), and thrombocytopenia (plts 146). His INR was 1.2. His
BMP was notable for BUN 35 and Cr 1.5 with glucose of 319. His
TnT was 0.7. LFTs notable only for mildly elevated AST (45) and
elevated Alk Phos (192) with normal TBili (0.8). UA demonstrated
moderate blood, protein and glucose without signs of a UTI. His
initial ABG was 7.27/___/43 and improved to ___ with a
lactate of 2.6. His imaging was notable for unremarkable CT
Head, and CT C-spine wit a CTA Chest with bibasilar
consolidation and a CT Abd/Pelvis with non-specific
lympadenopathy.
On arrival to the MICU, patient was intubated and sedated. He
was found to have multifocal pneumonia, with follow up blood
cultures revealing pseudomonas bacteremia which was
pan-sensitive. He also underwent bronchoscopy, with finding of
MSSA growing in sputum. He was originally on cefepime/vancomycin
for broad coverage, was extended to meropenem, and then managed
on Zosyn monotherapy.
Past Medical History:
- ?___
- Anemia
- Bipolar Depression
- Fatty liver
- GI bleed
- HTN
- HLD
- COPD
- DM
Social History:
___
Family History:
(Per chart review, unable to obtain from patient given
confusion/intubation)
Father healthy at ___
Mother died at ___ because of "weak muscles in her heart"
No siblings
Physical Exam:
ADMISSION EXAM:
================
GENERAL: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: obese, R IJ dressing soiled
LUNGS: Rhonchi bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Bilateral lower extremity venous stasis changes with skin
thickening
DISCHARGE EXAM:
================
VS Tc 98 BP 148-177/59-72 HR ___ RR18 100% 2L
Ambulatory sats: 88-94% on Room Air
315.7 lbs<<320.5 lbs<<318 lbs<< 320 lbs (dry weight unclear, per
report and patient 310 lbs)
Net negative from ___ (from 100 IV lasix)
General: Obese man, sitting up in chair, comfortable with nasal
cannula in place
Neck: supple
CV: regular rate and rhythm, S1 and S2, no m/r/g
Lungs: Bilateral crackles noted with air entry to bases, R>L,
crackles extending to mid lung fields, no wheezes
Abdomen: obese non tender non distended abdomen with present
bowel sounds, no guarding
GU: Foley out
Ext: Chronic venostasis with erythema bilaterally, ___ edema
bilaterally to below knee, legs elevated on exam
Neuro: Alert and oriented x3, pleasant, conversational
Skin: warm and well perfused, lower extremity exam as above,
isolated dark skin tag on stalk which is intermittently painful
per patient located below buttock on left side
Pertinent Results:
ADMISSION LABS:
___ 03:27AM WBC-12.1* RBC-3.27* HGB-9.4* HCT-31.2* MCV-95
MCH-28.7 MCHC-30.1* RDW-15.2 RDWSD-52.1*
___ 03:27AM NEUTS-76* BANDS-3 LYMPHS-14* MONOS-7 EOS-0
BASOS-0 ___ MYELOS-0 NUC RBCS-1* AbsNeut-9.56*
AbsLymp-1.69 AbsMono-0.85* AbsEos-0.00* AbsBaso-0.00*
___ 03:27AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
___ 03:27AM ___ PTT-30.0 ___
___ 03:27AM PLT SMR-LOW PLT COUNT-146*
___ 03:27AM cTropnT-0.07*
___ 03:27AM LIPASE-16
___ 03:27AM ALT(SGPT)-45* AST(SGOT)-35 ALK PHOS-192* TOT
BILI-0.8
___ 03:27AM GLUCOSE-319* UREA N-35* CREAT-1.5* SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 03:38AM O2 SAT-71
___ 03:38AM ___ RATES-26/ TIDAL VOL-450 PEEP-8 O2-60
PO2-43* PCO2-65* PH-7.27* TOTAL CO2-31* BASE XS-0 -ASSIST/CON
INTUBATED-INTUBATED
___ 03:39AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:39AM URINE RBC-21* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 03:39AM URINE HYALINE-12*
___ 03:39AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:45AM LACTATE-2.6*
___ 03:45AM O2 SAT-93
___ 03:45AM TYPE-ART PO2-77* PCO2-58* PH-7.28* TOTAL
CO2-28 BASE XS-0
PERTINENT LABS:
Venous PCO2 trend: High of 103 ___, transferred to
MICU)>>90>>89>>81>>80
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-3.3* RBC-3.02* Hgb-8.5* Hct-27.7*
MCV-92 MCH-28.1 MCHC-30.7* RDW-15.1 RDWSD-50.0* Plt ___
___ 06:00AM BLOOD Glucose-198* UreaN-17 Creat-1.1 Na-138
K-3.6 Cl-96 HCO3-32 AnGap-14
___ 06:00AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
MICROBIOLOGY:
==============
___: Blood culture: Pending
___: Urine Culture: Yeast
___ 3:30 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-CVL.
BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
__________________________________________________________
___ 5:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. <10,000 organisms/ml.
__________________________________________________________
___ 1:30 am BLOOD CULTURE LINE CVL.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:08 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 8:49 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
__________________________________________________________
___ 9:00 pm BLOOD CULTURE REQ WAS ALREADY SCANNED.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:02 pm BLOOD CULTURE Source: Line-aline.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:48 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. ~1000/ML.
__________________________________________________________
___ 2:36 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ___.
__________________________________________________________
___ 3:07 am BLOOD CULTURE Source: Line-art.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:48 am BLOOD CULTURE Source: Line-cvl.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:05 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 0.5 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
__________________________________________________________
___ 9:00 pm BLOOD CULTURE Source: Line-Lt IJ 2 ___ 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:21 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 pm BLOOD CULTURE Source: Line-A line.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:56 am BLOOD CULTURE Source: Line-Aline.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:55 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:30 pm BLOOD CULTURE Source: Line-art.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:24 pm BLOOD CULTURE Source: Line-central.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:24 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ~4000/ML.
__________________________________________________________
___ 2:29 am BLOOD CULTURE Source: Line-arterial line.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 4:03 am
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:27 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
CT Head noncontrast ___:
IMPRESSION: Normal CT of the brain. Aerosolized layering
secretions in the visualized paranasal sinuses is likely related
to intubation.
CTA Chest/Abdomen ___
IMPRESSION:
1. No evidence of acute pulmonary embolism.
2. Bilateral dependent consolidation is likely due to
atelectasis, although superimposed infection cannot be excluded.
3. No acute intra-abdominal process to explain the patient's
presentation.
4. Nonspecific retroperitoneal, mesenteric, and inguinal lymph
node
enlargement may be in part reactive. Correlate with any
available prior OSH studies.
5. A linear density along the right mesentery adjacent to
normal-appearing small bowel without associated fluid collection
is nonspecific, and may represent sequela of prior
lymphadenopathy or sclerosing mesenteritis. Correlation with
prior imaging or history would be helpful. Otherwise, attention
on followup imaging is advised.
CT Cspine ___
IMPRESSION: Mild changes of degenerative disc disease.
Otherwise normal study.
CXR ___:
Almost complete collapse of the lower lobes bilaterally right
greater than left is better seen in prior CT. There is moderate
cardiomegaly. Widened mediastinum is due to increased in
mediastinal fat. Left upper lobe perihilar atelectasis is again
noted. There is no pneumothorax or pleural effusion. ET tube
is in standard position. Right IJ catheter tip is upper SVC.
NG tube tip is out of view below the diaphragm.
TTE ___: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function. Right ventricle not well seen but limited
views suggest reasonably preserved systolic function (see
above). At least mild tricuspid regurgitation. Moderate
pulmonary hypertension with possible RV pressure/volume
overload. No 2D echocardiographic evidence of endocarditis.
CT Heat ___: 1. No evidence of intracranial hemorrhage. 2.
Sinus disease, as described above.
CXR ___
IMPRESSION:
There are low lung volumes. Severe cardiomegaly and widened
mediastinum are unchanged. Now mild pulmonary edema has
improved. Patient's chin obscures the apices of the lungs.
Bibasilar opacities are a combination of small effusions and
adjacent atelectasis.
Brief Hospital Course:
This is a ___ year old male with past medical history of chronic
venous stasis, diastolic CHF, OSA on CPAP admitted ___
with acute on chronic hypoxic respiratory failure requiring
intubation secondary to pseudomonas bacteremia and multifocal
pneumonia, bronchoscopy with MSSA, course complicated by
hypertensive emergency, ___, acute hypercarbic respiratory
failure attributed to medication effect, transferred from MICU
to hospitalist service ___, status post additional
diuresis, on room air, ready for discharge to rehab on PO
torsemide
# Acute hypoxemic respiratory failure / Acute and Chronic
Diastolic CHF / Acute Bacterial Pneumonia with Pseudomonas /
COPD without exacerbation / Obstructive Sleep Apnea - Patient
intubated at OSH ED in the setting of acute hypoxemia and was
transferred to ___ for further management. Workup notable for
CTA negative for PE, felt to have acute bacterial pneumonia and
acute on chronic diastolic CHF. He underwent bronchoscopy, with
BAL cultures growing MSSA pneumonia. Also found to have
pseudomonas bacteremia (as below). He was treated broadly and
then narrowed to Zosyn monotherapy once culture data returned.
His course was complicated by difficulty with weaning from
ventilator (remained intubated ___, attributed to
pulmonary edema. He required diuresis with a lasix gtt, and was
subsequently extubated ___. Antibiotics and diuresis were
continued with clinical improvement. He completed a 14-day
course of Zosyn while inpatient. Continued home nebulizers,
triotropium, and restarted nightly bipap which he reported poor
compliance with at home. He was discharged on Torsemide 40 mg
daily. His discharge weight was 315 lbs.
# Septic shock due to pseudomonas bacteremia and MSSA PNA:
patient presented with leukocytosis, tachycardia and hypoxia,
with evidence of end organ damage (elevated lactate, ___.
Thought to be related to above. He was treated with broad
spectrum antibiotics (Vanc/Zosyn) and he initially required
Levophed/Vasopressin/Dobutamine, he was able to be weaned off
pressors and his shock resolved.
# Acute Hypercarbic Respiratory Failure - His course was
complicated by acute onset of progressive somnolence during the
afternoon of ___. VBG demonstrated a pCO2>100 and a pH of
7.2. He required re-transfer to the ICU, and initiation of
non-invasive ventilation. He subsequently improved over the
following day, with concern for symptoms being precipitated by
his ongoing heart failure (above), as well as medication effect
from a dose of Seroquel he received.
# Acute Metabolic Encepahlopathy - in setting of above, patient
had significant agitation, requiring high doses of precedex and
fentanyl while in the ICU; confusion thought to relate to acute
illness, medication effect, complicated by his underlying
psychiatric disorder. He improved to baseline with above
treatments.
# Hypertension - Once hemodynamically stable, patient restarted
on home medications, Losartan, HCTZ, labetalol.
# Demand Cardiac Ischemia - had Troponin elevation TnT 0.04 ->
0.07 in setting of sepsis and above acute illness. Continued on
Aspirin.
# ___: Admited with ___, thought to relate to sepsis and
pre-renal state in setting of above. Improved with IV fluids
and treatment of sepsis and infection. Discharge creatinine:
1.1.
# COPD: He was continued on duonebs. He was discharged on
albuterol and ipratropium.
# DM type 2, uncontrolled, with complications - Last HgbA1c
10.4. Followed at ___. He was initially placed on an insulin
gtt, which was changed back to a long-acting regimen at the time
of his transfer to the floor. He was discharged home on his home
U500 and metformin. He will need ongoing follow-up with ___
for treatment with U500.
#Paranoid Schizophrenia : He was continued on his home
risperidone 1mg BID. Psychiatry evaluated him inpatient and
agreed on medication, and advised against Seroquel
administration. He is pending outpatient psychiatry followup.
TRANSITIONAL ISSUES:
-Discharge weight: 315 lbs
-Discharge BUN/Cr: ___
-Please monitor weights and creatinine, adjust diuretic regimen
as needed
-Please monitor blood pressure, titrate medications for goal BP
of <140/90.
-On discharge from rehab, please arrange for sleep clinic
follow-up for OSA management
-PER RADIOLOGY: 6 month followup CT should be considered to
reassess lymph nodes and the right mesenteric linear density.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. RISperidone 2 mg PO QHS
3. Furosemide 120 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. U-500 Conc 50 Units Breakfast
U-500 Conc 50 Units Bedtime
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
8. Atorvastatin 20 mg PO QPM
9. Ferrous Sulfate 325 mg PO BID
10. Lorazepam 1 mg PO QHS:PRN sleep
11. Nadolol 40 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Atorvastatin 20 mg PO QPM
3. Hydrochlorothiazide 25 mg PO DAILY
4. U-500 Conc 50 Units Breakfast
U-500 Conc 50 Units Bedtime
5. Losartan Potassium 100 mg PO DAILY
6. RISperidone 1 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Torsemide 40 mg PO DAILY
9. Ferrous Sulfate 325 mg PO BID
10. Fish Oil (Omega 3) 3600 mg PO DAILY
11. Lorazepam 1 mg PO QHS:PRN sleep
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
13. Nadolol 40 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Potassium Chloride 20 mEq PO DAILY
Hold for K >
16. Vitamin D 1000 UNIT PO DAILY
17. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN sob
18. Labetalol 200 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Acute on Chronic Respiratory Failure
-Acute Diastolic CHF
-Pseudomonas Bacteremia
-Hypertension
Secondary Diagnosis:
-Diabetes Mellitus, On insulin
-Hyperlipidemia
-Depression on Risperidone
-Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were initially admitted to ___ ___ with concerns
for infection and confusion, found to have an infection in your
blood, and were treated in the ICU with antibiotics, medications
to maintain your blood pressure, and intubation to help you
breathe. As you got better, your breathing tube was taken out
and you were managed with medications to help get fluid off from
your lungs.
You were transferred to the medicine floors for finishing
treatment with antibiotics for your infection. While here, you
had some trouble breathing, because you were not on your
breathing machine at night (called CPAP and BIPAP). You were
transferred to the ICU for closer followup and improved with
BIPAP. Your breathing has improved since then, and you have been
off oxygen therapy.
We recommend you use the CPAP machine at night to help with your
breathing. You were placed on a new water pill, called
Torsemide, which will replace your Lasix. It is very important
to watch how much salt you eat, and weigh yourself to monitor
your fluid status.
We wish you the best
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19631592-DS-9
| 19,631,592 | 22,179,879 |
DS
| 9 |
2124-03-29 00:00:00
|
2124-04-09 17:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / shellfish derived / ACE Inhibitors
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with a past medical history of
breast cancer (with local recurrence s/p L mastectomy, has also
had radiation, exemestane and anastrazole), HTN, HLD, CKD, DM2
who presents today with sudden onset of vertigo.
She states that she was in her normal state of health until
about
2am today (she normally goes to bed between 12 and 2am). She had
been laying in bed, on her back. She got up to go to the
bathroom, and then when she came back to lie in bed (again on
her
back), she had sudden onset of spinning (more like her head was
spinning, not like the room was spinning). This lasted for less
than 30 seconds, and got better when she sat up in bed. However,
after the acute episode resolved, she still felt somewhat dizzy
(can't really describe the feeling, but no longer spinning). As
this feeling didn't go away for about a half an hour, she
decided
to come in to the emergency room. She has a roommate who was
there during this episode, and came in to the ED with her.
Upon coming to the ED, she did vomit x 1 (although she did not
note severe nausea). Code stroke was called. Currently, on my
evaluation, less than 10 minutes after admission to ED, her
symptoms are resolved. Blood glucose was wnl, and systolic blood
pressure in the 160s.
She has never had symptoms like this before.
Throughout the rest of this time, she denied any focal weakness,
numbness, double vision, loss of vision, or clumsiness. She had
no speech difficulties.
On general review of systems, she denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HLD
- HTN
- CKD
- Breast cancer (mucinous carcinoma ___ s/p lumpectomy, then
grade 2 infiltrating ductal carcinoma s/p mastectomy +
anastrazole, then 1 mucinous carcinoma s/p excision, exemestane)
- DM2
- Primary hyperparathyroidism
Family History:
- Father Cancer - ___ Hypertension
- Maternal Aunt ___ Cancer
- Mother ___ - Type II; Glaucoma
- Sister CAD/PVD; Cancer - Colon; Cancer - Uterine; Diabetes -
Unknown Type; Hypertension
Physical Exam:
===========================
Admission Physical Exam
===========================
Vitals: 98.1 66 161/60 20 97% 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
Chest: Lungs CTA bilaterally. s/p L mastectomy
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No edema, well-perfused.
Skin: no rashes or lesions noted.
___ + only for symptoms, no nystagmus, to the left.
States these are the same symptoms that brought her in.
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. Speech
somewhat dysarthric - but related to missing teeth, and at
baseline per roommate. Able to read without difficulty. Able to
follow both midline and appendicular commands. 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. VFF to confrontation. Fundoscopic
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.
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 4 5 5 5 5
R 5 ___ ___ 5 5 4 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout.
Proprioception intact.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
===========================
Discharge Physical Exam
===========================
Vitals: 98.1 66 161/60 20 97% 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
Chest: Lungs CTA bilaterally. s/p L mastectomy
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No edema, well-perfused.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place and time. 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. Speech
somewhat dysarthric - but related to missing teeth, and at
baseline per roommate. Able to read without difficulty. Able to
follow both midline and appendicular commands. 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. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. Mildly
positive ___ to the left.
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 4 5 5 5 5
R 5 ___ ___ 5 5 4 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout.
Proprioception intact.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
=======
LABS
=======
___ 01:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:44AM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD %HbA1c-5.8 eAG-120
___ 01:00PM BLOOD Triglyc-81 HDL-56 CHOL/HD-3.3 LDLcalc-113
___ 01:00PM BLOOD TSH-2.3
___ 03:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
============
IMAGING
============
NCHCT (___):
IMPRESSION:
Focal 6 x 5 mm hyperdensity within the right cerebellar peduncle
for which an intraparenchymal hemorrhage cannot be excluded. No
infarction is identified. Please note MR is a more sensitive
examination and can be obtained for further evaluation.
NOTE ADDED ATTENDING REVIEW: The hyperdensity question in the
posterior fossa appears to be and artifact.
MRI (___):
Unremarkable, unenhanced MRI examination of the brain. The
previously seen focal hyperdensity within the right cerebellar
peduncle is most consistent with an artifact.
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a past medical history of
breast cancer (with local recurrence status post left
mastectomy, XRT, and exemestane and anastrazole chemotherapy),
hypertension, hyperlipidemia, and type 2 diabetes mellitus who
presented to ___ ___ with sudden onset of vertigo. Neurologic
examination was unremarkable. ___ examination was
positive for symptoms but no nystagmus. Her NCHCT in the ED
showed a hyperdensity in the right cerebellar peduncle, more
likely to be artifact than blood. However, given her history of
recurrent breast cancer and multiple vascular risk factors, she
was admitted to the stroke neurology service for MRI brain to
ensure that there was no bleed that is causing her symptoms.
While in the hospital, her symptoms resolved. On repeat
___ testing, she did have a mildly positive result on
the left. MRI was unremarkable and the previously seen focal
hyperdensity within the right cerebellar peduncle was most
consistent with an artifact. She was monitored on telemetry and
there were no abnormalities. Symptoms were attributed to BPPV
and she was prescribed ___ rehab therapy at time of
discharge.
==============================
TRANSITIONS OF CARE
==============================
- Patient presented with vertigo. There was question of
hemorrhage in the cerebellum on head CT. She was admitted for
MRI brain which was normal (no evidence of stroke or
hemorrhage). Does have mildly positive ___ on the left.
So, etiology of symptoms is most likely BPPV. Discharged home
with script for outpatient ___ for vestibular therapy.
Medications on Admission:
- Diltiazem ER 180mg daily
- Elder Berry
- Exemestane 25mg daily
- HCTZ 25mg daily
- Pravastatin 80mg daily
- Multivitamin daily
Discharge Medications:
1. Diltiazem Extended-Release 180 mg PO DAILY
2. exemestane 25 mg oral DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 80 mg PO DAILY
6. Outpatient Physical Therapy
Vestibular physical therapy
Discharge Disposition:
Home
Discharge Diagnosis:
benign paroxysmal positional vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with dizziness. We were worried that
you had a stroke so we did an MRI of your brain. The MRI looked
normal and showed that you DO NOT have a stroke or blood in the
brain.
The dizziness is from a calcium stone in your left ear. We will
give you a script for physical therapy to learn exercises to
help to improve your symptoms. Be cautious at home and try to
move slowly when you turn and change position to avoid bringing
on symptoms. You should not drive until your symptoms have
imprved.
You should see Dr. ___ in neurology clinic to check in. We
have scheduled the appointment for you.
We have not made any changes to your medications.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
19631604-DS-21
| 19,631,604 | 23,916,993 |
DS
| 21 |
2174-01-29 00:00:00
|
2174-02-25 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / mushrooms / amlodipine / Lyrica
Attending: ___.
Chief Complaint:
peritonitis
Major Surgical or Invasive Procedure:
___: Left L2 and L3 gelfoam and coil embo, L4 angio and
post division Left int iliac gelfoam embo
___: Removal of peritoneal dialysis catheter
___: Tunneled HD line (RIJ)
History of Present Illness:
___ PMH CKD IV on PD, high grade B cell lymphoma s/p radical
splenectomy and gastric wedge resection ___, history of ESRD
___
HTN on peritoneal dialysis daily who presents with cloudy
peritoneal dialysate. He was in his USOH until ___, when he
developed nausea. He had one episode of vomiting that was non
bloody. On ___, he developed weakness and dry heaves as well
as bilateral lower abdominal pain. He was seen by his
outpatient
nephrologist at ___ ___ and was told that his PD
catheter site was c/d/I but that his PD fluid was grey and
opaque/cloudy. PD fluid studies were sent, which showed over
20k
WBCs, 95% PMNs. He was given a dose of intraperitoneal
ceftazidime 1g yesterday. His PD fluid cultures then grew gram
negative rods so he was told by Dr. ___ to present to the ED.
Of note, recently admitted ___ for BRBPR likely due to
diverticulosis. He denied any symptoms except for mild bilateral
lower abdominal pain and mild productive cough. He had
intermittent diarrhea over the past few days but this is not
abnormal for him. The patient does not remember any
contamination
of his PD catheter site but did say he switched to manual rather
than machine dwells this ___.
In the ED:
- Initial vital signs were: 98.3 62 166/83 17 100% RA
- Exam notable for: no abdominal tenderness, PD catheter noted
on abdomen, otherwise unremarkable
- Labs were notable for: Chem panel with bicarb of 20, Agap of
22, azotemia c/w patient on PD. Leukocytosis to 11.3
- Studies performed include:
N/A
- Patient was given:
IV CefTAZidime 1 g
- Consults:
Nephrology (dialysis) who recommended blood and urine cultures,
repeat PD fluid gram stains, cxs, and cell counts, restarting PD
regimen, and IP ceftazidime
- Vitals on transfer:
97.8 65 175/70 18 100% RA
Upon arrival to the floor, the patient denies any symptoms
except
fatigue and hunger. He denies nausea, vomiting, fevers, chills,
chest pain, diarrhea, dysuria, BRBPR, lower extremity edema,
rash, drainage from PD site.
Past Medical History:
- high grade B cell lymphoma s/p radical splenectomy and
gastric wedge resection ___
- CKD stage IV
- Nephrolithiasis
- colloid cyst of ___ ventricle with secondary syncope s/p
neurosurgical resection (___) and VP shunt (MRI INCOMPLATIBLE)
- Anxiety & Claustrophobia
- LS radiculopathy
- chronic back pain
- HTN
- hyperuricemia
- repair of incisional & umbilical hernia with mesh ___
Social History:
___
Family History:
Mother-died of lung cancer
Father-died of lung cancer
Physical Exam:
ADMISSION:
VITALS: 97.6 PO 185 / 73 L Sitting 64 18 97 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: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
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.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
palpation in lower abdomen bilaterally, PD catheter in place and
LLQ c/d/i
EXTREMITIES: No edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE:
___ 0337 Temp: 97.5 PO BP: 165/79 R Lying HR: 60 RR:
18 O2 sat: 93% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: RRR, IV/VI systolic murmur best at the apex. Audible S1
and S2.
LUNGS: Clear to auscultation bilaterally anteriorly/laterally.
No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
palpation L side, mild L flank pain.
BACK: L side flank ecchymosis
EXTREMITIES: WWP, No edema. R groin access sign with large
hematoma, diffuse ecchymosis throughout groin and inner thighs,
onto R side, 2+ DPs, L thigh swollen with firm areas
NEUROLOGIC: AOx3. Grossly intact.
Pertinent Results:
ADMISSION:
=========
___ 02:10PM BLOOD WBC-11.3* RBC-2.45* Hgb-7.9* Hct-24.2*
MCV-99* MCH-32.2* MCHC-32.6 RDW-15.5 RDWSD-55.7* Plt ___
___ 02:10PM BLOOD Neuts-90.4* Lymphs-2.2* Monos-5.1 Eos-1.4
Baso-0.3 NRBC-0.3* Im ___ AbsNeut-10.17* AbsLymp-0.25*
AbsMono-0.57 AbsEos-0.16 AbsBaso-0.03
___ 07:07AM BLOOD ___ PTT-27.6 ___
___ 02:10PM BLOOD Glucose-111* UreaN-107* Creat-10.2*#
Na-137 K-3.9 Cl-95* HCO3-20* AnGap-22*
___ 07:07AM BLOOD Calcium-8.5 Phos-7.6* Mg-1.7
___ 07:37AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:37AM BLOOD HCV Ab-NEG
___ 03:00PM BLOOD Lactate-1.9
INTERVAL:
=======
___ 07:05AM BLOOD WBC-25.4*# RBC-1.91* Hgb-5.9* Hct-19.0*
MCV-100* MCH-30.9 MCHC-31.1* RDW-15.8* RDWSD-57.1* Plt ___
___ 11:38AM BLOOD Ret Aut-2.4* Abs Ret-0.04
___ 01:43PM BLOOD ___
___ 09:10AM BLOOD ALT-<5 AST-22 LD(LDH)-323* AlkPhos-54
TotBili-0.5
___ 07:54AM BLOOD CK-MB-6 cTropnT-0.10*
___ 07:10PM BLOOD Albumin-2.2* Calcium-7.2* Phos-4.5 Mg-1.8
___ 07:05AM BLOOD Hapto-137
___ 07:37AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:37AM BLOOD CRP-73.4*; ESR 11
___ 07:37AM BLOOD HCV Ab-NEG
___ 07:27PM BLOOD Lactate-2.8*
___ 09:30AM BLOOD Lactate-1.3
MICRO:
======
___:50 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___:
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
PSEUDOMONAS AERUGINOSA. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 8 S 8 S
CEFTAZIDIME----------- 4 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ 8 I 8 I
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- 8 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
___ BLOOD CULTURE X2: NO GROWTH
___ 5:40 pm DIALYSIS FLUID PERITONEAL DIALYSATE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ (___) AT 3:20
___
___.
PSEUDOMONAS AERUGINOSA. RARE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
___ 12:57 am DIALYSIS FLUID SOURCE: PERITONEAL
DIALYSATE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. RARE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
REFER TO REPORTED SUSCEPTIBILITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ BLOOD CULTURE X2: NGTD
REPORTS:
========
HD CATH ___:
Successful placement of a 19cm tip-to-cuff length tunneled
dialysis line. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
CT A/P ___:
1. Acute uncomplicated sigmoid diverticulitis.
2. Trace ascites, likely accounted for by the peritoneal
dialysis catheter.
3. Hepatic fibrosis.
4. Bilateral renal atrophy with numerous cysts. 6 mm
nonobstructing right
interpolar renal calculus.
5. Postsurgical changes from splenectomy.
6. Small right and trace left pleural effusions.
7. 9 mm left adrenal adenoma lipoma.
___ LLE U/S
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Left ___ cyst, measuring 2.4 x 4.5 x 0.9 cm.
CT A/P W/O CONTRAST ___
1. Intramuscular retroperitoneal hematoma involving the entire
imaged portion
of the left psoas and iliopsoas muscles. Several areas of
relatively
high-density material seen adjacent to or within these muscles
likely reflect
more acute hemorrhage. Evaluation for active extravasation is
limited on this
unenhanced study.
2. Moderate left and small right pleural effusions.
3. Cholelithiasis without evidence of cholecystitis.
CTA A/P ___
1. Increased size of a left retroperitoneal hematoma as
described above with
no evidence of active bleeding.
2. New hematoma within the right groin with areas of active
hemorrhage as
described above.
3. New moderate-sized high-density left pleural effusion
suggestive of a
hemothorax, of unclear etiology.
ABDOMINAL AORTA ___
1. Active hemorrhage from the left L2 and L3 lumbar arteries.
2. No active hemorrhage identified from the left L4 lumbar
artery.
3. Probable small pseudoaneurysm off of the posterior division
of the left
internal iliac artery.
4. Stasis of flow in the left L2, L3 lumbar arteries and
posterior division
of the left internal iliac artery post embolization.
CTA ___
1. Increased size of a left retroperitoneal hematoma as
described above with
no evidence of active bleeding.
2. New hematoma within the right groin with areas of active
hemorrhage as
described above.
3. New moderate-sized high-density left pleural effusion
suggestive of a
hemothorax, of unclear etiology.
U/S GROIN ___
1. Right groin hematoma which corresponds to the CTA finding.
2. No definitive color Doppler flow within the hematoma to
suggest ongoing
active arterial hemorrhage.
ARTERIAL DUPLEX U/S ___
1. Right groin hematoma, without internal flow to suggest
active bleeding.
2. No evidence of pseudoaneurysm.
CXR ___
Compared to chest radiographs since ___ most recently ___.
Abnormality in the left lower lobe appears to have progressed
since the
abdominal CT on ___. This could be pneumonia. Moderate
left pleural
effusion probably persists. Right lung and pleural space are
normal. Heart
size is top-normal. Dual channel right supraclavicular
catheters end close to
the superior cavoatrial junction
US EXTREMITY LIMITED SOFT TISSUE LEFT ___
Distal extension of known retroperitoneal hematoma extends
approximately 7.0
cm below the femoral head, similar to CT dated 1 day prior.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with ___ ESRD ___ HTN
on PD, high grade B cell lymphoma s/p radical splenectomy and
gastric wedge resection ___ who presents with PD-associated
peritonitis.
ACUTE ISSUES:
===========
# PD associated peritonitis:
The patient presented with abdominal pain and peritoneal
dialysate growing Pseudomonas aeruginosa (I to gentamicin,
otherwise pan-sensitive). Transplant surgery, infectious
disease, and renal were consulted. CT abdomen and pelvis was
obtained to evaluate for secondary causes given persistently
high peritoneal WBCs. Although the scan revealed findings
suggestive of diverticulitis, this was not thought to correlate
with symptoms or exam location. More likely that he had a
catheter-associated infection as his catheter has grown
Pseudomonas in the past. Therefore, he underwent placement of a
tunneled HD line ___ and had removal of his PD catheter
___. He continued to receive ceftazidime, initially IP
and subsequently IV with hemodialysis. Continue hemodialysis
___ with administration of IV ceftazidime for peritonitis
(END: ___ for a 28 day course. Follow-up pending cultures
in clinic.
# ESRD ___ HTN; transition from PD to HD ___:
The patient was switched from peritoneal dialysis to
hemodialysis in the setting of a catheter related PD
peritonitis. He can be evaluated for interval re-siting of a
peritoneal dialysis catheter per renal and transplant surgery.
He was continued on cinacalcet, sevelamer, vitamin D, and
torsemide at home dose.
# Spontaneous Retroperitoneal Hematoma
# R groin access site Hematoma
# Syncope ___ acute blood loss
Patient noted to have downtrending hemoglobin 7.7 -> 5.9 and
elevated WBC count 13.9 -> 25.4 for unclear reason ___. Did
not have appropriate response to 1u pRBC transfusion. CT A/P w/o
contrast showing extensive hematoma involving the entire imaged
portion of the left psoas and iliopsoas muscles with concern for
active bleeding. Unclear why this happened as patient did not
have any recent trauma to the area and was not anticoagulated.
CTA was then done which showed active bleeding. He underwent
gelfoam gelfoam and coil embolization of Left L2 and L3 lumbar
arteries, L4 angio and post division left int iliac gelfoam embo
___ in ___. Later in the day, he was noted to have downtrending
H/H despite receiving transfusions, found to have rapidly
expanding R groin hematoma associated with the femoral access
site. Triggered for syncope in the setting of acute blood loss.
Repeat CTA showed increased size of left retroperitoneal
hematoma without active bleeding, new hematoma within the right
groin with areas of active hemorrhage, however US of right groin
for thrombin injection in ___ did not show definitive active
hemorrhage or femoral pseudoaneurysm. Followup studies confirmed
no pseudoaneurysm. Pt c/o L thigh pain and firmness, u/s showed
no active bleeding in the L thigh.
# Acute on Chronic Anemia:
# Acute Blood Loss Anemia
The patient presented with anemia worse than recent baseline of
___. Initially no evidence of active bleed, received 1u pRBC and
blood count remained stable. Thought to be in the setting of
CKD/infection. Then had spontaneous RP bleed and associated
post-procedure complication and received 7 units pRBC, also
received 1 unit platelets and FFP, and DDAVP for possible
uremia. Heme/onc was consulted regarding spontaneous bleeding,
surmised it was most likely due to a combination of uremia
during time of ineffective dialysis plus ongoing use of aspirin,
which had been discontinued after bleeding started.
# Leukocytosis
Developed significant leukocytosis to 30k i/s/o bleeding,
thought likely to be reactive.
# Moderate L pleural effusion
# Concern for hemothorax
CTA ___ noted new moderate L side pleural effusion with
hyperintensity concerning for hemothorax. IP was consulted,
performed bedside u/s showing small simple effusion. Upon
further review of imaging, effusion had been present prior to
___. No intervention was necessary.
CHRONIC ISSUES:
============
# HTN: The patient was persistently hypertensive during his
hospital course, frequently to SBP 200, asymptomatic. Labetalol
was increased to 600 TID. Continued home clonidine patch. These
were discontinued in the setting of acute bleeding but restarted
prior to discharge. BPs remained elevated and minoxidil 5 mg was
added.
# Allergic rhinitis: Continued azelastine, flonase prn
# Nephrolithiasis: Continued on home allopurinol ___ PO daily
# Anxiety/Claustrophobia: Continued DULoxetine 20 mg PO DAILY
# CAD prevention: Was on 81 mg Aspirin daily, but was held after
bleeding event and not restarted due to risk of bleeding.
TRANSITIONAL ISSUES:
[ ] Continue hemodialysis ___ with administration of IV
ceftazidime for peritonitis (END: ___ for a 28 day
course. (Intake for HD on ___
[ ] Follow-up pending cultures in clinic.
[ ] Monitor BP in clinic and adjust regimen as appropriate.
Discharged on 600 mg labetalol TID and 5 mg minoxidil.
[ ] Aspirin was held in setting of acute bleeding. Could
consider restarting in the future but need to weigh
risks/benefits of CVD prevention versus bleeding.
# CODE STATUS: full
# CONTACT: ___ (landlord): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
2. DULoxetine 20 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NS DAILY
4. Labetalol 450 mg PO TID
5. Allopurinol ___ mg PO DAILY
6. sevelamer CARBONATE 2400 mg PO TID W/MEALS
7. Aspirin 81 mg PO DAILY
8. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
9. Torsemide 60 mg PO QAM
10. Vitamin D ___ UNIT PO DAILY
11. Cinacalcet 30 mg PO DAILY
Discharge Medications:
1. CefTAZidime 2 g IV POST HD (___)
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 g IV post-HD ___ Disp #*5 Intravenous Bag
Refills:*0
2. CefTAZidime 3 g IV POST HD (SA)
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 1
gram/50 mL 3 g IV post-HD ___ Disp #*3 Intravenous Bag
Refills:*0
3. Minoxidil 5 mg PO DAILY
RX *minoxidil 10 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Labetalol 600 mg PO Q8H
5. Allopurinol ___ mg PO DAILY
6. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
7. Cinacalcet 30 mg PO DAILY
8. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
9. DULoxetine 20 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NS DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Torsemide 60 mg PO QAM
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you talk to your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
#Catheter related PD peritonitis
#Hypertension
#End-stage renal disease due to hypertension
#Spontaneous L Psoas Hematoma
#Acute blood loss anemia ___ RP bleed and R groin vascular
access site bleed
#Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for an
infection in your peritoneal dialysis catheter.
While you were here:
-We gave you antibiotics to fight the infection
-We removed your peritoneal dialysis catheter
-We started you on hemodialysis
-You had a bleed in the muscles in your back and leg which
required clotting off the arteries
-You had a bleed in your groin as a result of the procedure to
stop the bleeding in your back
-You received many blood transfusions to stabilize your blood
count
When you go home:
-Please continue all medications as directed
-Please follow-up with the below doctors
___ the best,
Your ___ care team
Transplant Surgery Discharge Instructions
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, increased abdominal
pain, increased incisional redness, drainage or bleeding,
dizziness or weakness, decreased urine output or dark, cloudy
urine, swelling of abdomen or ankles, or any other concerning
symptoms.
.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotions or powder near the
incision. You may leave the incision open to the air. However,
we recommend covering the incision and PD catheter site with a
dry gauze if there is any drainage from your wounds, and
changing the dressing daily after you shower. The steri strips
will fall off on their own in ___ days.
.
No tub baths or swimming
.
No driving if taking narcotic pain medications
Followup Instructions:
___
|
19631604-DS-22
| 19,631,604 | 21,796,213 |
DS
| 22 |
2174-02-02 00:00:00
|
2174-02-05 08:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / mushrooms / amlodipine / Lyrica
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with ESRD on PD, high grade B
cell lymphoma s/p radical splenectomy and gastric wedge
resection ___, recent admission from ___ to ___ for
peritonitis who is now requiring admission to the medicine team
for safe discharge planning after mechanical fall.
Shortly after discharge yesterday, the patient sustained a
mechanical fall after slipping on ice while he was getting out
of his cab that brought him home from the hospital. He was able
to catch his fall on a nearby snow bank and did not have any
associated head strike or other trauma. He was unable to resume
standing without assistance, but subsequently able to ambulate
into his home.
Of note, the patient was recently admitted from ___ to ___
with peritonitis and his hospital course was complicated by
spontaneous RP hematoma requiring embolization, then groin site
hematoma, syncope from acute blood loss anemia, and difficult to
control HTN with systolics frequently exceeding 200. The patient
states that throughout his stay he had experienced new onset
thigh weakness and overall feels significantly deconditioned
from that stay.
In the ED, initial vitals: T97.3 HR55 BP 179/72 RR 18 98% RA.
Exam notable for hematoma extending below L knee over posterior
and lateral aspect of L knee. L knee without effusion, but TTP.
- Labs were significant for:
Cr 2.7, Na 141, K 3.5
WBC 19.0, Hg 8.3
-Imaging showed:
Knee plain film: No acute fracture or dislocation.
hip plain film: No acute fracture or dislocation.
In the ED, pt received:
-labetolol 600mg x3
-monixidil
-torsemide 60mg
Vitals prior to transfer: T98.1 HR 61 BP 144/71 RR 17 98% RA
Upon arrival to the floor the patient is in no acute distress
and walking around his room cautiously. States that his knee
pain is not particularly bothersome at rest, but some discomfort
with movement and palpation. He denies any leg numbness or bowel
incontinence.
Past Medical History:
- high grade B cell lymphoma s/p radical splenectomy and
gastric wedge resection ___
- CKD stage IV
- Nephrolithiasis
- colloid cyst of ___ ventricle with secondary syncope s/p
neurosurgical resection (___) and VP shunt (MRI INCOMPLATIBLE)
- Anxiety & Claustrophobia
- LS radiculopathy
- chronic back pain
- HTN
- hyperuricemia
- repair of incisional & umbilical hernia with mesh ___
Social History:
___
Family History:
Mother-died of lung cancer
Father-died of lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97.6 BP 106/61 HR 65 RR18 93% RA
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: RRR, IV/VI systolic murmur best at the apex. Audible S1
and S2.
LUNGS: Clear to auscultation bilaterally anteriorly/laterally.
No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
palpation L side, mild L flank pain. R groin access sign with
large
hematoma, diffuse ecchymosis throughout groin and inner thighs,
onto R side.
BACK: L side flank ecchymosis
EXTREMITIES: full ROM of left hip. no asymmetry noted of lower
extremities. left knee without warmth, erythema, or evidence of
effusion. 1+ pitting in LLE to shin.
NEUROLOGIC: AOx3. ___ strength in RLE. ___ strength in left hip
flexion. ___ strength in left knee flexion. Sensation intact.
DISCHARGE PHYSICAL EXAM
97.8
PO 126 / 66
R Lying 66 18 95 Ra
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: RRR, IV/VI systolic murmur best at the apex. Audible S1
and S2.
LUNGS: Clear to auscultation bilaterally anteriorly/laterally.
No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mildly tender to
palpation L side, mild L flank pain.
BACK: L side flank ecchymosis
EXTREMITIES: WWP. R groin access sign with large
hematoma, diffuse ecchymosis throughout groin and inner thighs,
onto R side, 2+ DPs, L thigh swollen with firm areas. Some lower
extremity edema b/l to shins.
NEUROLOGIC: AOx3. Grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 06:45AM BLOOD WBC-23.6* RBC-2.62* Hgb-8.0* Hct-24.3*
MCV-93 MCH-30.5 MCHC-32.9 RDW-20.2* RDWSD-61.9* Plt ___
___ 06:45AM BLOOD Glucose-80 UreaN-35* Creat-5.1*# Na-138
K-4.7 Cl-97 HCO3-26 AnGap-15
___ 06:45AM BLOOD Calcium-7.3* Phos-4.0 Mg-2.1
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-15.6* RBC-2.54* Hgb-7.8* Hct-24.2*
MCV-95 MCH-30.7 MCHC-32.2 RDW-19.5* RDWSD-66.7* Plt ___
___ 07:30AM BLOOD Glucose-91 UreaN-17 Creat-3.1*# Na-143
K-3.7 Cl-102 HCO3-30 AnGap-11
___ 07:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ man with ESRD now transitioned to
HD,
high grade B cell lymphoma s/p radical splenectomy and gastric
wedge resection ___, recent admission from ___ to ___ for
peritonitis who is now requiring admission to the medicine team
for safe discharge planning after mechanical fall.
# LLE Weakness:
# Mechanical fall:
No evidence of dislocation or fracture on imaging of the knee or
hip. Benign exam and no indication for MRI at this time. Fall
was
mechanical in nature. Suspect a degree of deconditioning from
prior prolonged hospitalization. Cleared by ___ initially, but
re-evaluated on ___ and suggested rehab.
# Intramuscular retroperitoneal hematoma
# R groin hematoma related to femoral access site # Concern for
left thigh hematoma
# Acute blood loss anemia on chronic anemia
# Leukocytosis
Spontaneous retroperitoneal hematoma s/p Left L2 and L3 lumbar
artery gelfoam and coil embolization, L4 angio and post-division
left interior iliac gelfoam embolization ___. Complicated by R
groin hematoma, with no current signs of active extravasation or
pseudoaneurysm. This problem was active during prior admission.
No further bleeding episodes and H/H stable.
# PD associated peritonitis:
Admitted ___ to ___ with peritoneal dialysate growing
pseudomonas. Felt to be catheter associated. Started on IV
Ceftazidime with HD.
# ESRD ___ HTN, now transitioned to HD:
The patient has been on PD since ___. Now switched to
hemodialysis during antibiotic course as above.
-continued Cinacalcet 30 mg PO DAILY
-continued sevelamer CARBONATE 2400 mg PO TID W/MEALS
-continued Vitamin D ___ UNIT PO DAILY
-Continued Torsemide 60 mg PO QAM
# Allergic rhinitis:
-continued azelastine, flonase prn
# HTN:
Difficult to control BP noted on recent admission but
hypotensive on ___ and minoxidil discontinued. Continued 600 mg
labetalol Q8H and clonidine patch.
# Nephrolithiasis:
-continued on home allopurinol ___ PO daily
# Anxiety/Claustrophobia:
-continued DULoxetine 20 mg PO DAILY
#CAD prevention:
-holding ASA 81mg PO daily
#Diverticulosis s/p LGIB:
Hospitalized here ___ for BRBPR ___ diverticulosis. No
evidence of GI bleed while in hospital.
TRANSITIONAL ISSUES:
[ ] Continue hemodialysis ___ with administration of IV
ceftazidime after HD for peritonitis (END: ___ for a 28
day course.
[ ] Follow-up pending cultures in clinic.
[ ] Monitor BP. If BP <120 or patient orthostatic/lightheaded,
please reduce labetalol to 450 mg TID.
[ ] Aspirin was held in setting of acute bleeding. Could
consider restarting in the future but need to weigh
risks/benefits of CVD prevention versus bleeding.
# CODE STATUS: full
# CONTACT: ___ (landlord): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Cinacalcet 30 mg PO DAILY
3. DULoxetine 20 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NS DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Torsemide 60 mg PO QAM
7. Vitamin D ___ UNIT PO DAILY
8. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
9. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
10. Labetalol 600 mg PO Q8H
11. CefTAZidime 2 g IV POST HD (MO,WE)
12. Minoxidil 5 mg PO DAILY
13. CefTAZidime 3 g IV POST HD (FR)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
3. CefTAZidime 2 g IV POST HD (MO,WE)
4. CefTAZidime 3 g IV POST HD (FR)
5. Cinacalcet 30 mg PO DAILY
6. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
7. DULoxetine 20 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NS DAILY
9. Labetalol 600 mg PO Q8H
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Torsemide 60 mg PO QAM
12. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Mechanical fall
Deconditioning/weakness
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking care of you at ___.
Why was I here?
- You fell on ice and were admitted to be re-evaluated for
rehab.
What was done for me here?
- You were seen by physical therapy who suggested rehab.
- You had your blood pressure medications adjusted.
What should I do when I leave the hospital?
- You should continue to take your medications as prescribed.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19631604-DS-23
| 19,631,604 | 27,980,645 |
DS
| 23 |
2174-03-05 00:00:00
|
2174-03-06 07:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / mushrooms / amlodipine / Lyrica
Attending: ___.
Chief Complaint:
L Headache, s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with PMH of ESRD on HD,
previously on peritoneal dialysis complicated by peritonitis in
___, chemical high-grade B-cell lymphoma status post
radical splenectomy, and gastric wedge resection ___ who
presents after mechanical vs. syncopal fall. Had just reached
the
top step when he apparently fell forward, landing on his face,
then slid on his back down to the bottom of the stairs. He
states
that he does not recall when or why he fell, and he cannot
consistently remember whether he lost consciousness or not. He
reports that he had otherwise been feeling well that day.
On ROS, endorsed post-fall R facial pain and mild headache.
Denies visual change, speech difficulty, or focal numbness or
weakness. Denies recent fever/chills, sore throat, cough, chest
pain, palpitations, dyspnea, n/v, abdominal pain, bloody stools.
Endorses several loose stools per day that he relates to his
phosphate binder medication. Denies ___ swelling. States that day
prior he had attended scheduled HD without complication.
Of note, the patient had a recent admission from ___ to
___
for safe discharge planning after a mechanical fall.
Unsteadiness
on his feet occurred while getting out of the taxi from the
hospital; patient also attributed this to chronic left lower
extremity weakness.
Per review of OMR, he also had a recent admission from
___ for peritoneal dialysis related peritonitis.
During that admission, he was found to have a spontaneous
retroperitoneal hematoma for which he underwent an ___
intervention. This was complicated by right groin hematoma
related to his femoral access site. He is noted during his
admission to have left lower extremity weakness.
In the ED:
Initial vital signs were: 98 66 159/87 16 97% RA
Exam notable for: NAD, R facial swelling/bruising, mildly tender
over R maxilla, OP clear with MMMs, no vertebral tenderness,
flex/extension without discomfort, JVP not elevated, CTAB, S1S2
RRR with soft systolic murmur at LLSB, abd soft, non-tender,
non-distended, bowel sounds present, no LLQ tenderness or
palpable mass, no edema, mild ecchymosis L flank, HD catheter R
chest, no erythema at exit site
While in the ED, othrostatic vitals showed 26 mmHg drop in SBP
and the patient stated the room was spinning.
Labs were notable for:
- WBC 17.9 (PMN 83.3) -> 15.5, Hgb 10.4 -> 8.9, INR 1.0
- Na 140 -> 142, K 5.5 -> 5.3, Cr 3.8 -> 4.3
- U/A with 300 Pr, -___, -Nit, 2 WBC, few bact, 0 Epi
EKG
Sinus 63. Normal axis. First-degree AV block. Normal QRS and QTc
intervals. No evidence of arrhythmia or territorial ST segment
deviation or T-wave inversion. Appears similar to ___.
Studies performed include:
- CXR: No acute cardiopulmonary process.
- NCHCT:
1. No acute intracranial abnormalities on noncontrast head CT.
2. Overall stable degree of hydrocephalus when compared to ___,
with stable positioning of the left frontal approach
ventriculostomy catheter placement.
3. Similar areas of hypodensities along the catheter tract and
at
the right vertex.
- CT Sinus
1. Dental amalgam streak artifact limits study.
2. No definite evidence of fracture.
3. Right periorbital and bifrontal supraorbital scalp soft
tissue
swelling.
4. Minimal paranasal sinus disease, as described.
5. Nonspecific subcentimeter lymph nodes as described, which may
be reactive.
6. 4 mm right frontal sinus osteoma.
7. Left maxillary first premolar periodontal disease.
8. Sigmoid nasal septal deviation with leftward bony spur.
- CT Spine
1. No acute fracture or acute malalignment.
2. Mild-to-moderate multilevel degenerative disc disease without
severe neural foramina or vertebral canal narrowing.
- CT Abd/Pelvis w/o contrast
1. Fat stranding around the loop of sigmoid colon, new since ___, concerning for diverticulitis. No fluid
collection
or macro perforation.
2. Interval decrease in left retroperitoneal and ileus psoas
intramuscular hematomas. No new or enlarging areas of
hemorrhage.
3. Minimally increased in displacement of the anterior inferior
corner
fracture of L1 vertebral body with minimal increase in
prevertebral swelling when compared to ___.
Consider
MRI for further evaluation of the anterior longitudinal ligament
stability.
- Rt Shoulder XR: Mild degenerative changes involving the
glenohumeral and AC joint. No acute fracture or dislocation.
- Rt Elbow XR: No acute fracture or elbow joint effusion.
Patient was given:
PO MetroNIDAZOLE 500 mg x 3
IVF NS 250 mL/hr
PO Ciprofloxacin 500 mg x 2
Cinacalcet 30 mg
Allopurinol ___ mg
Calcitriol 0.5 mcg
DULoxetine 20 mg
Sodium Bicarbonate 650 mg
Torsemide 60 mg
Vitamin D ___ UNIT
IV Epoetin Alfa 1000 UNIT
Labetalol 300 mg
Consults:
- Spine:
Patient examined. Imaging reviewed with Neurosurgery spine
fellow. Known L1 fracture appears healed and stable. There is no
indication for neurosurgical intervention. We recommend the
following:
- No need for brace
- No need for repeat imaging
- No need for neurosurgical follow-up
The patient underwent HD while in the ED, and per renal, the
patient was normotensive, however, endorsed feeling dizzy with
sitting up.
Vitals on transfer: T:99.2 P:63 BP:202/81 RR:18 POx:98% RA
Upon arrival to the floor, the patient corroborates with the
above history. He reports "I think I had a syncopal event" He
reports the day of his fall, he was experiencing more diarrhea
than usual. He states he felt dizzy when getting up from the
fall. In terms of PO intake, he reports that he has recently
been
having a low appetite and is "taking advantage of it" for health
reasons. Repots 10 pound weight loss over 1 month. Otherwise, he
reports no symptoms.
Past Medical History:
- high grade B cell lymphoma s/p radical splenectomy and
gastric wedge resection ___
- CKD stage IV
- Nephrolithiasis
- colloid cyst of ___ ventricle with secondary syncope s/p
neurosurgical resection (___) and VP shunt (MRI INCOMPLATIBLE)
- Anxiety & Claustrophobia
- LS radiculopathy
- chronic back pain
- HTN
- hyperuricemia
- repair of incisional & umbilical hernia with mesh ___
Social History:
___
Family History:
Mother-died of lung cancer
Father-died of lung cancer
Physical Exam:
ADMISSION EXAM
=========================
VITALS: 97.9 ___ Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Bruise on right forehead, orbital ecchymosis. PERRL, EOMI
Sclera anicteric and without injection. Moist mucous membranes,
good dentition. Oropharynx is clear.
NECK: Supple, non-tender. No cervical lymphadenopathy. No JVD.
CARDIAC: RRR, Audible S1 and S2. No murmurs, rubs or gallops.
CHEST: Dialysis catheter noted in the right upper chest, c/d/i
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: Bruising on right flank. No spinous process tenderness. No
CVA tenderness.
ABDOMEN: Normal bowel sounds, non-distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. 1cm abrasion on right forearm No rashes.
NEUROLOGIC: CN2-12 intact. AOx3. Speech fluent. Slowness on ___
backwards. ___ strength in RLE. ___ strength in left hip
flexion. ___ strength in left knee flexion. ___ strength in left
dorsiflexion/plantarflexion. Sensation intact.
DISCHARGE EXAM
==============================
VS: 24 HR Data (last updated ___ @ 544)
Temp: 97.5 (Tm 98.7), BP: 190/85 (159-200/77-98), HR: 71
(67-82), RR: 18, O2 sat: 98% (94-98), O2 delivery: Ra, Wt:
156.75
lb/71.1 kg
GENERAL: Elderly man, lying comfortably in bed, NAD
HEENT: Bruise on right forehead, orbital ecchymosis but
improving, Sclera anicteric, MMM
CARDIAC: RRR, no murmurs, rubs, or gallops
CHEST: Dialysis catheter noted in the right upper chest, c/d/i
LUNGS: CTAB, no wheezes, crackles, or rhonchi, no increased work
of breathing
ABDOMEN: Normal bowel sounds, non-distended, non-tender to
palpation
EXTREMITIES: No lower extremity edema
SKIN: Warm, Small abrasion on right forearm that does not appear
infected
NEUROLOGIC: Alert and interactive, moving all four extremities
with purpose
Pertinent Results:
ADMISSION LABS
========================
___ 08:50PM BLOOD WBC-17.9* RBC-3.22* Hgb-10.4* Hct-32.3*
MCV-100* MCH-32.3* MCHC-32.2 RDW-21.2* RDWSD-77.0* Plt ___
___ 08:50PM BLOOD Neuts-83.3* Lymphs-4.0* Monos-6.9 Eos-4.0
Baso-0.7 NRBC-0.2* Im ___ AbsNeut-14.92* AbsLymp-0.72*
AbsMono-1.24* AbsEos-0.72* AbsBaso-0.12*
___ 08:50PM BLOOD ___ PTT-24.9* ___
___ 08:50PM BLOOD Glucose-136* UreaN-32* Creat-3.8* Na-140
K-5.5* Cl-99 HCO3-24 AnGap-17
___ 09:00AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8
RELEVANT STUDIES
=======================
___ CXR PA/LATERAL: No acute cardiopulmonary process.
___ CT HEAD W/O CONTRAST:
1. Ventriculostomy catheter hardware streak artifact limits
examination.
2. No acute intracranial abnormality.
3. Within limits of study, no evidence acute intracranial
hemorrhage or acute fracture.
4. Bifrontal supraorbital and right periorbital scalp soft
tissue swelling.
5. Overall stable degree of ventriculomegaly compared to ___,
with stable
positioning of the left frontal approach ventriculostomy
catheter.
6. Similar areas of hypodensities along the catheter tract and
at the right vertex.
7. Please see concurrently obtained maxillofacial CT for
description of
maxillofacial structures.
8. Grossly stable right frontal parasagittal scalp probable
sebaceous cysts, as described.
___ CT ABDOMEN/PELVIS W/O CONTRAST:
1. Fat stranding around the loop of sigmoid colon, new since ___,
concerning for diverticulitis. No fluid collection or macro
perforation.
2. Interval decrease in left retroperitoneal and ileus psoas
intramuscular
hematomas. No new or enlarging areas of hemorrhage.
3. Minimally increased in displacement of the anterior inferior
corner
fracture of L1 vertebral body with minimal increase in
prevertebral swelling
when compared to ___. Consider MRI for further
evaluation of the
anterior longitudinal ligament stability.
RECOMMENDATION(S): Consider MRI for further evaluation of the
anterior
longitudinal ligament stability.
___ CT C-SPINE W/O CONTRAST:
1. Dental amalgam streak artifact limits study.
2. Within limits of study, no acute fracture or acute
malalignment.
3. Multilevel cervical degenerative changes as described with at
least mild vertebral canal narrowing at C6-7. If clinically
indicated, consider
dedicated cervical spine MRI for further evaluation.
___ CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST:
1. Dental amalgam streak artifact limits study.
2. No definite evidence of fracture.
3. Right periorbital and bifrontal supraorbital scalp soft
tissue swelling.
4. Minimal paranasal sinus disease, as described.
5. Nonspecific subcentimeter lymph nodes as described, which may
be reactive.
6. 4 mm right frontal sinus osteoma.
7. Left maxillary first premolar periodontal disease.
8. Sigmoid nasal septal deviation with leftward bony spur.
___ R GLENOHUMERAL SHOULDER X-RAY:
Superior subluxation of the humeral head is concerning for
rotator cuff tear. Slight widening of the glenohumeral joint
space likely represents underlying effusion.
No definite fracture.
___ R ELBOW AP/LATERAL/OBLIQUE X-RAY:
1. No acute fracture or elbow joint effusion.
2. 4 mm ovoid soft tissue appearing nodule projecting lateral to
the radial head may be on the skin surface or within the
subcutaneous tissues. Clinical correlation recommended.
Ultrasound could be obtained for further evaluation if
clinically warranted.
3. Small focus of what appears to be metallic density projects
over the mid-forearm on single view may be external to patient
versus foreign body. Clinical correlation recommended.
MICROBIOLOGY
========================
___ 7:02 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:40 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
========================
___ 07:00AM BLOOD WBC-17.4* RBC-3.44* Hgb-11.0* Hct-34.1*
MCV-99* MCH-32.0 MCHC-32.3 RDW-19.1* RDWSD-70.1* Plt ___
___ 07:00AM BLOOD Glucose-81 UreaN-40* Creat-4.8*# Na-140
K-4.4 Cl-100 HCO3-26 AnGap-14
___ 07:00AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of ESRD, and
hypertension, and recent admission for mechanical fall who
presents after syncopal event when he fell down a flight of
stairs.
ACUTE ISSUES:
==============
# Syncope:
# BPPV:
Patient had intermittent dizziness with positional changes and
positive orthostatics during admission. There was concern that
orthostasis was medication-related due to clonidine. Clonidine
was discontinued given persistent orthostasis. TTE in ___
showed new mitral regurgitation and repeat TTE showed interval
progression to mild-moderate MR. ___ were no arrhythmias on
telemetry and it was discontinued after 48 hours. Neurology was
consulted given persistent dizziness and concern for central
process. Neurology evaluated patient and felt dizziness to be
peripherally-mediated. He has a history of B cell lymphoma in
remission and there was concern a CNS lymphoma could be etiology
for dizziness. His primary oncologist, Dr. ___, was
contacted regarding utility of MRI head to evaluate for CNS
lymphoma. Dr. ___ not recommend MRI head given his lymphoma
was in remission. Patient was discharged to rehab where he will
continue to do ___ rehab. Recommend follow-up with ENT if
symptoms persistent for evaluation and further treatment.
# Hypertension:
SBP > 200 on arrival. During a previous admission, minoxidil 5
mg daily was stopped due to hypotension. He was persistently
orthostatic thus less strict blood pressure control was
tolerated. Clonidine was discontinued to avoid exacerbation of
orthostasis. His anti-hypertensive regimen was titrated during
admission and he was discharged on losartan 100 mg daily,
verapamil 120 mg daily, carvedilol 3.125 mg BID, and torsemide
60 mg daily. Stopped labetalol that also helped with minimizing
concerns with bradycardia. Per Renal, goal SBP is 160-180 to
avoid orthostatic hypotension. Continue to adjust blood pressure
medications as needed.
# Fall with facial injury:
Patient had facial injury and LLE weakness with hematoma in
setting of fall. ___ and OT evaluated patient and recommended
discharge to rehab. His pain was controlled with PRN tylenol.
# ESRD ___ HTN, on HD MWF:
Renal Dialysis followed during admission. Home torsemide was
decreased to 40 mg PO QAM from 60 mg on admission given
orthostatic hypotension. Given his persistently difficult to
control BP, his torsemide was titrated back to his home dose of
60 mg QAM. Home cinacalcet, sevelamer, and vitamin D were
continued.
# Lumbar Fracture:
Known history of L1 vertebral body fracture. He had CT
abdomen/pelvis upon admission to evaluate for trauma after his
fall which showed increased displacement of L1 fracture. Spine
evaluated patient and determined fracture was stable. He will
require follow-up AP/lateral plain films as an outpatient. Pain
was controlled with PRN Tylenol.
CHRONIC ISSUES:
===============
# Leukocytosis: Stable during admission, chronic, unchanged.
Heme-onc smear evaluated by heme-path with no gross
abnormalities suggestive of infection or malignancy. Can
follow-up as an outpatient.
# Nephrolithiasis: Continued home allopurinol ___ PO daily
# Anxiety/Claustrophobia: Continued DULoxetine 20 mg PO DAILY
# CAD prevention: Continued ASA 81mg PO daily
# Allergic rhinitis: Continued flonase prn. Holding azelastine
as NF
TRANSITIONAL ISSUES
====================
Discharge weight: 67.2 kg (standing)
Last HD session: ___
[ ] Patient had increased displacement of known L1 fracture
visualized on CT L-spine w/o contrast. Per spine, he will need
follow-up with Dr. ___ in ___ clinic with AP/Lateral
X-rays of the lumbar spine and same day clinic appointment.
Please call ___ to schedule.
[ ] Per primary oncologist, suspicion for CNS lymphoma and
central neurologic process causing dizziness is low at this
point. Patient did not have evidence of lymphoma on CT head w/o
contrast. If he develops new neurologic symptoms or worsening
dizziness, consider repeat head imaging. Per patient, he has
history of MRI non-compatible VP shunt.
[ ] Can consider follow-up of persistent leukocytosis as an
outpatient. Heme-onc smear was unremarkable and unchanged during
admission.
[ ] Ensure social work and evaluation as having issues with
housing once ready to leave rehab
[ ] Adjust BP meds as needed for goal SBP of 160-180.
CODE STATUS: Full code
HCP: ___ (friend), Phone: ___
> 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Cinacalcet 30 mg PO DAILY
3. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN
4. DULoxetine 20 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NS DAILY
6. Labetalol 600 mg PO Q8H
7. Torsemide 60 mg PO QAM
8. Vitamin D ___ UNIT PO DAILY
9. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
2. Losartan Potassium 100 mg PO DAILY
3. Meclizine 12.5 mg PO Q12H:PRN Dizziness, vertigo sx
4. Nephrocaps 1 CAP PO DAILY
5. Verapamil SR 120 mg PO Q24H
6. Allopurinol ___ mg PO DAILY
7. azelastine 0.15 % (205.5 mcg) nasal BID:PRN
8. Cinacalcet 30 mg PO DAILY
9. DULoxetine 20 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NS DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Torsemide 60 mg PO QAM
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
BPPV
HTN
Orthostatic hypotension
Secondary diagnosis:
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had ongoing dizziness and fell after leaving the hospital.
What was done for me while I was here?
- You had imaging studies showing no broken bones.
- You were evaluated by physical therapy for your ongoing
dizziness and fall. Your dizziness was from a condition called
BPPV (benign paroxysmal positional vertigo). The physical
therapists worked with you to improve your dizziness.
- Your medications were adjusted to decrease your risk of
becoming dizzy.
- Your blood pressure was difficult to control and your
medications were adjusted.
What should I do when I go home?
- You should attend all of your follow-up appointments.
- You should take all of your medications as prescribed.
We wish you the best in the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19631749-DS-13
| 19,631,749 | 26,788,951 |
DS
| 13 |
2133-08-20 00:00:00
|
2133-08-21 22:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
pelvic mass, pyosalpinx
Major Surgical or Invasive Procedure:
exploratory laparotomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy
History of Present Illness:
___ is a ___ G0 with h/o fibroids s/p LSC MMY in
___ presenting with right sided abdominal pain x 1 week and
found to have large pelvic mass.
Patient reports that she initially had sharp right sided
abdominal pain on ___. Describes the pain as twisting in nature
and non-radiating at that time. She also noted N/V x 2 days. She
took ibuprofen and Tylenol with no relied. She then presented to
___ on ___ for worsening sx. At the ___, she
was
noted to have leukocytosis of 14.___bd pelvis that
showed:
"right adnexal and left parasagittal complex multilocculated
mixed solid-cystic mass lesions are seen, highly suspicious of
malignant ovarian tumors....Uterus is unremarkable, measuring 8
x
6.7 x 3.9cm. In same report, uterus also noted to be massively
enlarged, protruding into the lower abdomen and containing
numerous solid mass lesions replacing most of the myometrium.
The
largest tumor in the uterine body measures 12.9cm x 11.1cm x
10.2cm. Multiple exophytic isodense enhancing tumors are seen
protruding from the right uterine fundus into the right lower
abdomen measuring 6.5cm for the lateral mass and 7.3cm for the
medial mass."
She was also noted to have a UA that was concerning for UTI and
was given ceftriaxone x 1 dose for concern for pylenonephritis.
She was then transferred to ___ ED and is now admitted to GYN
service. Since coming to ___, she had a pelvis U/S that
showed:
1. Dilated tubular structures in the bilateral adnexa with
complex fluid, most consistent with pyosalpinx.
2. Massively enlarged fibroid uterus
She was then started on gent/clinda for suspected pyosalpinx.
Reports that her pain has slightly improved from ___. Had
chills 2 days ago but no fevers. Has not brownish yellowish
discharge for the last 2 weeks. Had a BM ___, which was normal.
Denies a h/o constipation. Denies fevers, dysuria, hematuria,
cough, chest pain. Passing flatus. Denies h/o STIs and is not
currently sexually active for the last ___ years. Denies weight
loss, though last year she weighed 205lb and the year prior was
225lb; she reports she was trying to lose weight.
Past Medical History:
Obstetrical History: G0
Gynecologic History:
- LMP ___
- Menses regular every month. Denies history of menorrhagia or
dysmenorrhea.
- Last Pap negative last year per report, denies h/o abnormal
Paps
- +H/o fibroids s/p laparoscopic myomectomy a few years ago.
- +H/o PCOS, was previously on OCPs for rx without improvement
in
her hirsutism
- Denies h/o pelvic infections or STIs
Past Medical History:
- Obesity
- Denies h/o HTN, asthma
Past Surgical History:
- Wisdom teeth
- Laparoscopic myomectomy @ ___ in ___
Health Maintenance:
-Last Mammogram: never
-Last Colonoscopy: never
-Last bone density scan: never
Social History:
___
Family History:
Family History: Mother died suddenly when the pt was ___,
unclear cause ('was smoking and taking Nyquil and put a hole
through her heart'). She is not in touch with her father. Great
aunt with breast cancer. Different great aunt with 'bone
cancer'.
Has a half sister and step brother who are healthy. Denies other
h/o breast, ovarian, colon, and uterine cancers.
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i, staples in place, JP drain in place, secured and draining
sero-sanguinous fluid
Ext: no TTP
Pertinent Results:
___ 09:30AM URINE HOURS-RANDOM
___ 09:30AM URINE UHOLD-HOLD
___ 09:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-6.0
LEUK-NEG
___ 09:30AM URINE RBC-<1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-1
___ 09:30AM URINE MUCOUS-RARE
___ 08:45AM WBC-14.6* RBC-3.56* HGB-9.5* HCT-30.8* MCV-87
MCH-26.7 MCHC-30.8* RDW-15.3 RDWSD-48.8*
___ 08:45AM NEUTS-76.8* LYMPHS-8.7* MONOS-11.2 EOS-0.8*
BASOS-0.5 IM ___ AbsNeut-11.19* AbsLymp-1.27 AbsMono-1.64*
AbsEos-0.12 AbsBaso-0.07
___ 08:45AM PLT COUNT-389
___ 11:01PM LACTATE-0.9
___ 10:44PM GLUCOSE-114* UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17
___ 10:44PM estGFR-Using this
___ 10:44PM ALT(SGPT)-20 AST(SGOT)-23 ALK PHOS-119* TOT
BILI-0.3
___ 10:44PM LIPASE-56
___ 10:44PM ALBUMIN-3.3*
___ 10:44PM CEA-0.3 CA125-201*
___ 10:44PM WBC-13.7* RBC-3.72* HGB-10.0* HCT-31.2*
MCV-84 MCH-26.9 MCHC-32.1 RDW-15.0 RDWSD-45.7
___ 10:44PM NEUTS-76* BANDS-1 LYMPHS-7* MONOS-14* EOS-2
BASOS-0 ___ MYELOS-0 AbsNeut-10.55* AbsLymp-0.96*
AbsMono-1.92* AbsEos-0.27 AbsBaso-0.00*
___ 10:44PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL
TEARDROP-OCCASIONAL
___ 10:44PM PLT SMR-NORMAL PLT COUNT-430*
___ 10:44PM ___ PTT-27.7 ___
___ 10:32PM URINE HOURS-RANDOM
___ 10:32PM URINE UCG-NEGATIVE
___ 10:32PM URINE COLOR-Yellow APPEAR-Cloudy SP
___
___ 10:32PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG
___ 10:32PM URINE RBC-43* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-1
___ 10:32PM URINE WBCCLUMP-MOD
Brief Hospital Course:
On ___ Ms. ___ was admitted to the Gynecology service for
large pelvic mass, abdominal pain, nausea and vomiting. She was
started on IV gentamicin and clindamycin for possible
tubo-ovarian abscesses. Tumor markers were obtained which showed
a CEA of 0.3 and CA-125 of 201. The patient also had persistent
leukocytosis. The GYN oncology team was consulted. Please see
the consult note for full details.
On ___, she underwent exploratory laparotomy, total abdominal
hysterectomy, and bilateral salpingo-oophorectomy with
intraoperative findings notable for bilateral tubo-ovarian
abscesses and a fibroid uterus. She was admitted to the ICU for
hypotension post operatively, and was called out on post
operative day 1. Her post operative course is as follows:
# Hypotension: Patient was noted to have blood pressures in the
___ postoperatively, likely from hypovolemia versus septic
shock. She was closely observed in the ICU, and her BPs
responded to one additional unit of PRBCs (first unit of PRBC
was given intra-operatively). It was determined that her
hypotension was likely from under-resuscitation, and she was
called out of the ICU on POD#1.
# Tubo-ovarian abscesses
She started on IV gentamycin/clindamycin (___-) upon arrival.
Based on intraoperative abscess cultures which showed E. Coli,
there was concern from the infectious disease team that this
strain was multi-drug resistant. She was switched on ___ to
meropenem (recommended due to improved anaerobic coverage and
lower risk of nephrotoxicity). Additional infectious disease
team recommendations include a hepatic ultrasound on ___ which
was negative for hepatic abscesses, positive only for 2
hemangiomas and a small right pleural effusion. Her HIV
antibodies were negative. The plan is for a 2 week
post-operative IV ertapenem antibiotic course from ___.
# UTI
Patient was found to have E. Coli UTI on urine culture on
___, which was sensitive to Gentamycin. With her extended IV
ertapenem course after discharge, she has received adequate
treatment for her UTI with a negative urine culture on ___.
# Pain Control/Post Operative Care:
Pain was initially controlled with a split epidural, dilaudid
PCA and toradol until post operative day 3, when she was
transitioned to PO oxycodone and acetaminophen. Her foley
catheter was removed on post operative day 2, and she voided
spontaneously. Her diet was advanced without difficulty. She
was tolerating a regular diet by post operative day 4.
# JP drain
A JP drain was placed at the time of surgery. She will receive
daily drain care, and our recommendation is for JP drain removal
when the output is <100cc/day.
By post-operative day 5, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
with a JP drain in place, with ___ set up for IV antibiotic
administration as well as drain care, in stable condition with
outpatient follow-up scheduled.
Medications on Admission:
ASA PRN, ibuprofen PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*1
3. ertapenem 1 gram injection Q24H Duration: 9 Days
RX *ertapenem [Invanz] 1 gram 1 gram IV every 24 hours Disp #*9
Vial Refills:*0
4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
do not drive or drink alcohol while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pelvic mass, pyosalpinx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service with a pelvic mass
and an infection. You were transferred to the gyn oncology
service after the procedure listed below. You have recovered
well after your procedure and the team believes you are ready to
be discharged home. Please call Dr. ___ office with any
questions or concerns. Please follow the instructions below.
Pelvic infection:
* Please take the full course of your IV antibiotics your
antibiotics as prescribed. A visiting nurse ___ come daily to
administer your medications starting on ___, so you
will be administering the medication yourself on ___.
Please follow these instructions:
.
Abdominal instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* You should remove your port site dressings ___ days after your
surgery, if they have not already been removed in the hospital.
Leave your steri-strips on. If they are still on after ___
days from surgery, you may remove them.
* If you have staples, they will be removed at your follow-up
visit.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Please call ___ to coordinate rides to your ___ follow
up appointments. A form has been filled out for you that will
allow for transportation to ___ (unfortunately, not to your
follow up in ___ with Dr. ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
19631957-DS-20
| 19,631,957 | 23,082,454 |
DS
| 20 |
2137-09-26 00:00:00
|
2137-09-26 11:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fevers following prostate biopsy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ gentleman with a pmhx. significant for
elevated PSA and prostate biopsy on ___ who presents with
shaking chills and fever to 102.8. Patient states that he felt
well after the procedure but the next day felt unwell with
rigors and sweats. Of note, patient received CTX during
procedure. Also with some decreased appetitie, headache, and
hematuria. Came to the ED on ___ for further evaluation.
.
Patient states that he is otherwise healthy aside from bilateral
knee arthritis. ROS is negative for chest pain, shortness of
breath, abdominal pain, nausea, vomiting, or diarrhea. When
questioned, patient does say that he has had a ___
unintentional weight loss over the past few months.
.
Initial vitals in the ED were: 102.6, 102, 110/61, 18, and 99%
on RA. A u/a showed small leuks, moderate bood, negative
nitrates, 107 RBCs, 38 WBCs, and few bacteria. Patient received
levoflox 750mg IV x1 and 1000mg of tylenol. On admission to the
floor, vitals were: 99.4, 95/55, 81, 16, and 96% on RA.
Past Medical History:
Arthritis
Social History:
___
Family History:
Father with ___ Disease and Alzheimer's Disease. Died
in ___ of a blood clot. No family history of prostate cancer.
Physical Exam:
VS: 99.1, 110/60, 81, 16, 97% on RA
GENERAL: Well appearing, thin, no acute distress
HEENT: Mucous membranes slightly dry
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
NEURO: Alert and oriented x3
Pertinent Results:
___ 06:18PM LACTATE-2.0
___ 06:00PM GLUCOSE-128* UREA N-15 CREAT-1.4* SODIUM-134
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16
___ 06:00PM estGFR-Using this
___ 06:00PM WBC-8.2 RBC-4.87 HGB-15.3 HCT-44.2 MCV-91
MCH-31.4 MCHC-34.5 RDW-12.4
___ 06:00PM NEUTS-94.8* LYMPHS-2.8* MONOS-2.1 EOS-0.2
BASOS-0.1
___ 06:00PM PLT COUNT-107*
___ 06:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM
___ 06:00PM URINE RBC-107* WBC-38* BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:00PM URINE MUCOUS-RARE
CXR
IMPRESSION:
1. No focal consolidation to suggest pneumonia.
2. Probable left upper lobe bullae.
3. Left costophrenic angle blunting which may represent
scarring or small pleural effusion.
___
Prostate needle biopsies, twelve:
A. Right apex lateral:
No malignancy identified.
B. Right apex medial:
No malignancy identified.
C. Right mid lateral:
Focal acute inflammation. No malignancy identified.
D. Right mid medial:
No malignancy identified.
E. Right base lateral:
No malignancy identified.
F. Right base medial:
No malignancy identified.
G. Left apex lateral:
No malignancy identified.
H. Left apex medial:
No malignancy identified.
I. Left mid lateral:
No malignancy identified.
J. Left mid medial:
No malignancy identified.
K. Left base lateral:
No malignancy identified.
L. Left base medial:
No malignancy identified.
Brief Hospital Course:
This is a ___ gentleman with a pmhx. significant for
elevated PSA and recent prostate biopsy who presents with fever,
prostatitis, sepsis.
# Acute prostatitis: Pt was at increased risk of prostatitis as
he had more than 10 samples done during recent prostate biopsy.
He was treated with levofloxacin and improved. He was seen by
the infectious disease service which recommended a 14-day course
of antibiotics.
# Acute renal failure, sepsis: Improved with IV fluids.
# THROMBOCYTOPENIA: Pt was noted to have worsening
thrombocytopenia initially in the setting of sepsis and
prostatitis. He was seen by hematology and they suspected that
this was due to acute infection. He never developed DIC. There
was no evidence of hemolysis. On discharge his platelets were
improving.
Transitional issues:
- Follow up blood cultures (all pending on discharge, but ___
had not grown anything since admission)
- Follow up platelet level to confirm that has normalized
Medications on Admission:
None.
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Prostatitis
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 post-prostate biopsy
prostatitis. You were treated with antibiotics and your symptoms
improved. You will continue antibiotics for 9 more days to
complete a ___uring this hospitalization you also had abnormal blood counts.
Your platelet level was low, and you were seen by the hematology
service. They suspected that this was due to acute infection.
Your platelet level was increasing on discharge, but will need
to be followed up.
Followup Instructions:
___
|
19632088-DS-12
| 19,632,088 | 26,703,317 |
DS
| 12 |
2173-10-22 00:00:00
|
2173-10-22 20:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Pentothal
Attending: ___.
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH depression, HTN, CAD s/p CABG, AVR on AC, HLD, BPH,
prostate CA s/p cyberknife, dementia w agitation, p/w
progressively worsening behavioral outbursts over the past year,
with increased frequency over the past week. These include
physical violence towards others, as well as unsafe roving and
repeated falls. He was evaluated at ___ earlier
today for fall injury with head strike. CT Noncon of the head
was
performed and was reported to not have acute processes.
Patient accompanied by daughter. Pt has had no
f/c/n/v/d/CP/SOB/rash/joint pain/dysuria/urgency. Some loose
stools as per recent baseline but no diarrhea. No melena, no
hematuria, no other bleeding.
On ___ patient was found to have a small bruise on his
behind,
presumably from a fall. A few days later he had a larger bruise.
Patient denies abd pain, distention, lightheadedness. Saw PCP,
had labs drawn which showed hgb 11.5 from baseline around
___, and INR 3.2 (last month INRs have been in goal).
Daughter notes that he has had intermittent urinary stream over
the last few weeks, she has not observed before. No stool/urine
incontinence but he does have a history of urinating/stooling in
inappropriate places/times. She does not notice any ___ weakness
or numbness, notes he is at baseline somewhat staggering when he
walks.
Recently patient has had more aggressive behavior more
frequently, with striking other residents at his ALF, mood is
more labile and quicker to anger. Daughter brought him home to
her house at request of ALF, but they did not do well at home
and
she brought in to hospital.
Please see emails from patient and neurologist in ___ for more
details including apparently feined non-responsiveness,
agitation, spitting meds. She called EMS and he was combative
with the EMTs. Daughter hoping he can be admitted to a facility.
Outpatient providers have been apparently working on trying to
get a ___ psych admit. Outpatient neurologist increased
quetiapine to 50mg po BID with additional evening dose at 8pm;
started trazodone 12.5mg-25mg po QHS prn.
Brought to ___, CT head/neck unremarkable. Transferred
here for evaluation.
His wife has been admitted to ___ for brain surgery.
In the ___ here, AVSS. Labs unremarkable. Found to have urinary
retention (BS 451) and exam as below.
PE:
General: Well-appearing elderly male in no acute distress, but
with occasional aggressive speech pattern.
HEENT: NC, AT. PERRLA. EOMI. Dry mucous membranes.
Neck: No C-spine tenderness, no cervical lymphadenopathy, no
thyromegaly.
Chest: CTAB
CV: RRR, normal S1/S2, no M/G/R. Pulses present and equal in all
extremities.
Abdomen: Soft, nontender, mild distention in the suprapubic
region.
Extremities: Layered ecchymosis to the right buttock extending
to
the posterior thigh, edema of the right lower extremity with ill
appearance. No tenderness to palpation. 1+ pitting edema.
Neuro: AO x1, CN II-XII grossly intact, moving all extremities,
unable to participate in finger-nose-finger, or rapid
alternating
movements. No truncal ataxia appreciated.
-Contact info: ___ ___
Received olanzapine 10mg at 11am, 1L NS.
___ neg
Psych consulted. Recommended constant observation to prevent
escalation, glasses on, quiet room, psych will t/b w pt's
neurologist Dr. ___
___: positive or negative as above, otherwise negative in 12
systems
Past Medical History:
CABG/AVR mechanical ___, on AC (INR goal 2.5-3.5)
dementia, Ox1 at baseline, sometimes knows DOB
previous trials of risperidone/memantine per chart
per chart:
- Suicidal Ideation: episodic suicidal statements but unclear if
patient meant them or understood the meaning of the words
- Suicide Attempts: none reported
- Homicidal Ideation: episodic homicidal statements but unclear
if patient meant them or understood the meaning of the words
- Medication History: Risperdal, Memantine
- Interventional Psychiatry: none reported
HTN
HLD
depression
prostate ca s/p cyber knife
anal fissure
colonic adenoma, tubular/tubulovillous
elevated PSA, but on repeat checks has been coming down
Gallbladder & bile duct stone
BPH
RBBB, LAFB
Social History:
___
Family History:
no cancers
some dementia in family, some heart dz
otherwise reviewed and non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
Constitutional: VS reviewed, at times calm but can become quite
agitated
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no mrg, mechanical S2, JVP flat
Resp: CTAB
GI: sntnd, NABS
GU: no foley
MSK: no obvious synovitis
Ext: wwp, RLE 1+ ___, none on L;
Skin: large hematoma in lateral R thigh/buttocks, some resolving
hematoma/discoloration over RLE shin c/w absorbing bruise
Neuro: A&O to person only, difficult to fully do strength exam
in LEs despite multiple efforts and calming of patient but as
he tries to kick me and flail his legs around his strength
appears intact in BLEs, strength intact in B BUEs, SILT BUE/BLE
per his report, no facial droop, downgoing toes bilaterally, L
DTR knee 2+ but he will not permit me to check R patellar DTR,
1+ B ankle jerks
Psych: at times calm but then becomes agitated and at times
tries to bite me or grab me or not let me go, at times makes
non-cooperative/aggressive statements towards me, able to be
calmed by daughter for most part
DISCHARGE PHYSICAL EXAM:
VITALS: T97.7 PO BP 155/85 HR63 RR18 96%RA
GENERAL: sitting in the chair, no distress, smiles at me and is
answering some questions appropriately
CV: RRR, mechanical valve click noted
PULM: CTAB, no wheezes or rales
ABD: soft, NT, +BS
SKIN: no remaining ecchymosis of buttock and thigh
NEURO: moves all extremities, face symmetric
PSYCH: calm, interactive
Pertinent Results:
ADMISSION LABS:
___ 10:12AM BLOOD WBC-5.5 RBC-3.39* Hgb-11.1* Hct-32.9*
MCV-97 MCH-32.7* MCHC-33.7 RDW-14.0 RDWSD-48.6* Plt ___
___ 10:12AM BLOOD ___ PTT-35.8 ___
___ 10:12AM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-25 AnGap-11
___ 10:12AM BLOOD ALT-19 AST-28 AlkPhos-68 TotBili-1.6*
___ 10:12AM BLOOD cTropnT-<0.01
___ 10:12AM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.7 Mg-2.0
___ 10:12AM BLOOD TSH-6.7*
___ 09:19AM BLOOD Free T4-0.9*
___ 01:27PM BLOOD Lactate-1.5
MICRO:
___ URINE CULTURE<10,000 CFU
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.9 RBC-3.62* Hgb-11.4* Hct-34.8*
MCV-96 MCH-31.5 MCHC-32.8 RDW-14.3 RDWSD-50.3* Plt ___
___ 06:45AM BLOOD ___ PTT-35.0 ___
___ 06:45AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-141
K-4.4 Cl-104 HCO3-26 AnGap-11
___ 06:45AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.2
IMAGING:
___ CT abd/pelvis & LEs:
1. Mild edema and enlargement of the right gluteus maximus
compared to the
left suggestive of an intramuscular hematoma. There is mild
associated
subcutaneous edema along the posterior right thigh without focal
collection.
If deemed clinically relevant, this could be better evaluated
with MR.
2. No retroperitoneal hematoma. No free fluid within the abdomen
or pelvis.
3. Cholelithiasis without gallbladder wall thickening or
pericholecystic
fluid.
4. Heavy atherosclerotic calcification of the heart which is
moderate-severely
enlarged. Evidence of prior median sternotomy with related
surgical change.
5. Infrarenal abdominal aortic ectasia measuring 2.6 cm. No
aneurysm.
6. Ill-defined, intermediate density lesion within the
interpolar left kidney
measuring 1.6 cm. Recommend nonurgent follow-up with ultrasound.
7. Diverticulosis without evidence of diverticulitis.
___ right ___:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CXR:
Low lung volumes without evidence of pneumonia edema or
pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ y/o man w dementia and behavioral disturbance,
depression, CABG/AVR on AC, BPH, prostate ca in remission p/w
subacute on chronic behavioral disturbance/agitation. Also with
urinary retention but no evidence of UTI or spinal lesion, and
with hematoma-induced anemia.
TRANSITIONAL ISSUES
[ ] recheck TSH in ___ weeks (___)
[ ] CT abdomen finding: "Ill-defined, intermediate density
lesion within the interpolar left kidney measuring 1.6 cm.
Recommend non-urgent follow-up with ultrasound."
[ ] Coumadin plan: resumed home Coumadin regimen after INR
slightly down-trended while on 2.5 mg daily. Please check INR on
___ and then ___ thereafter.
#CODE STATUS: DNR/DNI, no artificial nutrition
#HCP: ___. Phone: ___
___ asks that we do not provide any information to ALF
as they do not have a release to obtain medical information***
ACUTE/ACTIVE PROBLEMS:
# Agitation
# Behavioral disturbance
# Dementia
# Depression
The patient was found to have no acute medical issues to explain
his presenting agitation. As per outpatient providers and the
record, this has been a progressive condition with recent
decline. He requires ___ psych placement for optimal care. His
antipsychotic and antidepressant regimen were adjusted slightly
for better management of his symptoms and may require ongoing
titration. He had no evidence of an infection. His labs were
notable for a slightly elevated TSH, but normal fT4. Per his
daughter and providers, patient responds well to not being
crowded, understanding when he will be examined, hearing
positive feedback, being allowed to chew his food, maintaining
neatness/orderliness, and providing him with organizational
tasks such as folding towels. We worked closely with psychiatry
and initiated Seroquel for his agitation, with IM Haldol only
for severe agitation. He notably improved on his new dosing
regimen. His Seroquel was uptitrated to 50 mg qam and
qafternoon, 75mg qhs (8 pm) and 25mg BID:PRN for agitation. He
last required IM Haldol on ___. He required prn Seroquel PO on
___ but was redirectable at all times.
# Anemia, acute blood loss:
# Large right buttock/thigh hematoma:
# Hyperbilirubinemia, indirect (RESOLVED):
He presented with a slight anemia of a Hgb of 11, compared to
his usual baseline of ___. He has had recent falls and small
visible ecchymoses/hematomas on hand and abdomen, and large one
on right buttock, in the setting of his therapeutic
anticoagulation. Given the extent of his RLE hematoma, a CT
abd/pelvis & ___ was obtained to r/o an RP bleed and/or active
bleeding, which was negative. His Hgb remained stable during
admission.
# Urinary retention: He presented with this symptoms. He has a
history of BPH and is on several anticholinergic medications
(antipsychotics), so this is likely due to those reasons, but
cannot know for sure. He was started on tamsulosin. His
urinary retention resolved while inpatient and he did not
require an IUC.
# S/p mechanical AVR:
# CABG:
Goal INR ___. He was initially continued on presumed home dose
of warfarin, however INR began to rise therefore dose was
adjusted to 2.5mg daily. INR on ___ was 2.2. This medication
is managed by ___ clinic through Atrius by ___
___, RN. He was continued on home beta blocker for rate
control. Cardiologist is Dr. ___ and ___ has an
appointment with him on ___.
# HTN: He was continued on his home lisinopril and atenolol.
[x] I spent 40 min in discharge planning and coordination of
care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. Multivitamins W/minerals Chewable 1 TAB PO DAILY
3. Sertraline 100 mg PO DAILY
4. Amoxicillin ___ mg PO PREOP pre-dental procedure
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
6. Atenolol 50 mg PO DAILY
7. Warfarin 2.5 mg PO 4X/WEEK (___)
8. Atorvastatin 80 mg PO QPM
9. Lisinopril 40 mg PO DAILY
10. QUEtiapine Fumarate 25 mg PO 0830
11. QUEtiapine Fumarate 25 mg PO 1400
12. QUEtiapine Fumarate 50 mg PO QHS
13. TraZODone 25 mg PO QHS:PRN insomnia
14. Warfarin 3.75 mg PO 3X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Ramelteon 8 mg PO QPM
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Tamsulosin 0.4 mg PO QHS
6. QUEtiapine Fumarate 25 mg PO BID:PRN agitation, anxiety
7. QUEtiapine Fumarate 75 mg PO QHS
8. QUEtiapine Fumarate 50 mg PO BID
9. Sertraline 150 mg PO DAILY
10. Amoxicillin ___ mg PO PREOP pre-dental procedure
11. Atenolol 50 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. Ezetimibe 10 mg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. Multivitamins W/minerals Chewable 1 TAB PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp
17. Warfarin 2.5 mg PO 4X/WEEK (___)
18. Warfarin 3.75 mg PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Agitation, behavioral disturbance
Dementia
Hematoma
Anemia, acute blood loss
Urinary retention
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why was I admitted to the hospital?
- to evaluate and treat your confusion
- to monitor and evaluate the bruising on your leg
What was done while I was in the hospital?
- your medications were adjusted slightly to help treat your
anxiety
- you had a CT scan of the leg to make sure there was no active
bleeding (negative)
- you were started on a medication to help with the urine
retention, which resolved
What will I need to do when I leave the hospital?
- continue all medications as prescribed
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19632296-DS-7
| 19,632,296 | 25,773,719 |
DS
| 7 |
2154-07-10 00:00:00
|
2154-07-11 08:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Complaint:
Fatigue/shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH rhematic heart disease with Mitral Valve Stenosis
s/p MVR in ___ course c/b tachy-brady syndrome s/p pacemaker
placement in ___ presenting to the ED with palpitations,
worsening fatigue, exertional SOB, and weakness for 3 weeks. She
presented to her primary care doctor's office the day prior to
admission complaining of fatigue and she was noted to be
tachycardic to 100s, so she was sent to the ER for further
evaluation. The patient states that she has felt weak and
fatigued x ___enies CP, orthopnea, dizziness, PND,
n/v, or ankle swelling.
As per OMR note, pt visited Dr. ___ on ___ and was found
to be in atrial fibrillation (at least since ___ with
heart rates in the low 100's and occassionally up to the high
100's. At that
visit, it was decided to stop sotalol attempt better rate
control with diltiazem CD 240mg daily and metoprolol succinate
50mg daily.
In the ED, initial vitals were Temp: 98.4 HR: 126 BP: 140/90
Resp: 18 O(2)Sat: 98 on RA. Pt endorses feeling tired, but
denies palpitations or chest pain or shortness of breath.
Overnight HR was found to be in the 120s refractory digoxin and
metoprolol tartrate 50 mg PO x 3. Diltiazem was discontinued.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, 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:
Rheumatic fever/severe mitral valve prolapse s/p mitral valve
annuloplasty done at the age of ___ by Dr. ___
Hyperlipidemia
AF/flutter
Migraines
Vasovagal syncope
Diastolic CHF
s/p hysterectomy
Pre diabetes
Anemia
Vitamin D deficiency
Cholecystectomy
Past Surgical History:
s/p mitral valve annuloplasty done at the age of ___ by Dr.
___
___ History:
___
Family History:
Father with a history of strokes and had "heart problems"- no
specifics. No hx of sudden cardiac death.
Physical Exam:
Upon Admission:
==========================================
VS: T=afebrile BP=122/91 HR=94 RR=18 O2 sat=95% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. No LAD. difficult to assess her JVP.
CARDIAC: tachycardic, irregular rate, loud S1, S2. No m/r/g. No
S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Minor
crackles at L lung base. No wheezes or rhonchi.
ABDOMEN: Obese. Soft, NTND. Can not appreciate size of liver or
spleen.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Upon Discharge: remained unchanged except
==========================================
Cardiac: regular rate and rhythm. loud S1, S2. No m/r/g. No S3
or S4
Pertinent Results:
___ 04:10PM BLOOD WBC-6.2 RBC-3.84*# Hgb-11.0* Hct-34.1*
MCV-89# MCH-28.6 MCHC-32.2 RDW-18.7* Plt ___
___ 05:50AM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-141
K-4.3 Cl-106 HCO3-26 AnGap-13
___ Thyroid ultrasound
No nodules or masses seen in the thyroid.
___ CXR: Cardiomegaly with mild pulmonary vascular
congestion.
Brief Hospital Course:
___ with a PMH rhematic heart disease with Mitral Valve Stenosis
s/p MVR in ___ course c/b tachy-brady syndrome s/p pacemaker
placement in ___ presents with symptomatic a.fib with rvr.
Active Issues:
=========================
# A.fib with RVR: She is symptomatic for past 3 weeks with
fatigue and palpations. Unsuccessful outpatient rhythm control
with sotalol was attempted by Dr. ___ since
transitioned to rate control. Initial presentation to ED, she
has had poorly controlled HR in the 120-130 while on metoprolol
and diltiazem. She was transitioned to verapamil SR 240mg twice
daily, metoprolol succinate 50mg daily, and digoxin 125mcg
daily. Given that patient has pacemaker placed in ___ for
tachy-brady, there was low concern for giving high doses of AV
nodal blocking agents to attempt rate control for symptomatic
bradycardia. The day before discharge, patient developed nausea
and EKG was obtained showing her paced rhythm. Her pacemaker was
interrogated and programmed mode switch on to DDIR 60bpm and
decreased the lower rate limit from 70 to 60 bpm. She was
discharged on verapamil 180mg BID, metoprolol succinate 100mg
BID, and digoxin 0.125mg daily.
.
Inactive Issues:
========================
#chronic diastolic heart failure: During her hospital stay
patient appeared euvolemic without symptoms of orthopnea, PND,
___ edema. She was maintained on home dose of furosemide.
.
#Anxiety: She was continued on home dose of lexapro and
lorazepam.
#Migraine: She was continued on home gabapentin.
Transitional Issues:
=========================
None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Diltiazem 240 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 300 mg PO DAILY:PRN migraine
5. Lorazepam 1 mg PO BID
6. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
7. Warfarin 5 mg PO 4X/WEEK (___)
8. Warfarin 6 mg PO 3X/WEEK (___)
9. Vitamin D ___ UNIT PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Docusate Sodium 100 mg PO DAILY:PRN constipation
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
Please administer with iron supplementation
2. Escitalopram Oxalate 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 300 mg PO DAILY:PRN migraine
6. Lorazepam 1 mg PO BID
7. Ranitidine 150 mg PO BID
8. Warfarin 5 mg PO 4X/WEEK (___)
9. Warfarin 6 mg PO 3X/WEEK (___)
10. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
11. Aspirin 81 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
13. Vitamin D ___ UNIT PO DAILY
14. Verapamil 180 mg PO BID
RX *verapamil 180 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
15. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
16. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
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:
Dear ___, thank you very much for giving us the
opportunity to take care of you.
You were admitted to the hospital for fatigue and weakness
likely resulting from fast irregular heart rate called atrial
fibrillation. We slowed your heart rate down with a number of
medications.
Please go to the ___ lab to pick up your ___ of hearts
monitor, this will help us monitor your heart rate when you are
having symptoms as an outpatient.
Given your history of fast and irregular heart rates, we will
start you on a new regimen of heart rate-controlling
medications.
New medications:
START Verapamil 180mg twice a day
START Metoprolol succinate 100mg twice a day
START Digoxin 0.125 mg once a day
Followup Instructions:
___
|
19632296-DS-9
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DS
| 9 |
2160-03-31 00:00:00
|
2160-03-31 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with PMH acute on chronic anemia, rheumatic
heart disease s/p mechanical mitral valve replacement (___) and
ICD on Coumadin, afib, ___, DM, HTN, CKD presents with fatigue.
Over the past month, patient noticed a decline in her energy
level. Over the past 2 weeks, she also noticed increased
bilateral ankle/foot swelling, DOE, and PND. Normally she sleeps
with two pillows; more recently, she's needed to be in a near
upright position and yet, awakens short of breath with the need
to sit upright. In view of progressive fatigue, she saw her PCP
yesterday who reportedly advised hospitalization which she
declined. Increased Lasix to BID at this time but did not note
increase in urination on day of presentation back to clinic (due
to persistent symptoms). Felt lightheaded when standing up after
bending over. Pt not sure of dry weight, but has been losing
weight this week. Denies f/c/cp/n/v/abd pain/urinary or bowel
symptoms, hematemesis, black or tarry stools.
In clinic today patient noted to be becoming progressively more
anemic with decline in hemoglobin from 9.7 g/dl to 7.3 g/dl
along
with decline in renal function and elevated BNP. Hospitalization
advised for diuresis and possible transfusion.
Of note patient began developing renal failure in ___ with rise
in creatinine to as high as 3.6 in ___. Coincident with
renal failure, she developed anemia. Anemia thought to be
normochromic anemia in the context of chronic kidney disease
with
proteinuria and poorly controlled diabetes mellitus, borderline
low B12 and elevated MMA. Inflammatory block to iron utilization
as well as impaired EPO
production and EPO responsiveness also suspected in addition to
CKD. Took twice daily iron tablets ___ to ___.
Colonoscopy on ___ showed diverticulosis. EGD performed on
___ was normal; biopsies were not obtained.
Last seen by cardiology ___ with plan for repeat TTE next
visit iso mechanical MVR and to eval LV function iso HF symptoms
on exam. Pacemaker interrogated and showed good function with
excellent pacing and sensing thresholds.
In the ED initial vitals were: 98.4 62 154/86 16 95% RA
EKG: Sinus vs. afib with frequent ventricular ectopy
Exam: 1+ nonpitting edema in both legs bilaterally, No JVD
Labs/studies notable for:
WBC 7.8 with 84% PMNs, Hgb 7.5 (from 7.6 on ___, plts 198
INR 2.2, PTT 43.9
Retic 3.3%,
Cr 2.7
BNP 3053
Trop <0.01 x 2
Dig level 1.9
ESR and EPO: pending
U/A: 300 protein, neg nit, neg leuk, 2 WBC, few bact
CXR: Small right pleural effusion and pulmonary vascular
congestion. No focal consolidation.
Patient was given:
IV Furosemide 40 mg
Vitals on transfer: T98.0, P68, BP 149/61, RR18, PO2 95% RA
On the floor patient stable and confirms above story. Starting
feeling more fatigued about a month ago but progressive DOE and
worsened fatigue noted a week ago when she was unable to walk
her
usual 30 minutes on the treadmill. Was having DOE, orthopnea (3
vs 2 pillows), PND, worsened ___ edema (R>L and couldn't bend
knees due to swelling), dizziness with bending down, and
difficulty taking in a deep breath with some chest pressure
after
walking 10 steps. Denies chest pressure/pain otherwise,
heartburn, rashes, abd pain, N/V, fevers, chills, URI sx,
dysuria, diarrhea, melena, BRBPR. Did have one episode of
palpitations yesterday. Thinks her dry weight is around 186. No
diet or medication changes other than stopping metformin four
days PTA. Reports started taking Lasix ___ after telling
cardiologist about sx, at Lasix 20mg daily. Had not taken Lasix
prior to this for months. Then increased to BID one day prior to
admission. Last time patient was swollen iso increased salt
intake, swelling was not this severe. Since Lasix given in ED,
notes improved swelling and orthopnea.
Past Medical History:
Rheumatic fever/severe mitral valve prolapse s/p mitral valve
annuloplasty done at the age of ___ by Dr. ___
Hyperlipidemia
AF/flutter
Migraines
Vasovagal syncope
Diastolic CHF
s/p hysterectomy
Pre diabetes
Anemia
Vitamin D deficiency
Cholecystectomy
Past Surgical History:
s/p mitral valve annuloplasty done at the age of ___ by Dr.
___
___ History:
___
Family History:
Father with a history of strokes and had "heart problems"- no
specifics. No hx of sudden cardiac death.
Physical Exam:
ADMISSION EXAM
==============
VS: T 97.9, BP 133/86, P67, RR18, PO2 95 Ra
GENERAL: Well developed, well nourished F in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Pale conjunctiva. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple. JVP of 8 cm.
CARDIAC: irregular rate and rhythm. mechanical S1, normal S2.
___
SEM at RUSB; no rubs, or gallops. No thrills or lifts.
LUNGS: Respiration is unlabored with no accessory muscle use.
Crackles at left lower base; no wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema up to shins
bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
===============
VITAL SIGNS: ___ 1151 Temp: 98.3 PO BP: 153/79 HR: 60 RR:
20
O2 sat: 97% O2 delivery: RA FSBG: 226
GENERAL: Well developed, well nourished F in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Pale conjunctiva. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple. JVP of 8 cm.
CARDIAC: irregular rate and rhythm. mechanical S1, normal S2.
___
SEM at RUSB; no rubs, or gallops. No thrills or lifts.
LUNGS: Respiration is unlabored with no accessory muscle use. no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. trace pitting edema up to
shins
bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 12:40PM BLOOD WBC-7.8 RBC-2.63* Hgb-7.5* Hct-24.1*
MCV-92 MCH-28.5 MCHC-31.1* RDW-16.3* RDWSD-54.0* Plt ___
___ 12:40PM BLOOD Creat-2.7* Na-142 K-4.7
___ 02:04PM BLOOD ___ PTT-43.9* ___
___ 12:40PM BLOOD ALT-16 AST-18
___ 12:19PM BLOOD LD(LDH)-202 TotBili-0.4
OTHER PERTINENT LABS
===================
___ 12:40PM BLOOD Iron-42
___ 12:19PM BLOOD Hapto-162
___ 12:40PM BLOOD Ferritn-124
___ 12:40PM BLOOD %HbA1c-6.7* eAG-146*
___ 12:40PM BLOOD TSH-3.9
___ 12:19PM BLOOD CRP-2.8
___ 07:10AM BLOOD Digoxin-1.0
___ 12:40PM BLOOD Digoxin-1.9*
IMAGING
=======
CXR ___
Small right pleural effusion and pulmonary vascular congestion.
No focal
consolidation.
CXR ___
Persisting pulmonary vascular congestion. Increased aeration of
the lung
bases.
TTE ___
Good image quality. Well seated, normal functioning bileaflet
mechanical MVR with normal gradient and no mitral regurgitation.
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function. Moderate pulmonary
artery systolic hypertension. Biatrial enlargement.
DISCHARGE LABS
==============
___ 06:31AM BLOOD WBC-7.3 RBC-2.72* Hgb-7.7* Hct-24.5*
MCV-90 MCH-28.3 MCHC-31.4* RDW-16.7* RDWSD-54.4* Plt ___
___ 06:31AM BLOOD ___ PTT-47.0* ___
___ 06:31AM BLOOD Glucose-142* UreaN-60* Creat-2.8* Na-143
K-4.4 Cl-104 HCO3-20* AnGap-19*
___ 06:31AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.8
Brief Hospital Course:
Key Information for Outpatient ___ year old female
with PMH acute on chronic anemia, rheumatic heart disease s/p
mechanical mitral valve replacement (___) and ICD on Coumadin,
afib, dCHF, DM, HTN, CKD presents with DOE/fatigue concerning
for acute on chronic anemia and HFpEF exacerbation. Patient was
diuresed and received blood.
===============
ACTIVE ISSUES:
===============
# Fatigue
# DOE:
Patient's recent symptoms of orthopnea and fatigue likely
multifactorial iso worsening renal function, acute on chronic
normocytic anemia, and volume overload i/s/o HFpEF. Patient
endorsed orthopnea, PND, and worsened leg swelling iso elevated
BNP and pulm vascular congestion on CXR. ACS unlikely as trigger
for exacerbation given trop negative x2, no acute ST changes on
EKG, and no chest pain. Recent interrogation of PPM ___. TR
from pacing wires possible but pt more with left sided failure
and no elevation of JVP. Anemia most likely secondary to reduced
EPO production iso progressive CKD. Interrogation of device
unremarkable. Repeat TTE with preserved EF, normal functioning
MVR, and 2+ TR. s/p IV Lasix with improved DOE and transitioned
to daily PO Lasix. Cr remained at baseline and patient received
1u pRBC.
# HFpEF Exacerbation:
Exacerbation this visit iso elevated BNP and pulm edema, unclear
etiology. Ddx includes ACS but less likely given trop negative
x2, no acute ST changes on EKG, and no chest pain. Last
cardiology visit noted to only develop heart failure symptoms
with excessive intake of salty food but patient reports
medication and dietary compliance. Other possible etiologies
could include infection but denies localizing sx, arrhythmias
although recent interrogation of device ___ without events and
only one episode of subjective palpitations, failure/clot of
mechanical MVR, or pacing wire related regurg. Repeat TTE with
normal EF and MVR. Interrogation of device with no events. s/p
IV Lasix doses with improved symptoms.
- PRELOAD: Lasix 20 mg daily
- NHBK: continued metoprolol, verapamil
- Afterload: continued amlodipine
# Acute on chronic normocytic anemia:
Acute decline to 7.3 from 9.7 ___, and 11.4 on ___. Iron
studies wnl, bili/hapto/LDH normal pointing away from hemolysis.
Reticulocyte index 1.31% suggesting hypoproliferation which
could be from progressive CKD (reduced EPO production) vs other
etiologies for BM suppression. s/p 1u pRBC. EPO level high. Hgb
stable on discharge.
# Acute on chronic CKD:
Cr up to 2.7 from recent baseline 2 on ___. HCO3 20 with AG
19. Improved to 2.5 with diuresis suggesting possible
cardiorenal etiology of acute insult. Stable on discharge.
# Mitral valve replacement w/ St. ___ mechanical valve ___:
Patient with mechanical MVR stable on echo in ___, presenting
with pulm edema. However, valve functioning well on repeat TTE.
INR goal 2.5-3.5. As per guidelines added aspirin for dual
anticoagulation in the setting of a mechanical valve.
# Atrial fibrillation s/p PPM iso sinus pauses:
INR goal 2.5-3.5 with mechanical MVR. Rates controlled. Dig
level slightly elevated at 1.9 on admission, down to 1.1 two
days later. Continued verapamil and metoprolol. Restarted
digoxin at half the dose on discharge. Will need monitoring of
INR on discharge.
================
CHRONIC ISSUES:
================
# HTN: continued amlodipine
# HLD: continued pravastatin 80mg
TRANSITIONAL ISSUES
===================
DISCHARGE WEIGHT: 82.3 kg / 181.44 lb
DISCHARGE HGB: 7.7
DISCHARGE CR: 2.8
DISCHARGE INR: 3.4
CHANGED MEDICATION:
- Digoxin 0.0625 mg QD (dose halved)
- Lasix 20 mg QD (reduced from BID)
[ ] Will need lab draw on ___: Chem-10, Digoxin level,
and ___
[ ] consider low dose ACE-inhibitor if renal function stable
[ ] Digoxin dose reduced in half
[ ] Lasix reduced to daily
# CODE STATUS: full
# CONTACT: sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil 180 mg PO Q12H
2. Metoprolol Succinate XL 100 mg PO BID
3. Pravastatin 80 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Warfarin 3 mg PO 3X/WEEK (___)
8. Warfarin 3.5 mg PO 4X/WEEK (___)
9. Vitamin D ___ UNIT PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Digoxin 0.125 mg PO DAILY
12. Fenofibrate 160 mg PO DAILY
13. Furosemide 20 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Digoxin 0.0625 mg PO DAILY
RX *digoxin [Lanoxin] 62.5 mcg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
4. amLODIPine 10 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Fenofibrate 160 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO BID
10. Pravastatin 80 mg PO QPM
11. Verapamil 180 mg PO Q12H
12. Vitamin D ___ UNIT PO DAILY
13. Warfarin 3 mg PO 3X/WEEK (___)
14. Warfarin 3.5 mg PO 4X/WEEK (___)
15.Outpatient Lab Work
Chem-10 panel, Digoxin level, and ___
Dx: 585.9 (ICD-9) / N18.9 (ICD-10)
Fax results to ___ (c/o ___ MD)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
HFPEF exacerbation
Acute on chronic anemia
SECONDARY DIAGNOSES
====================
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of shortness of breath and fatigue
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have fluid in your lungs and were given
diuretics through the IV.
- You had an echocardiogram of your heart that showed normal
pumping and normal pumping function of the heart.
- Your pacemaker was interrogated with no abnormal events found.
- You were given a unit of blood for low blood counts.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- You will need to get your blood drawn for a lab check on
___.
- Your weight at discharge is 181 pounds. Please weigh yourself
today at home and use this as your new baseline.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19632593-DS-21
| 19,632,593 | 28,149,301 |
DS
| 21 |
2161-12-11 00:00:00
|
2161-12-12 08:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ h/o CAD s/p CABG (___) (recent cath ___ with severe
disease), recent diagnosis AF s/p cardioversion on apixaban
(last week), HTN, HLD and AAA presented to OSH with abdominal
pain found to have pancreatitis.
Mr. ___ was recently admitted to the ___ last week for type
II NSTEMI iso AF with RVR. He had TEE/cardioversion and was
started on Sotalol and Apixaban. He had been doing well until
last night when he developed progressive, acute onset ___
sharp, epigastric pain. He describes the pain as unlike his
angina pain. He tried to wait the pain out, but it persisted,
thus he went to OSH ED. There, he had CT showing dilated CBD and
lipase >1000 concerning for gallstone pancreatitis. His EKG was
without ischemic changes and he had troponin 0.02. Due to need
for MRCP and ? ERCP, he was transferred here. In the BID ED, he
was seen by ERCP who recommended MRCP.
Notably, he drinks EtOH only intermittently. No previous history
of pancreatitis. On my interview, he feels well with ___ pain.
No nausea vomiting or diarrhea. He has no chest pain or SOB.
Past Medical History:
-Coronary Artery Disease s/p CABG in ___
--coronary artery bypass graft x3, left internal mammary artery
to left anterior descending artery, saphenous vein graft to
distal right coronary artery and obtuse marginal arteries.
-Abdominal Aortic Aneurysm
-Hypercholesterolemia
-Hypertension
-Spinal Stenosis
-recent d/x of afib, now s/p DCCV, now on sotalol and apixiban
Social History:
___
Family History:
Father - myocardial infarction in his ___
Brother - myocardial infarction in his ___
Physical Exam:
ADMISSION EXAM:
98.4 PO 132 / 64 59 18 99 % RA
Well appearing, NAD
Moist mucous membranes
RRR, S1, S2, no JVD
CTAB
Abdomen is soft, non-tender, no-distended, + BS, no rebound or
guarding
Ext are warm, well perfused without edema
DISCHARGE EXAM:
Vital Signs: 97.3PO 110 / 60R Sitting 78 16 100 RA
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present
EXT: no ___ edema or calf tenderness
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 05:07PM BLOOD WBC-6.9 RBC-3.14* Hgb-10.1* Hct-28.9*
MCV-92 MCH-32.2* MCHC-34.9 RDW-16.2* RDWSD-54.3* Plt ___
___ 05:07PM BLOOD Glucose-75 UreaN-17 Creat-1.0 Na-134
K-4.8 Cl-99 HCO3-25 AnGap-15
___ 06:32PM BLOOD ___ PTT-36.9* ___
___ 05:07PM BLOOD ALT-50* AST-43* AlkPhos-128 TotBili-1.8*
___ 05:07PM BLOOD Lipase-___*
___ 09:05AM BLOOD cTropnT-0.01
___ 09:17AM BLOOD Lactate-0.8
Discharge Labs:
___ 07:55AM BLOOD WBC-4.3 RBC-2.76* Hgb-8.8* Hct-25.1*
MCV-91 MCH-31.9 MCHC-35.1 RDW-15.2 RDWSD-50.7* Plt ___
___ 07:55AM BLOOD Glucose-159* UreaN-17 Creat-1.1 Na-130*
K-4.7 Cl-98 HCO3-26 AnGap-11
___ 07:55AM BLOOD ALT-36 AST-32 AlkPhos-123 TotBili-1.2
Blood Cx x 2 pending, ___
CXR - FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy
wires and
overlying EKG leads are present. There is mild bibasilar
atelectasis without
convincing signs of pneumonia, edema, effusion or pneumothorax.
The
cardiomediastinal silhouette is unchanged. Bony structures are
intact. No
free air seen below the right hemidiaphragm.
MRCP -
IMPRESSION:
3D MRCP images were not diagnostic in the region of common bile
duct. Small
gallstone. There are ___ small stones within common bile duct.
Cholangitis.
Mild gallbladder wall thickening, enhancement, may represent
acute
cholecystitis in the appropriate clinical setting.
Suggestion of mild pancreatitis, no peripancreatic fluid
collection.
Infrarenal Abdominal aortic aneurysm measures 5.5 cm,
Incompletely seen.
ERCP -
Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film was normal.
The major papilla was severely stenotic.
The CBD was successfully cannulated with the CleverCut 3V
sphincterotome preloaded with a 0.025in guidewire.
The guidewire was advanced into the intrahepatic biliar tree.
Careful contrast injection revealed a dilated CBD to
approximately 12mm in diameter and a few filling defects
consistent with stone and sludge in the distal CBD.
The intrahepatic biliary tree was not opacified due to active
cholangitis.
A sphincterotomy was successfully performed at the 12 o'clock
position.
No post-sphincterotomy bleeding was noted.
The CBD was swept several times with successful removal of a
small stone, stone fragments and some sludge material.
There was excellent spontaneous drainage of bile and constrast
material at the end of the procedure.
The PD was not injected or cannulated.
HIDA - IMPRESSION: Delayed filling of the gallbladder and
delayed emptying into the
small bowel. No evidence of cholangitis.
Brief Hospital Course:
___ h/o CAD s/p CABG (___) (recent cath ___ with severe
disease), recent diagnosis AF s/p cardioversion on apixaban
(last week), HTN, HLD and AAA presented to OSH with abdominal
pain found to have pancreatitis.
# Gallstone Pancreatitis: Stones seen on MRCP. With some concern
for cholangitis on MRCP. S/p ERCP with sphx and stone/sludge
extraction. Diet successfully advanced following ERCP. HIDA scan
showed delayed GB empyting without evidence of cholangitis.
LFT's normalized. Pt was seen by surgery team, who felt that,
given clinical picture as well as ___ medical
comorbidities, surgery was not warranted at this time. Pt will
continue 7 day course of antibiotics for empiric cholangitis
coverage (initially placed on cipro; however, switched to
Augmentin at discharge given ECG showed borderline QTc ~460).
# Atrial Fibrillation: RRR on exam. On sotalol, s/p recent DCCV.
Initially placed on heparin gtt bridge. Anticoagulation held
following ERCP per GI recommendations, given large
sphincterotomy and high risk for post procedural bleeding. ASA
was continued, as it would take 5 days to wash out of system
anyway. After discussions with GI, given high stroke risk as
well in the setting of recent DCCY, decision was made to restart
a/c with Apixiban 3 days following ERCP (___). Pt understood
this plan. He was instructed to monitor closely for any signs of
GI bleeding.
# CAD: On ASA, statin.
# HTN: Antihypertensive agents held during admission. Given that
BP's were in the low normal range throughout admission, he was
only restarted on spironolactone and HCTZ at discharge. BP
should be rechecked at f/u appt and lisinopril added back as
needed.
# Hyponatremia: Mild. Pt endorses history of intermittent
hyponatremia. Na 130 at discharge. Should be rechecked at f/u
appointment.
TRANSITIONAL ISSUES:
- Please repeat sodium at follow up appointment. Na was 130 at
discharge.
- Please recheck BP, consider adding back lisinopril as needed.
- 2 blood cultures pending at discharge with ___ need to
be followed up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Sotalol 80 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Hydrochlorothiazide 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Spironolactone 25 mg PO BID
8. Lisinopril 20 mg PO BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last day ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*11 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Sotalol 80 mg PO BID
7. Spironolactone 25 mg PO BID
8. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until ___
9. HELD- Lisinopril 20 mg PO BID This medication was held. Do
not restart Lisinopril until you follow up with your primary
care physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital and were found to have evidence of
pancreatitis (inflammation in your pancreas). This was likely
related to gallstones. You had an endoscopic procedure called an
ERCP, during which you had a small cut placed in your bile ducts
to allow drainage of your gallstone. You tolerated this well.
You are now being discharged home. You will continue antibiotics
for a total of 7 days to treat any possible infection in your
bile ducts.
You will restart your anticoagulation on ___ given
your high risk of stroke from your recent cardioversion. You
should monitor your stools for any blood. If you notice any
blood in your stools, black stools, or lightheadedness, you
should go to the emergency room.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
19632936-DS-10
| 19,632,936 | 28,139,980 |
DS
| 10 |
2139-11-09 00:00:00
|
2139-11-12 18:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Transfusion of 2 units packed red blood cells
History of Present Illness:
___ year old male ___ CAD s/p 2 stents, Afib on warfarin, sick
sinus s/p PPM, HTN, HLD, moderate AS, macrocytic anemia,
referred from clinic with chief complaint of worsening SOB over
2wk.
Patient reports progressive SOB over the past 8 months up to ___
years that has gradually worsened, but with acute progression
over the past ___ weeks, particularly over the past few days.
Patient reports he is now having difficulty walking half a
flight of stairs or to the end of his driveway without
significant SOB. Patient was seen by cardiology on ___ for
this complaint due to concern of a cardiac etiology of his
symptoms. Patient had a stress test that was negative. Echo
revealed mild MR, mild AS and mild pulmonary HTN. LVEF > 55%.
biatrial enlargement but no noted diastolic dysfunction. Per
cardiology consult today in the ED, CHF and ACS are unlikely.
Presentation is more concerning for valvular disease vs
pulmonary HTN vs acute anemia.
Patient denies fevers/chills. No CP/palpitations with his SOB.
No changes in his weight or worsening ___ edema. Endorses a
chronic cough over the past year, productive of clear sputum, no
other infectious symptoms. No orthopnea.
In the ED, initial VS were 97.4 79 160/44 17 100%RA. Exam
pertinent for ___ holosystolic murmur, RRR, nl S1 S2; JVP 8cm;
lungs CTAB; 4+ pitting edema to knees bilaterally with chronic
venous stasis skin changes; 3cm patch on L posterior shoulder
(likely SCC). Rectal exam heme positive, brown stool.
Labs notable for Hgb 6.8, WBC 8.6, Plt 341, negative trop X1,
BUN 23, Cr 1.4, proBNP 129, PTT 37.4, INR 2.6.
CXR demonstrated no acute cardiopulmonary process. EKG
demonstrates no ischemic changes.
Received 1L NS and 1u pRBCs in ED for Hb 6.8. Patient reports he
has had gradually worsening anemia over the past year or so of
unclear etiology. He presented to an OSH in ___ for dark
stools and concern for blood in his stools. He had
endoscopy/colonoscopy that found colonic polyps but were
otherwise negative for source of GI bleed. No abdominal pain,
N/V, diarrhea/constipation.
Transfer VS were 98.1, 89, 132/51, 18, 100%
On arrival to the floor, patient reports the above history.
Otherwise is comfortable stating he feels at his baseline health
at rest.
Past Medical History:
CAD s/p stent ___
Afib on warfarin
Sick sinus s/p PPM
HTN
HLD
Moderate AS
Macrocytic anemia
H/o colonic polyps
Social History:
___
Family History:
No family history of premature CAD, arrhythmia, or CHF.
Physical Exam:
==================
ADMISSION EXAM
==================
VS: Tc 98.0 BP 169/67 HR 87 RR 22 O2 sat 99%RA
GENERAL: Elderly male in NAD
HEENT: EOMI, PERRL, anicteric sclera, mild conjunctival pallor,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, positive systolic murmur heard greatest at
RUSB, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally. Chronic venous stasis changes.
2+ edema, nonpitting.
NEURO: CN II-XII intact. No focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=====================
DISCHARGE EXAM
=====================
VS: Tc 98.3 BP 123/68 HR 86 RR 18 O2 sat 95%RA
GENERAL: Elderly male in NAD
HEENT: EOMI, PERRL, anicteric sclera, no conjunctival pallor,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, positive III/XI systolic murmur heard
greatest at RUSB, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally. Chronic venous stasis changes.
2+ edema, nonpitting.
NEURO: CN II-XII intact. No focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
====================
ADMISSION LABS
====================
___ 01:22PM WBC-6.5 RBC-2.08* HGB-6.8* HCT-23.8* MCV-114*
MCH-32.7* MCHC-28.6* RDW-14.1 RDWSD-58.9*
___ 01:22PM NEUTS-72.7* LYMPHS-14.7* MONOS-10.1 EOS-1.7
BASOS-0.5 IM ___ AbsNeut-4.75 AbsLymp-0.96* AbsMono-0.66
AbsEos-0.11 AbsBaso-0.03
___ 01:22PM PLT COUNT-308
___ 01:22PM ___ PTT-37.4* ___
___ 01:22PM cTropnT-<0.01
___ 01:22PM proBNP-129
___ 01:22PM GLUCOSE-114* UREA N-23* CREAT-1.4* SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
==================
DISCHARGE LABS
==================
___ 07:40AM BLOOD WBC-4.6 RBC-2.59* Hgb-8.1* Hct-27.6*
MCV-107* MCH-31.3 MCHC-29.3* RDW-19.4* RDWSD-73.8* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-32.9 ___
___ 07:40AM BLOOD Glucose-79 UreaN-23* Creat-1.5* Na-141
K-3.8 Cl-101 HCO3-28 AnGap-16
___ 07:40AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.3
==================
MICROBIOLOGY
==================
NONE
==================
IMAGING/STUDIES
==================
CXR ___ IMPRESSION:
No acute cardiopulmonary process.
CT ABDOMEN/PELVIS WITHOUT CONTRAST IMPRESSION:
1. No evidence of retroperitoneal or intraabdominal hematoma.
2. Gallstones without evidence of cholecystitis.
3. Aneurysmal dilation of the infrarenal aorta up to 2.3 cm in a
densely calcified area.
4. Right renal simple cyst.
Brief Hospital Course:
___ with PMH extensive CAD s/p 2 stents, AFib on warfarin, sick
sinus syndrome s/p PPM, presenting with acute on chronic dyspnea
on exertion. Patient has ___ year history of progressive SOB found
to have new anemia of 6.8 (from baseline Hb 8s). In the ED,
patient also had guiac positive stools with no bright red blood
per rectum or melena. Patient was transfused total 2u pRBCs with
increase in hemoglobin to only 7.9. Upon additional labs, there
was no evidence of hemolysis, patient had appropriate
reticulocyte count. Of note, patient had a recent work up 2
weeks prior to admission that showed normal iron studies,
B12/folate levels WNL, TSH WNL. Therefore, the acute worsening
of anemia was felt likely secondary to acute blood ___. CT
Abd/Pelvis was negative for RP bleed or other areas of hematoma.
Patient had additional 2 guaiac positive stools. GI was
consulted for work up of GI bleed. Since patient had no visible
blood stool, endoscopy/colonoscopy were deferred for outpatient
work up. Patient was monitored for >36 hours s/p ___ transfusion
with stable H&H.
Of note, the differential for the patient's shortness of breath
included cardiac etiologies given his known significant CAD.
Patient had stress echo that was normal and TTE that showed
mild-moderate AS, mild pulmonary HTN. Stable angina was
considered as a possible explanation for his DOE; however
unlikely to be the main contributor to the patient's acute
worsening of DOE. Could consider outpatient cardiac
catheterization when Hb stabilized and if symptoms persist.
#Anemia: Patient has chronic macrocytic anemia currently on
folate supplementation although normal B12 and folate levels.
Hgb on admission 6.8 and stable on repeat, decreased from
baseline of approximately 8s. Patient endorses possible bloody
stools and has positive hemoccult stool c/f GI bleed. Had repeat
guaiac positive stool on the floor. Of note, patient on warfarin
for atrial fibrillation and INR on admission is 2.6. Acute drop
in Hgb concerning for bleed. CT Abd/Pelvis negative for
retroperitoneal or other intra-abdominal sources of bleeding.
Hematology was requested to review peripheral smear of patient.
Per hematology, most concerning for GI bleed. Patient was
transfused total 2u pRBC with stabilization of H&H. GI was
consulted, however no overtly melanotic/bright red blood in
stool, so deferred endoscopy/colonoscopy for close outpatient
follow up. Recommend further follow up with hematology as
outpatient.
#Progressive Dyspnea: Has had progressive dyspnea over the past
___ years with worsening particularly over the past couple of
weeks. Most likely acutely worsened due to significant anemia.
DDx includes symptomatic AS vs other valvular disease although
read as mild on echo vs severe anemia. Patient has had negative
cardiology work up thus far; therefore echo deferred inpatient
since done 2 weeks ago. Patient denied chest pain and EKG shows
no signs of ischemia. Additionally, he denies orthopnea, lungs
are CTAB, no pleural effusions or pulmonary edema noted on CXR,
and BNP not elevated. Given long-standing CAD, considered stable
angina with DOE as angina equivalent. Recommend patient follow
up with cardiologist as outpatient for ?cardiac cath.
___: Unclear baseline creatinine. Lowest Cr 1.2 in ___.
Creatinine 1.4 on admission. Possibly pre-renal etiology given
anemia/volume depletion. Did not significantly improve s/p 1L
IVF. Recommend follow up as outpatient.
#CAD s/p Stent: No current complaints of chest pain. Recent
stress echo negative. Continued home statin, ASA. Can consider
cardiac cath as above.
#HLD: continued statin.
#AFib: Currently rate controlled. INR on admission 2.6.
Continued on diltiazem for rate control. Held warfarin during
admission for concern of GI bleed, restarted on discharge.
#Sick sinus syndrome s/p pacemaker: Recently adjusted settings
per outpatient cardiology with no change in fatigue or SOB
#GERD: Continued home pantoprazole.
======================
TRANSITIONAL ISSUES
======================
[ ] Repeat CBC and INR at ___ office on ___.
[ ] Restart warfarin 1.5mg daily. Conservative INR goal.
[ ] Follow up with hematology for etiology of chronic macrocytic
anemia.
[ ] GI office to call patient on ___ to schedule outpatient
endoscopy/colonoscopy.
[ ] Consider cardiac catheterization for chronic DOE ___ ?stable
angina
[ ] CT Abdomen/Pelvis Findings:
___ IMPRESSION:
1. No evidence of retroperitoneal or intraabdominal hematoma.
2. Gallstones without evidence of cholecystitis
3. Aneurysmal dilation of the infrarenal aorta up to 2.3 cm in a
densely calcified area
4. Right renal simple cyst (1.3 cm x 1.5 cm)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. BusPIRone 15 mg PO BID
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Furosemide 40 mg PO BID
6. Pantoprazole 40 mg PO BID
7. Potassium Chloride 20 mEq PO DAILY
8. Warfarin 1.5 mg PO DAILY16
9. Aspirin 81 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. FoLIC Acid Dose is Unknown PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID:PRN Disp
#*60 Tablet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID:PRN Disp
#*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. BusPIRone 15 mg PO BID
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Ferrous Sulfate 325 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Furosemide 40 mg PO BID
11. Pantoprazole 40 mg PO BID
12. Potassium Chloride 20 mEq PO DAILY
13. Warfarin 1.5 mg PO DAILY16
14.Outpatient Lab Work
Date: ___
Labs: CBC, ___ (INR)
ICD10: D64.9, I48.91
Please fax to ___, Attn: ___ MD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Anemia, Dyspnea on Exertion
Secondary Diagnoses: Coronary Artery Disease, Atrial
Fibrillation, Sick Sinus Syndrome
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 ___.
WHY YOU WERE ADMITTED TO THE HOSPITAL:
=======================================
- You were having shortness of breath due to very low red blood
cell counts.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
==============================================
- You received two blood transfusions with significant
improvement in your symptoms.
- You were evaluated by our gastroenterology team who
recommended you have an endoscopy and colonoscopy as an
outpatient to check for GI bleed.
WHAT YOU NEED TO DO WHEN YOU GO HOME:
=====================================
- It is very important that you follow up with your primary care
doctor and have your blood counts and INR checked on ___
___.
- Please do not hesitate to return to the emergency room or seek
medical care if you develop worsening shortness of breath or
have any black tarry stools or bright red blood in your stools.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19633126-DS-7
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DS
| 7 |
2146-10-10 00:00:00
|
2146-10-11 14:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
Mr. ___ is an ___ year old male with history of PVD, HTN,
COPD, dCHF, CAD s/p status post multiple PCIs ___ with a
DES to ___ and a DES to ___ and ___ with DES to proximal RCA
___ presents with recurrent CP similar to last admission. He
was discharged from ___ on ___ where PCI was performed for
unstable angina. Since discharge he has not been feeling well
with "shakiness, unsteadiness and intermittent chest pain".
___ afternoon he noted a moderate tightness across his chest
that radiated to his neck and with jaw pain which is his anginal
equivalent. There were no associated symptoms of dypnea,
diaphoresis, nausea or vomiting. He took ntg x3 and the pain
dissipated. He called the Cardiology Call Center yesterday and
was able to talk with one of the nurses, but was unable to touch
base with a physician. Last night he had similar pain though jaw
only without chest tightness around 2AM which relapsed and
remitted throghout the night, he did not take ntg and the pain
resolved spontaneously. This morning he developed jaw pain again
but this time with chest pressure and diaphoresis. He called the
cardiology center who referred him the the the ED for
evaluation. He has been taking aspirin and plavix continuously
without interruption.
In the ED, initial VS were: 55 138/64 16 100%, he arrived CP
free. He did not received Nitro in the ED and ___ took full
dose aspirin for the day. Cardiology attending was consulted who
recommended initiation of Heparin drip and admission for
possible cath in the AM.
VS prior to transfer were: 133/52, RR 18, O2 sat 99%, CP fre
On arrival to the floor, patient stable and in no chest pain.
This morning patient is still chest pain free on heparin drip.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Coronary Artery Disease s/p stents x8 (LCx X 4, RCA X 4)
COPD
Hiatal Hernia
___ Esophagus
HLD
HTN
Osteoarthritis
S/P Right and Left Hip replacement
Tranisient Ischemic Attacks
Peripheral vascular Disease (S/P stent)
Small Bowel Obstruction in ___ s/p LOA
Social History:
___
Family History:
Father died at ___ of an MI. Brother died of MI at ___.
Physical Exam:
VITALS: 98.4 142/68 55 18 100% RA
GENERAL: Well appearing, comfortable and in NAD. Pleasant,
appropriate and interactive.
HEENT: PERRL, EOMI, NCAT
NECK: no carotid bruits, JVP ~8cm
LUNGS: faint bibasilar crackles, moving air well and
symmetrically. Lungs clear anteriorly and posteriorly superior
to bases. No expiratory wheezes, no prolonged expiratory phase
HEART: Bradycardic, regular rhythm, S1 S2 ___ and of good
quality, ___ soft systolic murmur heard throughout preordium
ABDOMEN: Soft, NT, NABS, no HSM
EXTREMITIES: Trace ___ edema
NEUROLOGIC: A+OX3
Pertinent Results:
___ 02:40PM BLOOD WBC-6.6 RBC-3.33* Hgb-10.4* Hct-30.8*
MCV-93 MCH-31.2 MCHC-33.8 RDW-14.1 Plt ___
___ 03:07AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.5* Hct-31.4*
MCV-94 MCH-31.3 MCHC-33.5 RDW-14.4 Plt ___
___ 02:40PM BLOOD ___ PTT-28.8 ___
___ 03:07AM BLOOD ___ PTT-51.7* ___
___ 02:40PM BLOOD Glucose-88 UreaN-24* Creat-1.2 Na-137
K-4.4 Cl-103 HCO3-24 AnGap-14
___ 03:07AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-142
K-3.7 Cl-107 HCO3-25 AnGap-14
___ 02:40PM BLOOD proBNP-833
___ 02:40PM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
___ 03:07AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
.
Cardiac Cath ___ (prelim report):
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated no flow limiting disease. The ___ had no
angiographically
apparent disease. The Cx had widely patent stents and no
angiographically apparent disease. The LAD had no
angiographically
apparent disease. The RCA had widely patent stents and no
angiographically apparent disease.
2. Limited resting hemodynamics revealed a central aortic
pressure of
109/51 mmHg.
FINAL DIAGNOSIS:
1. Coronary arteries have no flow limiting lesions.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr. ___ is an ___ year old male with a history of PVD, HTN,
COPD, dCHF, and CAD s/p status post multiple PCIs (most recently
DES to mLCx, DES to dRCA, and DES to ___ 2 weeks ago) who
presented with recurrent chest pain
ACTIVE ISSUES:
=======================
# Chest pain: Patient presented with increasing frequency of
chest pain radiating to the jaw which were consistent with
patients previous ischemic episodes. He was treated with IV
heparin and then taken to the cath lab for unstable angina.
Cardiac catheterization did not show any flow limiting CAD and
all stents were patent.
- The patient's anti-anginal regimen was increased (increased
imdur from 30mg to 60mg). The patient was stable and chest pain
free prior to discharge.
- Continued current CAD regimen: Clopidogrel, ASA, Losartan,
Metoprolol, and Atorvastatin.
- Patient will follow-up with his cardiologist Dr. ___ in
1 week.
CHRONIC ISSUES:
=====================
# Chronic Diastolic CHF with LVEF of >55%. No signs of
exacerbation during this admission. Currently he meets NYHA
Class II-III criteria given SOB/symptoms with minimal exertion
including house work though he does walk 2 blocks per day.
Unclear though if this limitations are ___ from CHF related as
patient also has underlying COPD and PVD which are likely both
contributing to symptoms.
- Continued Metoprolol and Losartan
# PVD: Chronic, stable, on good anti-atherosclerotic therapy.
- Atorvastatin 80 mg PO DAILY
# HTN:
- Continued metoprolol, losartan, amlodipine
- Incrased imdur as above
# HLD: Chronic, stable
- Continue Atorvastatin 80mg
TRANSITIONAL ISSUES:
======================
# Patient may need continued uptitration of anti-anginal
regimen. Imdur increased from 30 to 60mg during this admission.
# CODE STATUS: Confirmed full
# CONTACT: ___ (___) ___, ___
___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Clopidogrel 75 mg PO DAILY
2. Sulindac 150 mg PO BID
3. Pantoprazole 40 mg PO Q24H
4. Losartan Potassium 50 mg PO DAILY
Hold for SBP<100
5. Amlodipine 10 mg PO DAILY
Hold for SBP<100
6. Atorvastatin 80 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold for SBP<100
8. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP<100 or HR<60
9. Aspirin 325 mg PO DAILY
10. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral DAily
11. Tiotropium Bromide 1 CAP IH DAILY
12. Multivitamins 1 TAB PO DAILY
13. ___ Oil (Omega 3) 1000 mg PO TID
14. melatonin *NF* 1 mg Oral QHS
15. Acetaminophen 650 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO BID
2. Amlodipine 10 mg PO DAILY
Hold for SBP<100
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. ___ Oil (Omega 3) 1000 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Hold for SBP<100
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
8. Losartan Potassium 50 mg PO DAILY
Hold for SBP<100
9. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP<100 or HR<60
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Tiotropium Bromide 1 CAP IH DAILY
13. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral DAily
14. melatonin *NF* 1 mg Oral QHS
15. Sulindac 150 mg PO BID
Take this medication at least 30 minutes after taking aspirin.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Chest Pain
-Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, it was a pleasure taking care of you here at ___.
You were admitted to the hospital after several episodes of
chest pain. Fortunately however you were NOT having a heart
attack. You had a cardiac catheterization which showed that all
of your stents were open and working correctly.
We are adjusting your medications slightly as detailed on the
next page. Make sure you take Sulindac and any other
Anti-Inflammatory Medications (aleve, ibuprofen, etc.) at least
30 minutes after taking aspirin. These medications can decrease
the effectiveness of aspirin if you take them first.
Followup Instructions:
___
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2146-10-19 00:00:00
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2146-10-20 23:37:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiography with intravascular ultrasound and pressure
evaluation of the right coronary artery followed by balloon
angioplasty
History of Present Illness:
Mr. ___ is a ___ yo man with H/O PVD, hypertension, COPD,
diastolic CHF, CAD s/p multiple PCIs (most recent ___ DES to
mid LCx and DES to distal RCA and ___ DES to proximal RCA)
who presented with acute substernal chest pressure at rest which
awoke him from sleep. He states that it feels similar to (though
less severe than) pain that brought him in for his initial
stents. The discomfort was not relieved by NTG x 3 at home,
relieved by morphine and 1 inch nitro paste at OSH. He was also
started on heparin gtt at OSH where Trop I was 0.05, as well as
ASA 325 mg and Lasix 20 mg IV for question of fluid overload.
Upon arrival to the ___ ED, he was chest pain free.
In the ED, initial vitals were T 97.9 HR 62 BP 142/76 RR 18 SaO2
99%. EKG showed inferior Q waves but no change from prior.
Vitals prior to transfer were T 97.6 HR 68 RR 18 SaO2 99% on RA
BP 125/67. Labs here notable for baseline anemia and Troponin-T
of 0.05.
On review of systems, he endorses snoring with witnessed apneas
but denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-CAD: s/p multiple PCI, most recently ___ and ___.
-CHF, diastolic. LVEF >55%
-PVD: Carotid, vertebral and ilio-femoral disease.
-Hypertension
-Hyperlipidemia
-COPD, well controlled
Social History:
___
Family History:
Father died at ___ of an MI. Brother died of MI at ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.0 BP=149/77 HR=73 RR=22 O2 sat=99% on RA
GENERAL: WDWN elderly Caucasian man in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD at level of the neck at 90 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, diffuse pan-inspiratory crackles in bilateral
bases.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAMINATION:
VS: T 98.2 BP 114/62 HR 64 RR 18 SaO2 97% on RA Wt 73.3 kg
24hr I/O: ___
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
NECK: Supple with low JVP.
CARDIAC: RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts.
LUNGS:Resp were unlabored. CTAB.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
PULSES:
Right: Femoral 2+ DP 2+ ___ 2+
Left: Femoral 2+ DP 2+ ___ 2+
Pertinent Results:
Admission Labs:
___ 06:20AM BLOOD WBC-6.0 RBC-3.41* Hgb-10.6* Hct-32.1*
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.2 Plt ___
___ 06:20AM BLOOD ___ PTT-150* ___
___ 06:20AM BLOOD Glucose-107* UreaN-24* Creat-1.3* Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
Interim Labs:
___ 06:20AM BLOOD cTropnT-0.05*
___ 01:00PM BLOOD CK-MB-1 cTropnT-0.03*
___ 12:19AM BLOOD CK-MB-1
___ 05:55AM BLOOD CK-MB-3
___ 05:55AM BLOOD calTIBC-309 Ferritn-61 TRF-238
Discharge Labs:
___ 06:20AM BLOOD WBC-7.2 RBC-3.37* Hgb-10.3* Hct-31.4*
MCV-93 MCH-30.7 MCHC-33.0 RDW-14.1 Plt ___
___ 05:55AM BLOOD Glucose-96 UreaN-15 Creat-1.1 Na-138
K-4.1 Cl-101 HCO3-30 AnGap-___
_________________________________________________________
ECG ___ 6:12:44 AM
Artifact is present. Sinus bradycardia. Non-specific ST-T wave
changes. Compared to the previous tracing of ___ there is no
significant change.
_________________________________________________________
Cardiac Catheterization ___
1. Selective angiography of this right dominant system revealed
moderate disease in the LAD and RCA. The LMCA was normal. The
LAD had mild-moderate ISRS with somewhat sluggish flow within
and beyond the stent. D1 had a 60% ostial stenosis which is
unchanged from prior. The LCX artery had patent previously
placed stents. The RCA angiographically had no significant
change in appearance compared to cath done on ___.
2. Limited resting hemodynamics showed elevated systemic
arterial pressure with a central aortic pressure of 162/65.
3. Mild-moderate ISRS of ___ LAD stents (unchanged)
4. Significant stenoses of RCA stents seen on IVUS
5. Successful POBA of the overlapping proximal-middle RCA stents
with 3.5 and 4.0 mm balloons.
6. Post procedure nadir FFR of 0.87 indicating non-obstructive
residual disease.
7. Residual disease including mild-moderate ISRS in the LAD
stent and 60% D1 origin as well as moderate disease in the
mid-distal RCA segment (in-between stents).
___ Comments:
Diagnostic angiogram showed similar appearance of RCA compared
to cath done on ___. LAD stent had mild to moderate ISRS
which was again unchanged.
Decision was made to proceed with IVUS. Using the F Fr sheath,
JR4 guide was used to engage the RCA. IV heparin was initiated
for anticoagulation and therapeutic ACT confirmed. A Prowater
wire was used to cross the stents with ease and placed distally
into the PLV. Solid state Volcano IVUS RX catheter was then
advanced and manual pullback performed. IVUS showed moderate
disease between the most distal and middle stents. 2mm vessel,
area 4mm2). ISRS in the distal stent (placed ___ was also
noted. There was significant ISRS in the middle stent (placed
several years ago at an OSH). This stent was undersized for the
vessel. The most proximal stent (placed ___ spans from the
ostium and overlapping with older stent. This has an area of
significant stenosis. The stent reached all the way back to the
guide, and covered the ostium adequately.
Given IVUS findings, we decided to perform POBA to the
overlapping proximal and mid stents starting with a 3.5 X 20mm
NC Apex balloon at ___ ATM followed by 4.0 X 20mm balloon at
___ ATM (this was applied to the more proximal stent and to
the diseased area seen on IVUS). The 4.0 balloon ruptured at
24ATM. We then removed the Prowater wire and advanced the
Volacano pressure wire, positioned into the distal RCA stent.
After equalization into the guide, the resting FFR was 0.93,
decreasing to a nadir of 0.87 at maximum hyperemia (>3 minutes
of Adenosine at 140mcg/kg/min). We also performed pullback
during Adenosine infusion and the FFR improved to 0.93 within
the overlapping stents, indicating that the segment in between
stents is more significant, albeit non-obstructive. Notably,
upon pulling the pressure wire into the guide, the Pd/Pa was
0.94 and never returned to 1.0 (as was the case upon
equalization). Final angiography showed excellent result without
evidence of dissection or distal emboli. The RCF arteriotomy was
then used with a ___ Angioseal with excellent hemostasis.
_________________________________________________________
CXR: ___
The cardiac silhouette is mildly enlarged. Cardiomediastinal
contours are unchanged. Reticular opacities seen at the
periphery of both lungs likely represent chronic interstitial
lung disease and are unchanged. Lung fields are otherwise clear
with no evidence of focal consolidation to suggest acute
pneumonia. No pleural effusions. No pneumothorax.
_________________________________________________________
Barium Swallow: ___
A traction diverticulum in the mid esophagus and small hiatal
hernia. No evidence of stricture within the esophagus.
Brief Hospital Course:
___ yo man with PVD, hypertension, COPD, diastolic CHF (LVEF
50%), CAD s/p multiple PCIs (most recently DES to mid LCx, DES
to distal RCA, & DES to proximal RCA 2 weeks ago) who presented
with recurrent chest pain and found to have underinflated RCA
stent on repeat coronary angiography.
Active Diagnoses:
# Chest pain: He has a history of CAD s/p PCI and recent history
of recurrent chest pain leading to multiple admissions and
catheterizations. Prior to this admission, he presented with
chest pain to an OSH where his pain was relieved with
nitropaste. However, given his recurrent chest pain and multiple
coronary angiograms in the past month, he was started on a nitro
drip and taken to the cardiac catheterization laboratory. His
troponin was falling from his most recent admission for NSTEMI,
which had been treated conservatively with escalation of his
medical regimen and change from clopidogrel to ticagrelor. He
was found to have an underinflated proximal RCA stent on IVUS
(treated this time with balloon angioplasty) and mild-moderate
in-stent restenosis of the LAD with moderately stenosed jailed
diagonal. He tolerated this procedure well and remained chest
pain free for the remainder of the admission. He continued his
home doses of ticagrelor, Imdur, atorvastatin, and low-dose
aspirin.
# ___ Esophagus: He has had ___ esophagus since 1980s
with esophageal strictures requiring multiple esophageal
dilations in the past. During this admission, he was seen by GI
given concern that his chest pain could be partly explained by
esophageal pathology. He had a barium swallow that showed
traction diverticulum without esophageal stricture or other
obstruction. He continued his pantoprazole. He will follow up
with GI on an outpatient basis.
Chronic Diagnoses:
# Chronic Diastolic CHF: Stable with LVEF of >55%. Continued
losartan, Imdur and metoprolol.
# CKD: Baseline creatinine 1.1-1.3. Remained at baseline
throughout admission.
# Hypertension: stable, continued on metoprolol, losartan,
amlodipine.
# Hyperlipidemia/PVD: Chronic, stable, continued on Atorvastatin
80 mg.
Transitional Issues:
-Confirmed full code status
-Discharged with ___ services
-Follow-up scheduled with cardiology, GI, sleep medicine (to
evaluate for OSA), and PCP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient list.
1. Acetaminophen 650 mg PO BID
2. Amlodipine 10 mg PO HS; Hold for SBP<100
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY; Hold for SBP<100
6. Pantoprazole 40 mg PO Q12H
7. Sulindac 150 mg PO DAILY; Take this medication at least 30
minutes after taking aspirin.
8. Metoprolol Succinate XL 100 mg PO DAILY; Hold for SBP<100 or
HR<60
9. Multivitamins 1 TAB PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Fish Oil (Omega 3) 1000 mg PO TID
12. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral DAily
13. melatonin *NF* 1 mg Oral QHS
14. Isosorbide Mononitrate (Extended Release) 90 mg PO HS; Hold
for SBP<100
15. ticagrelor *NF* 90 mg ORAL BID Reason for Ordering:
Attending recommendation
Discharge Medications:
1. Amlodipine 10 mg PO HS; Hold for SBP<100
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO TID
5. Losartan Potassium 50 mg PO DAILY; Hold for SBP<100
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. ticagrelor *NF* 90 mg ORAL BID Reason for Ordering: Attending
recommendation
9. Tiotropium Bromide 1 CAP IH DAILY
10. Acetaminophen 650 mg PO BID
11. melatonin *NF* 1 mg Oral QHS
12. Metoprolol Succinate XL 100 mg PO DAILY; Hold for SBP<100 or
HR<60
13. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral DAily
14. Isosorbide Mononitrate (Extended Release) 90 mg PO HS; Hold
for SBP<100
15. Sulindac 150 mg PO DAILY; Take this medication at least 30
minutes after taking aspirin.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease
Recent myocardial infarction
In-stent restenosis
___ Esophagus
Esophageal diverticulum
Hypertension
Hyperlipidemia
Chronic obstructive pulmonary disease
Chronic kidney disease, stage 3
Peripheral arterial disease
Chronic left ventricular diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted with chest pain and were found to have
a dislodged stent in one of the vessels of your heart. This
stent was properly reopened during your cardiac catheterization.
You tolerated this procedure well. You will follow up with your
cardiologist.
You were also seen by the gastroenterology doctors during your
___ because some of your chest pain may be caused by
severe gastroesophageal reflux disease. For this you had a
special Barium Swallow x-ray to evaluate your esophagus. You
will follow up with the GI doctors as ___ outpatient for this
issue.
There were no medication changes made during this
hospitalization.
Followup Instructions:
___
|
19633185-DS-20
| 19,633,185 | 20,100,338 |
DS
| 20 |
2133-01-13 00:00:00
|
2133-01-13 12:51:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Left parietal SDH and SAH.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ woman with a history of depression and
ulcerative colitis status post mechanical fall while walking her
dog.
She states that her dog pulled her forward aggressively and she
fell onto her right side, struck the right side of her head.
Unclear if there was loss of consciousness. Patient was
evaluated
at ___ where she was noted to have blood
from the right ear canal, CT head performed there shows
nondisplaced right mastoid air cell fracture, small subdural
hematoma and subarachnoid on the left parietal area. No other
traumatic injuries identified externally.
Past Medical History:
Depression
Ulcerative Colitis
Social History:
___
Family History:
No family history of aneurysm.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
98.2 79 138/86 16 99% ra
Gen: WD/WN, comfortable, NAD.
HEENT: right temporal and parital scalp tenderness.
Pupils: 2mm intact EOMI
Neck: on c-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: slightly drowsy, wake up upon voice, cooperative
with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm bilaterally
and reactive. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Decreased hearing over the right.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Toes downgoing bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
Slight left facial and decreased hearing in right ear, otherwise
CN II-XII grossly intact.
Motor examination full strength throughout upper and lower
extremities bilaterally.
Pertinent Results:
CT Cervical Spine: ___
No evidence of cervical spinal fracture or acute malalignment.
CT Head: ___
1. Left frontal, parietal, and temporal subarachnoid
hemorrhage.
2. Small subdural hematoma along the left frontal convexity as
well as
layering along the left tentorium.
3. Longitudinally oriented non-displaced fracture of the right
mastoid air cells. Additional hemorrhagic fluid is noted within
the sphenoid sinus. Evaluation of the skull base with skull
base CT is recommended to further evaluate this fracture.
CT Orbit, Sella and IAC: ___
1. Fracture of the posterior wall of the sphenoid sinus, also
involving the bony covering of the carotid canal (3, 94). CTA
is recommended to rule out any injury to the carotid.
2. Longitudinally oriented temporal bone fracture extending
into the squamous portion of the temporal bone, the external
auditory canal as well as to the middle ear, but without
disruption of the ossicles, facial canal or otic capsule.
CTA Head: ___
1. No evidence of carotid injury.
2. Expanding left extraaxial collection which now takes a more
cresecentic
shape. Concern for epidural hematoma, although no underlying
fracture seen in this areas. Close clinical/imaging follow up.
CT Head: ___
1. Slightly increased left subarachnoid hemorrhage.
2. Nondisplaced right temporal bone fracture extending into the
right carotid canal and right sphenoid sinus is again seen.
Brief Hospital Course:
Ms. ___ was transferred to the Emergency Department at ___
from ___ with a left parietal subdural
hematoma after experiencing a mechanical fall while walking her
dog. Upon arrival to ___ she underwent a CT of the cervical
spine which was negative for fracture. She also underwent a
dedicated CT of the orbit, sella and internal auditory canal
which showed a right mastoid air cell non-displaced fracture.
Head CTA showed no evidence of carotid injury. She was started
on Keppra twice daily and admitted to the neurosurgical service
for close monitoring overnight.
On ___, the patient remained neurologically stable with
complaints of diminished hearing in the right ear and a slight
left facial droop. She complained of a headache and was started
on Fioricet. Her cervical spine was cleared clinically. She
underwent a repeat CT of the head which showed a stable
hemorrhage. Otolaryngology was consulted and placed a wick
within the right ear. She was also started on Ciprofloxacin otic
drops into the right ear two times daily.
On ___, the patient remained neurologically stable and her
headaches were better tolerated on Fioricet. Tramadol was added
to her pain regimen. She ambulated with the nursing staff and it
was determined she would be discharged to home.
Medications on Admission:
1. Topiramate (Topamax) 150 mg PO BID
2. Sertraline 150 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. BuPROPion (Sustained Release) 200 mg PO QAM
5. FoLIC Acid 1 mg PO DAILY
6. Mercaptopurine 75 mg PO DAILY
7. Mesalamine ___ 1600 mg PO TID
Discharge Medications:
1. Topiramate (Topamax) 150 mg PO BID
2. Sertraline 150 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. BuPROPion (Sustained Release) 200 mg PO QAM
5. FoLIC Acid 1 mg PO DAILY
6. Mercaptopurine 75 mg PO DAILY
7. Mesalamine ___ 1600 mg PO TID
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every 4 hours Disp #*50 Capsule Refills:*1
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN headache
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*50
Tablet Refills:*0
10. LeVETiracetam 1000 mg PO BID Duration: 7 Days
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
11. Ciprofloxacin 0.3% Ophth Soln 5 DROP RIGHT EAR BID
RX *ciprofloxacin 0.2 % 5 drops into right ear BID. Disp #*1
Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left parietal Subdural Hematoma and Subarachnoid Hemorrhage
Right mastoid air cell non-displaced fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nonsurgical Brain Hemorrhage:
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
¨ You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring. You will take this
medication for 7-days.
*** You have been discharged on Ciprofloxacin ear drops to the
right ear two times daily. Continue to take this medication
until seen in follow-up with the Ear, Nose and Throat physician.
Follow-up information is listed below.
*** You have been provided reading material about Traumatic
Brain Injury (TBI). Please do not hesitate to contact the
outpatient Neurosurgery office at ___ with any
questions or concerns.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
¨ New onset of tremors or seizures.
¨ Any confusion, lethargy or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ New onset of the loss of function, or decrease of function
on one whole side of your body.
Followup Instructions:
___
|
19633416-DS-11
| 19,633,416 | 28,218,045 |
DS
| 11 |
2150-07-25 00:00:00
|
2150-07-28 06:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine / cephalexin / Sulfa (Sulfonamide Antibiotics) /
prochlorperazine
Attending: ___.
Major Surgical or Invasive Procedure:
EGD w/ placement of duodenal stent
Pertinent Results:
ADMISSION LABS:
==============
___ 11:28PM BLOOD WBC-13.0* RBC-4.09 Hgb-13.0 Hct-38.8
MCV-95 MCH-31.8 MCHC-33.5 RDW-12.2 RDWSD-42.9 Plt ___
___ 04:45AM BLOOD ___ PTT-27.5 ___
___ 11:28PM BLOOD Glucose-75 UreaN-24* Creat-0.7 Na-141
K-3.4* Cl-95* HCO3-25 AnGap-21*
___ 04:45AM BLOOD ALT-12 AST-24 LD(LDH)-204 AlkPhos-55
TotBili-0.5
___ 11:28PM BLOOD Calcium-9.5 Phos-4.3 Mg-1.9
DICHARGE LABS:
==============
___ 04:31AM BLOOD WBC-8.4 RBC-3.52* Hgb-11.1* Hct-33.8*
MCV-96 MCH-31.5 MCHC-32.8 RDW-12.0 RDWSD-42.1 Plt ___
___ 04:31AM BLOOD ___ PTT-28.9 ___
___ 04:31AM BLOOD Glucose-98 UreaN-8 Creat-0.5 Na-139 K-3.9
Cl-102 HCO3-23 AnGap-14
___ 04:31AM BLOOD ALT-13 AST-17 LD(LDH)-244 AlkPhos-57
TotBili-0.4
___ 04:31AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
IMAGING:
========
CT Abdomen/Pelvis w/ Contrast ___ at ___
1. Mucosal edema and mural thickening of the proximal duodenum
with an apparent transition point in the ___ part of the
duodenum with severe distension and layering fluid within the
stomach proximally. Findings are suspicious for a duodenal
stricture with upstream obstruction which is new from prior
study. Urgent decompression with an enteric tube is recommended.
Upper endoscopy can be considered for further evaluation
following enteric tube placement.
2. Stable appearance of the pancreatic head mass measuring
approximately 1.7 cm with fiducial markers in situ, not
substantially changed from prior study. However, there is
interval increase with marked pancreatic ductal dilatation
measuring up to 14 mm, previously measuring up to 9 mm.
MICROBIO:
==========
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Ms. ___ is an ___ female with hypertension,
hyperlipidemia, and pancreatic adenocarcinoma who presents with
abdominal pain found to have small bowel obstruction. ___ had
EGD with placement of a duodenal stent. Patient tolerated the
procedure well and was able to advance diet and be discharged
home.
TRANSITIONAL ISSUES:
=====================
[] Had hypertension with systolics in the 150s on home
lisinopril 20mg daily. Continue to monitor and titrate up/add
medications as needed
[] Patient had duodenal stent placed for small bowel
obstruction. She will need to chew her food very well from now
on and eat a low fiber diet to ensure the stent does not get
clogged. Follow-up how tolerating PO, nausea and abdominal pain.
[] Patient with elevated CA ___, and duodenal obstruction
worrisome for progression of pancreatic cancer. CT scan with
stable mass at head of pancreas. Consider additional imaging to
monitor for progression of cancer.
ACTIVE ISSUES:
===============
# Malignant Small Bowel Obstruction:
Patient presented with abdominal pain and nausea/vomiting found
to have small bowel obstruction with transition point in the
___ part of the duodenum. Likely due to progression of
pancreatic cancer. Interestingly, she has continued to have
bowel movements. ___ had EGD w/ 5mm area of stenosis in first
section
of duodenum, placed stent. Per signout did not see exophytic
mass but biopsied duodenal walls at area of stenosis. Biopsy
showed duodenal mucosa with reactive change and foveolar
metaplasia, suggestive of peptic injury, negative for
malignancy. Was able to advance diet and discharge.
# Pancreatic Adenocarcinoma: She was treated with definitive
chemoradiation initially in ___, then relapsed in ___ and
received further chemotherapy. She has been off treatment since
___. She likely has progressive disease given rising CA ___,
interval increase in pancreatic ductal dilatation, and small
bowel obstruction.
# Hypokalemia
- Monitor and replete as needed
# Insomnia
- Hold home oxazepam
# GERD
- Hold home omeprazole and sucralfate as NPO
Greater than 30 min were spent in discharge counseling and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit PO DAILY
2. Omeprazole 20 mg PO BID
3. Oxazepam 15 mg PO QHS:PRN insomnia
4. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain - Moderate
5. Sucralfate 1 gm PO BID
6. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 dose by mouth
twice a day Disp #*60 Packet Refills:*0
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Oxazepam 15 mg PO QHS:PRN insomnia
7. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain -
Moderate
8. Sucralfate 1 gm PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Small bowel obstruction
SECONDARY DIAGNOSES:
====================
Pancreatic cancer
HTN
Hypokalemia
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 caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for 10 days of abdominal pain with nausea
and vomiting
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital we got imaging which showed that you had an
obstruction of your gastrointestinal tract. You had a stent
placed to open the obstruction. After this we slowly allowed you
to eat food. You tolerated the food well and were able to go
home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Chew your food very well to prevent obstruction of your new
stent.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19634192-DS-9
| 19,634,192 | 21,051,321 |
DS
| 9 |
2164-09-03 00:00:00
|
2164-09-03 13:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin
Attending: ___.
Chief Complaint:
Left wrist pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ fell from scaffolding while at work, landing on his left
arm. He noted immediate pain and deformity and proceeded to ___
___, where he had extensive imaging done but positive
only for a closed left distal radius fracture for which he was
sent to ___. On arrival he complained of significant pain and
intermittent paresthesias throughout his hand.
Past Medical History:
None
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Discharge Exam:
Vitals: AFVSS
Gen: NAD, A and OX3
LUE: Reduced in splint, C/D/I
Forearm and hand compartments soft
EPL/FPL/DIO fire
SILT: m/r/u
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 an isolated left distal radius fracture and was admitted
to the orthopedic surgery service. The fracture was closed
reduced in the emergency room and a splint was applied. The
patients home medications were continued throughout this
hospitalization. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications and the patient was
voiding/moving bowels spontaneously. The patient is non-weight
bearing in the left upper extremity, and does not have an
indication for DVT prophylaxis as he is ambulatory. The patient
will follow up in one week for repeat films and a discussion of
further management. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*50 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Not indicated
WOUND CARE:
-Remain in your splint until your post-operative visit.
ACTIVITY AND WEIGHT BEARING:
- non-weight bearing left upper extremity
Followup Instructions:
___
|
19634294-DS-22
| 19,634,294 | 20,160,944 |
DS
| 22 |
2174-08-15 00:00:00
|
2174-08-15 13:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim DS
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo F with a PMH of vascular dementia and recurrent
urosepsis who presents from home with her son for decreased
energy, low PO intake, and periods of unresponsiveness. Looking
at clinic notes, it seems as though the patient has not been
doing well at home for ___ months, including episodes where she
becomes more lethargic, has a decreased appetite, and is more
dependent on her ADLs/IADLs. For the last 2 days, the patient
has declined further. At baseline, she responds in one word
answers and will eat and drink with prodding.
.
In the ED, her VS 98.1 88 119/54 16 96% RA. The patient had a
head CT that did not show an acute process. CXR showed increased
interstitial markings and possible retrocardiac opacity. The
patient had a UA that had 34 WBC, many bacteria, +nitrites,
+leuks. Blood and urine cultures were sent. The patient recieved
500cc NS and was given ceftriaxone and azithromycin.
.
On the floor, patient was obtunded.
ABG pH 7.32 pCO2 81 pO2 116 HCO3 44 BaseXS 11
Admitted to MICU
In MICU, placed on BiPAP with improvement in gas:
pH 7.36 pCO2 68 pO2 165 HCO3 40 BaseXS 10, Lactate:0.8
She was treated for presumptive pneumonia.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. Osteoporosis.
2. Depression/anxiety.
3. Vascular dementia.
4. Constipation.
5. Hearing loss.
6. Peripheral neuropathy.
7. History of low back pain.
8. Squamous cell carcinoma.
9. Urinary incontinence.
10. Asthma.
11. Vitamin B12 deficiency.
12. Status post small-bowel obstruction
Social History:
___
Family History:
Both parents died in their ___, she does not know the cause of
their deaths. Her two brothers died of myocardial infarctions,
age ___ and ___. Another sister died in her ___, unsure of the
cause.
Physical Exam:
Vitals: 97.9 134/58 85 20 95%
General: frail, opens her eyes to name 'B', minimally verbal
___: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no heaves /
thrills, 2+ radial pulses
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: thin extremities Warm, well perfused, no edema
Pertinent Results:
CXR ___
There is diffuse increased interstitial
markings compared to multiple prior examinations. No pleural
effusions are
evident. This could reflect developing new mild interstitial
edema or
atypical pneumonia. Calcification and tortuosity of the
descending thoracic aorta appear unchanged. Confluent
consolidation is evident. There are no pleural effusions.
Cardiomediastinal and hilar contours are stable noting enlarged
hila.
IMPRESSION: Diffuse interstitial prominence which may reflect
mild
interstitial pulmonary edema or atypical pneumonia.
Hilar enlargement though relatively stable
CT HEAD ___ No acute intracranial process. Aerosolized
secretions in the sphenoidal sinuses, left worse than right,
mildly worsened from ___.
___ 05:45AM BLOOD WBC-10.4 RBC-4.07* Hgb-11.7* Hct-34.5*
MCV-85 MCH-28.8 MCHC-34.0 RDW-15.1 Plt ___
___ 12:53PM BLOOD ___ PTT-30.3 ___
___ 05:45AM BLOOD UreaN-7 Creat-0.6 Na-140 K-3.3 Cl-95*
HCO3-36* AnGap-12
___ 05:45AM BLOOD Calcium-9.0 Phos-2.1* Mg-1.9
___ 06:06PM BLOOD Type-ART pO2-62* pCO2-48* pH-7.46*
calTCO2-35* Base XS-8 Intubat-NOT INTUBA
Brief Hospital Course:
___ yo F who presented with lethargy ___ hypercarbic resp failure
and possible UTI and/or pneumonia.
.
# Hypercarbic Resp Failure - Acute on chronic given HCO3 of 30
previously. Likely Senile emphysema with acute component
attributable to AMS from UTI/PNA. The patient was initially
started on Bipap and had CO2 retention with initial CO2 of 81.
She improved throughout the day on the day following admission
and was weaned down to 2L NC. She was treated with
bronchodilators and abx.
.
# Increased Interstitial Lung Markings: Progression of these
markings in one month. Concern was for pneumonia. She was
empirically treated with levofloxacin and ceftriaxone. When
repeat CXR was unchanged, and WBC improved, levaquin was
stopped.
.
# Cystitis: Based on UA, patient was initiated on ceftriaxone.
Urine culture showed gardnerella, which was concerning for
bacterial vaginitis. Ceftriaxone was stopped, and we started
flagyl instead. Whether the cystitis contributed to her AMS is
unknown.
.
# Goals of Care:
On discharge, a discussion was had with patient's son and his
wife regarding her code status, which was full code on
admission. They continued to express a wish to treat all
reversible causes, including temporary intubation if necessary.
Her living will noted that she would not want to live in a
persistant vegetative state. On further discussion regarding
resuscitation in cardiac arrest, her family agreed that that
would likely lead to a poor outcome and would be against her
wishes, and her code status was changed to DNR, ok to intubate.
CODE STATUS: DNR, ok to intubate.
Medications on Admission:
ALBUTEROL SULFATE - Nebs
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler
ESCITALOPRAM [LEXAPRO] - 10 mg qd
FLUTICASONE [FLOVENT HFA] - 110 mcg BID
HYDROCHLOROTHIAZIDE - 12.5 mg ___ and ___
Medications - OTC
ACETAMINOPHEN - 650 mg BID
ASPIRIN - 81 mg Tablet qd
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule 4x/week
DOCUSATE SODIUM [COLACE] - 100 mg qHS
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for wheezing.
Disp:*120 nebs* Refills:*0*
2. fluticasone 110 mcg/actuation Aerosol Sig: One (1)
Inhalation twice a day.
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*0*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO 4x week.
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Altered Mental Status
Bacterial Vaginosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to the hospital for confusion, and it is
thought that you may have had a urinarty tract infection which
was treated with antibiotics. You will need to continue the
antibiotics until they are finished.
MEDICATION CHANGES
change HYDROCHLOROTHIAZIDE to daily
start METRONIDAZOLE 500mg twice daily for five more days
stop LEXAPRO
Followup Instructions:
___
|
19634374-DS-18
| 19,634,374 | 24,731,514 |
DS
| 18 |
2132-05-14 00:00:00
|
2132-05-17 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / diazepam / Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
___: Percutaneous endoscopic gastrostomy
History of Present Illness:
___ s/p mechanical fall while getting up off the toilet on ___
(48 hours prior to presentation). Per family, following her
fall, she was persistently confused and complaining of severe
left hip pain, stating that her hip was broken. She was
transferred from her long term care facility to ___ for
further evaluation. At ___, she was pan-CT scanned and
given 10mg IV morphine. GCS 15 on arrival.
Here, she is alert but oriented x0, and refused to cooperate
with our exam, stating "Everyone asked me those questions
before". Her son and daughter are at bedside, so history
obtained from them and from ___ records.
Past Medical History:
PMH: CAD, DM, HLF, HTN, IBS, RA, congenital lumbar
spondylolisthesis
PSH: Hysterectomy Balloon valvuloplasty for aortic stenosis
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: 98.3 106 173/78 16 100% Nasal Cannula
Exam:
GEN: Frail-appearing, NDA, lying on her side on the gurney,
appears older than stated age. When asked to roll on her back
for
an exam, she refuses.Wearing hearing aids.
HEENT: NC/AT
Chest: resps nonlabored.
Abd: Soft, Nondistended
Ext: Inconsistently reports pain in all 4 extremities, but not
reproducible
Discharge Physical Exam:
VS: T: 98.1, HR: 110, BP: 146/54, RR: 20, O2: 93% RA
General: Sleeping, unresponsive to voice, groans and opens eyes
with palpation
CV: borderline tachycardia, regular rhythm
PULM: CTA b/l, non-labored respirations
ABD: soft, mildly distended, non-tender. G tube in place, no s/s
infection
Extremities: RUE with +1 edema without erythema or induration,
elevated. LUE and b/l ___ warm, well-perfused, no edema.
Pertinent Results:
___ 05:25AM BLOOD WBC-11.1* RBC-2.68* Hgb-9.0* Hct-30.3*
MCV-113* MCH-33.6* MCHC-29.7* RDW-16.8* RDWSD-69.7* Plt ___
___ 05:10AM BLOOD WBC-10.4* RBC-2.64* Hgb-8.9* Hct-29.5*
MCV-112* MCH-33.7* MCHC-30.2* RDW-16.8* RDWSD-68.0* Plt ___
___ 05:05AM BLOOD WBC-13.6* RBC-2.75* Hgb-9.4* Hct-30.2*
MCV-110* MCH-34.2* MCHC-31.1* RDW-16.5* RDWSD-65.4* Plt ___
___ 05:00AM BLOOD WBC-13.0* RBC-2.78* Hgb-9.3* Hct-30.8*
MCV-111* MCH-33.5* MCHC-30.2* RDW-16.8* RDWSD-68.3* Plt ___
___ 09:25AM BLOOD WBC-10.9* RBC-2.57* Hgb-8.6* Hct-28.1*
MCV-109* MCH-33.5* MCHC-30.6* RDW-16.6* RDWSD-65.4* Plt ___
___ 05:25AM BLOOD Glucose-208* UreaN-33* Creat-1.0 Na-145
K-4.3 Cl-104 HCO3-29 AnGap-16
___ 05:10AM BLOOD Glucose-116* UreaN-26* Creat-0.8 Na-144
K-4.4 Cl-105 HCO3-24 AnGap-19
___ 05:05AM BLOOD Glucose-136* UreaN-29* Creat-0.8 Na-142
K-4.5 Cl-102 HCO3-23 AnGap-22*
___ 05:00AM BLOOD Glucose-135* UreaN-28* Creat-0.9 Na-144
K-4.6 Cl-104 HCO3-27 AnGap-18
___ 09:25AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-141
K-4.1 Cl-101 HCO3-23 AnGap-21*
___ 05:25AM BLOOD Calcium-9.9 Phos-2.3* Mg-2.4
___ 05:10AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9
___ 05:05AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.9
___ 05:00AM BLOOD Calcium-10.2 Phos-3.2 Mg-2.0
___ 05:25AM BLOOD Valproa-30*
___ 05:05AM BLOOD Valproa-77
___ 12:07AM BLOOD Valproa-66
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
IMAGING
====================
CT head: 1. Acute left parafalcine epidural hematoma extending
along the superior medial border of the incisura of left
tentorium. There is associated mild subfalcine herniation to the
right by 0.36cm. For the time being, no diagnostic evidence of
transtentorial cerebral herniation could be seen. 2. No skull
fracture is seen. 3. Age-related cerebral atrophy and bilateral
frontal and parietal ischemic white matter disease due to
microangiopathy are seen. 4. No evidence of space occupying
lesion could be found. 5. The current plain CT scan of the brain
shows no diagnostic evidence of acute cerebral infarction. The
need for MRI examination will have to be decided on clinical
grounds
CT cspine: 1. Advanced cervical spondylosis including advanced
C5-C6 and C6-C7 degenerative cervical disc disease is seen. 2.
Grade 1 C3-C4, C6-C7 and C7-T1 spondylolisthesis is present. 3.
No cervical fracture or dislocation is seen.
CT torso/L hip: 1. No acute internal injuries int he chest,
abdomen or pelvis. 2. Compression fractures of T7, T12, L1, L3
and L4. There is no prior exam to assess the acuity of these
fractures. 3. No evidence of fracture of the left hip
L hip w/pelvis 1 view: No acute osseous abnormality.
Degenerative
changes
Head CT ___:
Stable left subdural hematoma along the left cerebral convexity,
left falx
and left tentorium. Unchanged 4 mm of rightward shift of
normally midline
structures. Trace intraventricular hemorrhage has decreased. No
new hemorrhage.
Head MRI ___:
1. No acute infarct.
2. Stable subdural hematoma along the left convexity, falx, and
tentorium,
with stable mild rightward shift of midline structures.
___: Abdomen (Lateral Decub Only) x-ray:
Small amount of pneumoperitoneum status post PEG tube placement.
Brief Hospital Course:
Mrs. ___ is an ___ year old female who fell and presented to
___ as transfer with concern for traumatic brain injury after
fall with acute left parafalcine epidural hematoma and concern
for T and L spine compression fractures of unknown chronicity.
Her main complaints were headache and left leg pain. Outside
hospital CT showed no hip fracture. She was seen by neurosurgery
and spine surgery and, given that acute ___ spine compression
fractures could not be excluded in setting of spinous process
tenderness in those areas, she was admitted to the Trauma/Acute
Care Surgery service for polytrauma and transferred to the
intensive care unit for hourly neurochecks, Keppra and blood
pressure control. Her imaging was reviewed with radiologists at
___ who deemed the compression fractures most likely chronic.
From a spine perspective, the fractures were non-operative. The
patient was fitted with a TLSO to wear for comfort and could be
weight bearing as tolerated with, no bending/twisting/lifting.
Her neurochecks were liberalized by neurosurgery who asked that
her aspirin be held for 5 days. A bedside speech and swallow
study was also performed which she failed. She was transferred
to the floor in the evening of hospital day 2.
On HD6 the patient became more lethargic and weak. A repeat head
CT was stable. Neurology was consulted due to the deficits and a
MRI showed no acute infarct. The patient was started valproic
acid and will continue to need weekly levels checked.
The patient again failed speech and swallow and was not
tolerating dobhoff tube. Out of concern for nutritional failure
due to dysphagia owing to the traumatic brain injury and the
need for a long-term nutritional access site, the family
consented to a PEG. On ___, the patient underwent
percutaneous endoscopic gastrostomy, which went well without
complication. Tubefeeds were started on POD1, which the patient
tolerated at goal.
On POD3, the patient was started on valproic acid ___ BID.
Nutrition recommended tube feedings be changed to bolus
feedings.
At the time of discharge, the patient's mental status continued
to wax and wane, but was mostly ___ to self, and was a total
assist out of bed to chair. She was afebrile with stable vital
signs. The patient was tolerating tube feeds at goal,
incontinent of urine, and moving her bowels. The patient was
discharged to a rehab & nursing care center. The patient and her
family received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. She had follow up scheduled with neurology, neurosurgery,
and spine.
Medications on Admission:
ASA81 daily, gabapentin 100 TID, lovastatin 20 daily, MTX 10
___, prednisone 5 BID, Lasix 40 daily, oxycodone 5 BID/5
q4prn, amitriptyline 30 qPM, Prilosec 20 BID, lisinopril 20
daily, Zofran ODT 4 q6prn
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Amitriptyline 30 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Heparin 5000 UNIT SC BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB wheezing
9. Lidocaine 5% Patch 1 PTCH TD ONCE:PRN pain
10. Lisinopril 20 mg PO DAILY
11. Senna 8.6 mg PO BID Constipation
12. PredniSONE 5 mg PO BID
13. Valproic Acid ___ mg PO Q12H
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
do NOT drink alcohol or drive while taking this medication
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Left parafalcine subdural hematoma,
-Chronic T7/12, ___ compression fracture
Secondary diagnosis:
Urinary tract infection
Oropharyngeal dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were transferred to ___ on ___ after a fall. You had
a head CT scan which revealed intracranial bleeding. You were
also noted to have old thoracic and lumbar spine fractures. You
were seen by Neurosurgery, and started on a medication to
prevent seizures. The Orthopaedic Service evaluated your spinal
fractures and no surgical intervention was necessary. Due to
declining mental status, you demonstrated signs of aspiration
while swallowing and therefore required a gastric tube be placed
to provide nutrition and medications. You were evaluated by the
Neurology service to evaluate for seizures or a stroke, and had
an EEG and an MRI of your head which were reassuring. Your
antiseizure medication was adjusted by the Neurology service.
You are now stable and medically clear to return to your nursing
home to continue your recovery. Please note the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
19634644-DS-20
| 19,634,644 | 28,075,382 |
DS
| 20 |
2159-06-12 00:00:00
|
2159-06-13 07:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfatrim
Attending: ___.
Chief Complaint:
Right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo G0 presents with pelvic pain RLQ>LLQ. She reports that she
was in her usual state of health when she felt sudden onset
pelvic pain in the RLQ on ___. The pain did not respond to
Motrin or heat packs but did improve with time. It did not
resolve entirely, however, and then acutely worsened over the
past 24 hrs. The pain is now constant and diffuse with
intermittent sharp RLQ pain. The pain is worse with movement,
deep inspiration, and coughing. She reports some nausea
associated with pain but no vomiting.
She reports fevers at home to Tmax 100.3. She denies urinary
symptoms or constipation and reports normal flatus.
Of note, the patient had a similar presentation in ___. At
this time she ruptured, presumed endometrioma with thick
chocolate fluid coating the pelvis. There were normal tubes
bilaterally and the right ovary was normal at the time.
Notably, the ovaries were adhesed in the posterior cul-de-sac
and adhesed
to each other as well. Following her surgery she declined
hormonal contraception.
Past Medical History:
OBHx: G0
GynHx: Patient reports that she was told that she might have
PCOS
at one point by her PCP because she was having irregular menses
but she was also on high doses of spironolactone at the time
(for
derm issues). Her dose of spironolactone was lowered and her
periods have been regular for the past year. She denies any h/o
STIs, abnl paps, cysts, or uterine fibroids.
PMHx: Anxiety and Depression
PSHx: none
Social History:
___
Family History:
Not discussed
Physical ___:
Physical Examination on Discharge
VSS
Gen: NAD, comfortable
CV: RRR
Pulm: CTAB
Abd: soft nondistended, mild RLQ tenderness, no rebound no
guarding
Ext: warm well perfused, nontender to palpation
Pertinent Results:
___ 08:45AM BLOOD WBC-8.3 RBC-3.35* Hgb-10.2* Hct-29.8*
MCV-89 MCH-30.3 MCHC-34.1 RDW-12.5 Plt ___
___ 03:30AM BLOOD WBC-10.1 RBC-3.33* Hgb-10.1* Hct-29.3*
MCV-88 MCH-30.3 MCHC-34.5 RDW-12.4 Plt ___
___ 01:50PM BLOOD WBC-14.1*# RBC-4.24# Hgb-12.9# Hct-37.6#
MCV-89 MCH-30.5 MCHC-34.4 RDW-12.5 Plt ___
Brief Hospital Course:
Ms ___ is a ___ yo G0 admitted with severe. RLQ pain and
right adnexal endometrioma on ___. There was minimal concern
for torsion based on ultrasound and previous laparoscopy which
showed ovaries were adherent to posterior cul-de-sac. Patient
was managed conservatively with IV pain control with dilaudid
and serial abdominal exams were performed and patient was made
NPO for possibility of OR in the case that pain could not be
managed. On HD #2 pain was improved and patient was transitioned
to PO pain meds and regular diet. On HD #2 patient was
discharged home in stable condition. Patient has scheduled
follow up with ___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 200 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. BuPROPion 200 mg PO DAILY
2. Spironolactone 25 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 #*60 Capsule Refills:*0
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Do not exceed 4000mg acetaminophen in 24 hours
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Every 4 hours Disp #*30 Tablet Refills:*0
5. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 horus Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right adnexal Endometrioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the gynecology service with abdominal pain
likely related to endomtrioma rather than ovarian torsion.
Decision was made to manage conservatively at this time. You
were given IV pain medication and observed overnight then
advanced to oral pain medications. The team feels that you have
recovered well and are ready to go home. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19634675-DS-12
| 19,634,675 | 23,911,703 |
DS
| 12 |
2128-07-02 00:00:00
|
2128-07-05 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right visual field deficit
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of IDDM, CHF, afib, prior right sided stroke,
COPD, CKD stage 3, right BKA due to osteomyelitis, who presents
from OSH where he was being treated for stump osteomyelitis with
right-sided visual blurriness and confusion.
He was admitted to ___ for stump osteomyelitis
and was being treated with cefazolin. The week prior, he had
been
moving his home, and notes that his right leg prosthesis was not
fitting well and rubbing badly on his stump. He then awoke one
day with severe pain in his leg, which led to his presentation
to
___.
He describes increasing confusion since yesterday, for example
having increasing difficulty remembering phone numbers. Today at
2PM he complained of being unable to see anything on the right,
so a CTA was performed and showed right vertebral occlusion so
he
was transferred to ___. (On detailed interview, he says he
said
he could not "see" anything on the right, but means that it was
blurry -- not a true hemianopia). His pupils were noted to be
constricted and not reactive. He notes that he had been
receiving
oxycodone in the hospital for pain, and in the past oxycodone
had
caused him to become very confused - similar to how he felt
today.
He has had intermittent double vision and other trouble with
vision in the right eye for the last ___ years. He says that
sometimes his right eye turns outwards.
In the ___, initial NIHSS on exam was 2 due to inability to
answer
LOC questions, however this appears due to anxiety, as on
re-examination his NIHSS was 0 and he was able to provide his
medical history in greater detail. He also complained of left
frontal headache, and says he does not typically get headaches.
Past Medical History:
CHF
A. fib
Stroke
Insulin-dependent diabetes
COPD
Current smoker
Stage III CKD
Bipolar disorder
Right below-knee amputation in ___
Osteomyelitis
Social History:
Lives in ___. On disability due to leg
amputation and diabetes, previously worked as a ___ and
___. Divorced, has 3 adult children. Smokes 6
cigarettes per day. Used to drink 375 mL of whiskey every night
into his early ___. Does not drink anymore
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[x] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No family history of bleeding or clotting disorders.
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T: 98.1 HR: 76 BP: 160/77 RR: 15 SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, on arrival only oriented to self and able
give history of present illness but unable to name year, month,
or age. During interview after acute setting of arrival,
appeared
less confused/nervous and able to provide more detailed history
and orientation. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects in room but
unable to see objects on stroke card due to blurry vision. No
dysarthria. Able to follow both midline and appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1.5mm and sluggishly reactive. EOMI
without nystagmus. Normal saccades. VFF to confrontation, though
complained of objects on right being blurrier.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 ------ amputated ------
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 1 1
R 2 2
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF.
-Gait: Unable due to BKA.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 97.4 (Tm 98.9), BP: 176/76 manual) ___
manual)), HR: 55 (51-57), RR: 18 (___), O2 sat: 100% (97-100),
O2 delivery: RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: L BKA
Neurologic:
-Mental Status: Alert, partly oriented to place (able to
identify
___ on multiple choice) and time (month, year). Language is
generally fluent with intact comprehension, though with frequent
word-finding difficulty. Able to follow both midline and
appendicular commands.
-Cranial Nerves: Right upper quadrantanopsia. EOMI without
nystagmus. Facial sensation intact to light touch. Face
symmetric
at rest and with activation. Hearing intact to conversation.
Palate elevates symmetrically. ___ strength in trapezii
bilaterally. Tongue protrudes in midline.
-Motor: No pronator drift bilaterally.
Delt Bic Tri WrE FE IP Quad Ham TA
L 5 ___ 5 5 - - -
R 5 ___ ___ 5 5
-Sensory: Intact to LT throughout.
-DTRs: ___.
-Coordination: No dysmetria on FNF bilaterally.
Pertinent Results:
___ 09:19PM BLOOD WBC-6.5 RBC-3.54* Hgb-10.0* Hct-31.1*
MCV-88 MCH-28.2 MCHC-32.2 RDW-17.5* RDWSD-53.4* Plt ___
___ 09:19PM BLOOD Neuts-66.9 ___ Monos-8.7 Eos-3.7
Baso-0.8 Im ___ AbsNeut-4.38 AbsLymp-1.25 AbsMono-0.57
AbsEos-0.24 AbsBaso-0.05
___ 09:19PM BLOOD ___ PTT-27.2 ___
___ 09:19PM BLOOD Glucose-184* UreaN-27* Creat-1.2 Na-136
K-4.7 Cl-99 HCO3-24 AnGap-13
___ 01:38AM BLOOD ALT-17 AST-56* LD(LDH)-232 AlkPhos-156*
Amylase-72 TotBili-0.8
___ 01:38AM BLOOD Lipase-23
___ 01:38AM BLOOD %HbA1c-8.5* eAG-197*
___ 01:38AM BLOOD Triglyc-245* HDL-24* CHOL/HD-7.2
LDLcalc-100
___ 01:38AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 01:38AM BLOOD Albumin-2.9* Cholest-173
___ 12:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:25PM URINE Blood-TR* Nitrite-NEG Protein-300*
Glucose-100* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:25PM URINE RBC-6* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:25PM URINE Mucous-RARE*
___ 12:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-POS*
___ 12:25 pm URINE
URINE CULTURE (Pending)
___ 2:27 am BLOOD CULTURE
Blood Culture, Routine (Pending)
___ 1:38 am BLOOD CULTURE
Blood Culture, Routine (Pending)
___ 10:54 ___ CTA HEAD AND CTA NECK
Acute-subacute left posterior cerebral artery distribution
infarction with no evidence of hemorrhage.
No intracranial arterial occlusion, marked stenosis or aneurysm
formation.
Moderate atherosclerotic changes of the distal CCA and proximal
ICAs with
approximately 10% stenosis of the proximal left ICA by NASCET
criteria. No right ICA stenosis by NASCET criteria.
Complete occlusion of the origin of the right vertebral artery
with poor
opacification again seen in the mid V2 segment. Opacification
of the more
distal right vertebral artery apparently arises via retrograde
flow from the basilar artery. The left vertebral artery is
widely patent.
Suspected small bilateral pleural effusions and mild septal
thickening in the lung apices may suggest pulmonary edema and
cardiac decompensation.
Mildly enlarged mediastinal lymph nodes is nonspecific and may
be secondary to congestion or may be pathological due to a
different etiology and if clinically indicated dedicated chest
imaging may be performed.
___ 9:24 AM MR HEAD W/O CONTRAST
1. Diffusion abnormality in the left occipital region is
consistent with late acute to subacute infarct.
2. Right occipital and frontal encephalomalacia are consistent
with sequela of old infarcts.
___ 6:11 ___ CHEST (PORTABLE AP)
The left PICC terminates in the distal SVC. There are low lung
volumes. This causes crowding of the bronchovascular markings
and exaggeration of heart size. Mild atelectatic changes are
seen at the left lung base. Developing pneumonia cannot be
excluded. Degenerative changes are evident in the spine. The
aorta is atherosclerotic.
Brief Hospital Course:
Mr. ___ is a ___ man with history notable for
IDDM, AFib (previously on rivaroxoban, discontinued ___ ileal
Dieulafoy lesion s/p APC and clipping) c/b R PCA and R frontal
infarcts, COPD, CHF, CKD III, and R BKA ___ ___
transferred from ___ after presenting from
rehab with right-sided blurring of vision. CT/CTA of the head
and neck and brain MRI demonstrated acute left occipital
ischemic infarct as well as likely chronic right vertebral
artery occlusion. Infarct was most likely secondary to atrial
fibrillation not on anticoagulation. Although anticoagulation
had previously been held per outpatient records (warfarin,
initially, due to fluctuating INR, and rivaroxaban,
subsequently, due to a lower GIB ascribed to an ileal Dieulafoy
lesion requiring transfusion), given Mr. ___ evident
elevated risk of future strokes as well as reduced risk of
future GI bleeding following APC and clipping of his known
lesion, anticoagulation was again resumed with apixaban.
Additionally, per discussion with Gastroenterology, a prior
gastrointestinal hemorrhage would not necessarily constitute an
absolute contraindication to anticoagulation in a patient at
high risk for strokes. Atorvastatin was also initiated for
secondary stroke prevention, along with lisinopril for
management of hypertension (with SBPs of 170s noted during the
admission). Cefazolin therapy for Mr. ___ osteomyelitis
and methadone maintenance therapy were continued without
changes.
Of note, following discharge, Mr. ___ blood cultures
yielded gram-positive bacilli, suggestive of Corynebacterium or
Propionibacterium spp., presumptively reflective of skin
contamination. This result was discussed with Mr. ___ and
with ___, RN at his PCP's office, with both confirming
plan for repeat blood culture as soon as feasible for
confirmation.
TRANSITIONAL ISSUES
1. Monitor blood pressure in the outpatient setting and
gradually adjust lisinopril accordingly.
2. Consider gastroenterology follow-up (recommended on previous
admission, though appointment apparently not kept by patient).
3. Continuation of cefazolin for osteomyelitis per outpatient
providers.
4. Continue smoking cessation counseling.
5. Please obtain follow-up blood culture.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (X) Yes - () No
4. LDL documented? (X) Yes (LDL = 100) - () No
5. Intensive statin therapy administered? (X) Yes - () No
6. Smoking cessation counseling given? (X) Yes - () No
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A
Medications on Admission:
1. Methadone 75 mg PO DAILY
2. ARIPiprazole 10 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. melatonin 5 mg oral QHS
8. BuPROPion (Sustained Release) 150 mg PO BID
9. Gabapentin 600 mg PO BID
10. CeFAZolin 2 g IV Q8H
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH
PAIN
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
14. LORazepam 0.5 mg PO QHS:PRN insomnia
15. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Lisinopril 5 mg PO DAILY
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. ARIPiprazole 10 mg PO DAILY
7. BuPROPion (Sustained Release) 150 mg PO BID
8. CeFAZolin 2 g IV Q8H
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 600 mg PO BID
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. melatonin 5 mg oral QHS
13. Methadone 75 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH
PAIN
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
17. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute cardioembolic ischemic infarct
2. Atrial fibrillation
3. Osteomyelitis
4. Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of right-sided vision change. Head and neck CT and
MRI showed signs of a new stroke on the left side of your brain
responsible for the right side of your vision. Your stroke was
most likely due to your atrial fibrillation. Although you had
previously stopped taking blood thinners because of a bowel
bleed, you were again started on a blood thinner (apixaban)
given your high risk of strokes as well as your lower change of
bowel bleeding after having the source of your bowel bleed
adequately treated. You were also started on a
cholesterol-reducing medication (atorvastatin) to reduce your
risk of future strokes.
Please continue taking your remaining medications as instructed.
Please follow up with your primary care provider ___ ___
weeks of discharge from your acute rehabilitation facility, and
with Neurology at your appointment listed below.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
19634960-DS-4
| 19,634,960 | 29,044,204 |
DS
| 4 |
2163-04-01 00:00:00
|
2163-04-01 17:26:00
|
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, somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old man with stage IV NSCLC with symptomatic brain
metastases. He completed a full course of whole brain
radiotherapy with the last dose on ___. He is presenting
with 7 days of worsening abdominal pain, nausea and vomiting.
His wife called today to clinic, reporting that he has no fever,
no respiratory symptoms, but was harder to wake up from sleeping
and is reporting abdominal pain. Patient also endorses
persistent hiccups, and poor po intake.
He was admmitted to ___ from ___ to ___ for evaluation
of growing pulmonary lesions; the CT Scan suggested an
infectious process/pneumonia. Multiple sputum cultures showed
presence of Streptococcus pneumoniae and fungal (yeast/mold)
specimens. The patient was started on moxifloxacin on ___
and has taken it since. His appetite has decreased and he lost
10 pounds in the last 2 weeks. Pt denies fevers/chills, n/v, CP,
diarrhea. Reports some chest discomfort with coughing.
His other main complaint continues to be related to severe (on
occasion ___ headaches. He is using both long acting and short
acting opiates with some relief. He continues to have some
decreased visual acuity. He denies other significant
neurological deficits.
Past Medical History:
___ stage IV w/ brain mets, s/p whole brain XRT finished ___
COPD, tobacco use
Anxiety
chronic MSK pain
Social History:
___
Family History:
Father has high blood pressure and had a
myocardial infarction at age ___. His mother has no known health
problems. There is no history of any other cancers in the
family.
Physical Exam:
ADMISSION EXAM
VS: 97.5 BP 114/76 HR 82 RR 18 O2 94% RA
GEN: ill appearing in obviouse discomfort
HEENT: sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. rhonchorous
breath sounds in all fields.
ABD: Soft, diffusely tender, ND, bowel sounds decreased but
present
EXT: No c/c/e,
SKIN: No rash, warm skin
DISCHARGE EXAM
97.2 78 132/76 18 100RA
Gen- chronically ill appearing. No acute distress.
Psych- more animated and energetic appearing today (earlier, had
much more flattened affect)
ENT- stable hoarse voice
CV- RRR no m/g
Lung- no resp distress. Coarse and rhonchorous BS throughout.
Abd- soft NT/ND
Pertinent Results:
___ 02:45PM BLOOD WBC-9.2 RBC-4.26* Hgb-12.1* Hct-36.0*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.4 Plt ___
___ 06:50AM BLOOD WBC-9.1 RBC-3.51* Hgb-10.0* Hct-30.4*
MCV-87 MCH-28.5 MCHC-32.9 RDW-15.3 Plt ___
___ 07:30AM BLOOD ___ PTT-34.1 ___
___ 06:50AM BLOOD ___
___ 07:35AM BLOOD ___
___ 02:45PM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-136
K-3.3 Cl-96 HCO3-28 AnGap-15
___ 06:50AM BLOOD Glucose-75 UreaN-5* Creat-0.8 Na-138
K-3.4 Cl-103 HCO3-24 AnGap-14
___ 07:30AM BLOOD ALT-20 AST-19 LD(LDH)-239 AlkPhos-112
TotBili-0.5
___ 06:50AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7
Beta glucan pending
Galactomannan pending
CT chest/abd/pelvis
1. 3.4 cm spiculated dominant left upper lobe mass, similar to
prior. As before, a 2.7 cm aorticopulmonary window node
obliterates the left pulmonary artery and left upper lobe
bronchus.
2. Large areas of cavitation replace much of the left lung apex
and superior segment of left lower lobe, similar in extent to
prior. No definite new area of involvement. Previously seen
thick rind around cavitations have improved. Previously seen
air-fluid levels within the cavitations are decreased.
Previously seen nodularity within the left upper lobe cavitation
is not visualized on today's exam. Single new 7-mm peripheral
left lower lobe nodule.
3. Approximately 1.8-cm hepatic dome hypodense lesion,
evaluation of which is limited due to motion.
4. 2.3 cm left adrenal lesion with macroscopic fat, suggestive
of a
myelolipoma, similar in size to prior.
Brain MRI
1. Interval development of small bilateral subdural fluid
collections in the frontal regions on both sides, along with
thin linear smooth enhancement of the pachymeninges in the
temporal, parietal, and occipital regions as described above.
Correlate clinically for the etiology. Possibilities include
intracranial hypotension, status post LP, related to
inflammatory or reactive changes. Consider close followup as
clinically indicated.
2. Multiple enhancing lesions as described above representing
the known
metastasis; minimal increase in the left temporal and the left
frontal lesions as described above. No obvious new lesions,
within the limitations of motion artifacts.
Brief Hospital Course:
___ with stage IV ___ w/ brain mets admitted for abdominal
sx and somnolence. Transitioning towards hospice care for
general overall decline.
# encephalopathy- patient had some clinical evidence of
hypoactive delirium with waxing and waning periods. He also had
persistent unchanged headaches. A head CT was done without acute
bleed. He was empirically started on IV dexamethasone for
concern of cerebral edema from worsening metastatic diease. An
MRI was done and showed relatively stable tumor burdern;
dexamethasone switched back to low PO dose. Of concern, the
brain MRI did show subdural fluid collections and some meningeal
enhancement. Differential includes low CSF pressure headache
(but patient has not had any recent LP or instrumentation);
infection; bleeding; meningeal tumor involvement. Outpatient
neuro oncologist Dr ___ most likely subdural hemorrhage
that would reabsorb over time. He will follow up with Dr ___ in
clinic, at which time repeat brain imaging and/or LP will be
considered.
# severe protein calorie malnutrition, failure to thrive, goals
of care. Taking in very poor PO despite appetite stimulants
(megace, dronabinol). Likely multifactorial combo of malignancy,
encephalopathy. Dobhoff feeding tube attempted twice but patient
pulled it out before feeding could be started. Oncology met with
family and discussed overall goals, lack of evidence for long
term enteral feeding, etc. Plan is to transition patient to
hospice approach. He will be given contact and referral info to
___ in ___.
# pneumonia with cavitations- on previous admission, sputums
grew pneumococcus and aspergillus. He has been on Moxifloxacin,
this was continued and finished the course on this
hospitalization. He missed outpatient ID appointments to assess
need for treatment of the aspergillus. Inpatient ID service felt
treatment is warranted. Started on voriconazole and will f/u
with ___ clinic.
# abd pain/N/V- no clear etiology of this was found. Exam
benign, labs reassuring, and CT scan without acute pathology.
Attributed perhaps to overall general decline, and no further
investigation or treatment was done aside from continuation of
chronic pain medications.
# coagulopathy- elevated INR to ~2.0, likely nutritional. Given
vitamin K. INR on day of discharge still up at 1.8.
# electrolyte abnormalities. Hypokalemia and hypophosphatemia
were repleted.
# Dispo: home with services, ___, transition to hospice.
TRANSITIONAL ISSUES
- rpt INR
- voriconazole to be managed by ID
- Beta glucan and galactomannan are pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dronabinol 2.5 mg PO BID
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Megestrol Acetate 40 mg PO QID
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
7. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
8. Nystatin Oral Suspension 5 mL PO QID
9. Omeprazole 20 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Megestrol Acetate 40 mg PO QID
3. Multivitamins 1 TAB PO DAILY
4. Nystatin Oral Suspension 5 mL PO QID
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
7. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
RX *OxyContin 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*60 Tablet Refills:*0
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
9. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
10. Dexamethasone 1 mg PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
12. Voriconazole 400 mg PO Q12H aspergillus Duration: 4 Doses
RX *voriconazole 200 mg 1 tablet(s) by mouth q12h as directed
Disp #*90 Tablet Refills:*0
13. Voriconazole 200 mg PO Q12H aspergillus
14. Morphine Sulfate (Oral Soln.) ___ mg PO Q2H:PRN pain or
dyspnea
to be given by hospice
15. Hyoscyamine 0.125 mg PO Q4H:PRN congestion
to be given by hospice
16. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety
ongoing prescriptions to be given by hospice
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non small cell lung cancer with brain metastases
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain, headaches,
confusion. Your abdominal pain improved without further
treatment and no dangerous causes of it were identified. You
had difficulty eating due to your cancer. We recommended
hospice care as an outpatient. You should follow up with your
oncologist.
Followup Instructions:
___
|
19635255-DS-21
| 19,635,255 | 29,529,904 |
DS
| 21 |
2160-12-19 00:00:00
|
2160-12-19 19:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o CAD, known 3VD, s/p ___ dual-chamber ICD
(placed at ___ transferred from OSH with ___ s/p fall. Patient
walks with walker at baseline, had an unwitnessed fall at his
assisted living facility. Was found in the bathroom, no loss of
bowel or bladder noted on notes. Initially he was taken to
___ where he was found on CT scan to have a
subdural hemorrhage and questionable mass lesion. There he was
also noted to have left shoulder dislocation which was reduced
and laceration near left eye which was repaired. He was
transferred to ___ for neurosurg evaluation.
In the ED, initial VS were 97.0 96 ___ 96%2L. Had labs
significant for WBC 8.2, Hct 24.1, Cr 2.3. CT head shows small R
SDH and brain lesion. Left shoulder plain film shows
successfully reduced shoulder. Neurosurgery evaluated him and
determined that no operative intervention was needed; his family
desired no surgical intervention for the ___ and no workup for
the brain lesion. Transfer VS were 97.3 61 122/63 18 95%.
Per his daughter, he has had about four falls in the past year,
including one several weeks ago with no injury. He frequently is
impulsive and walks without his walker. He also has had
decreasing vision and right visual field deficit found on a
ophthalmology visit. No fever/chills, cough, chest pain,
shortness of breath, urinary retention or bowel incontinence.
On arrival to the floor, patient reports no new complaints.
Feels fatigued. Does not remember fall. No chest pain, shortness
of breath, nausea/vomiting.
Past Medical History:
- AICD (automatic cardioverter/defibrillator) ___
dual-chamber ICD in ___
- CAD (coronary artery disease) 3VD, turned down for CABG given
age, EF 20%, overall hypokinetic. Cath ___ with 40%
stenosis left main, 95% stenosis proximal LAD, 90% stenosis
mid-LAD, 95% ___ marginal branch, 80% stenosis mid-RCA (right
dominant).
- CHF (congestive heart failure) EF 20%
- Dyslipidemia
- Hemorrhoids
- Post-phlebitic syndrome
- Chronic Anemia
- Chronic kidney disease (CKD), stage III (moderate)
- Cardiomyopathy
- BPH (benign prostatic hyperplasia)
- Urinary frequency
- Gait abnormality
- Adhesive capsulitis of shoulder
- Cognitive decline
- Hemianopia, homonymous, right
Social History:
___
Family History:
2 Brother died of cancer, father died of cancer, mother died of
CAD/PVD, 2 sisters died of cancer (breast). No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7 58 123/64 18 97%RA
GEN - awake, AOx1 (to name, says he's at ___, says the
year "changes every day")
HEENT - left periorbital ecchymosis with 2cm laceration, no
tenderness to palpation on scalp, dry mucous membranes, EOMI,
4-3mm PERRLA, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - left arm in sling, no c/c/e, 2+ pulses palpable
bilaterally, no gross deformities
NEURO - mild right lower facial droop but otherwise CNII-XII
intact, 4+/5 strength in arms/legs, gait deferred
SKIN - scattered ecchymoses on arms, L periorbital ecchymosis
DISCHARGE PHYSICAL EXAM:
VS - VS - T___.9 T 97.8 BP 132/54 (120-130s/50-60s) HR 64
(50-60s) RR 20 95%RA
GEN - sleeping, but easily arousable, AOx2 (to name, says he's
in a hospital, does not know the year), more energetic than
prior
HEENT - left periorbital ecchymosis with 2cm laceration, no
tenderness to palpation on scalp, dry mucous membranes, 4-3mm
PERRLA, sclera anicteric, OC/OP ___
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - ICD palpable in L upper chest wall, RRR, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - left arm in sling, no c/c/e, 2+ pulses palpable
bilaterally, no gross deformities, mild pain with palpation of
calves
NEURO - mild right lower facial droop but otherwise CNII-XII
intact, 4+/5 strength in arms/legs, gait deferred
SKIN - scattered ecchymoses on arms, L periorbital ecchymosis
Pertinent Results:
ADMISSION LABS:
___ 03:41PM BLOOD WBC-8.2# RBC-2.41* Hgb-7.8* Hct-24.1*
MCV-100* MCH-32.2* MCHC-32.3 RDW-13.3 Plt ___
___ 03:41PM BLOOD Neuts-73.8* ___ Monos-4.7 Eos-1.0
Baso-0.6
___ 03:41PM BLOOD Glucose-124* UreaN-34* Creat-2.3* Na-141
K-3.8 Cl-103 HCO3-29 AnGap-13
Outside CT/Xrays:
CT head noncon ___
There is extensive abnormality is clearly identified including a
large right convexity subdural hematoma and a second process
with extensive edema throughout the left hemisphere upper marrow
involving posterior centrum semiovale of the parietal, temporal
prior occipital lobes. There is an area of high density in the
posterior inferior parietal lobe suggestive of a large
intracerebral hematoma but the appearance is more suggestive of
artifact and difficutl to be 100% sure if this is artifact or
hematoma in the posterior inferior parietal region. There is
however a cystic-appearing density mor ecentrally and abutting
the ventricle and is significant mass effect on the trigone and
posterior horn of hte left lateral ventricle. There is severe
extensive hemispheric edema on the left posteriorly and I
suspect this is a mass, a cerebral tumor, extensive interstitial
edema and mass effect. The edema and the cystic change appear to
be more extensive than expected from an acute traumatic and is
highly suggestive of an underlying mass.
IMPRESSION:
Large right convexity subdural hematoma. Only mild mass effect
and non intracerebral edema on the right side from the subdural
hematoma at this time.
Extensive edema in the left parietal and posterior temporal
region with an area of cystic change in the centrum seminal
ovale with extensive mass effect. THere is some high density
appearance posteriorly but I suspect that's all from beam
hardening artifact but some element of intracerebral hemorrhage
cannot be excluded. The amount of edema and mass effect is quite
extensive more so than I would suspect from an acute injury and
this is likely to be a brain tumor causing extensive edema and
mass effect in this patient.
CT spine ___
No fracture or spondylolisthesis.
L shoulder xray ___
Posterior left glenohumeral subluxation
No labs were drawn prior to discharge
Brief Hospital Course:
___ with h/o CAD, known 3VD, s/p ___ dual-chamber ICD
(placed at ___ transferred from OSH with reduced L shoulder
dislocation and SDH s/p fall.
ACTIVE ISSUES BY PROBLEM:
# Fall: Pt had an unwitnessed fall at his assisted living
facility, suffering a left eyebrow laceration, posterior
shoulder dislocation (reduced at outside hospital) and a small
right subdural hematoma on CT. He is a poor historian, but
denied chest pain, shortness of breath. He does have a new mass
lesion on head CT that could be an epileptic focus and posterior
shoulder dislocations are rare and typically seen from seizures.
However, had no reported loss of bowel or bladder, postictal
confusion, or witnessed tonic-clonic movements, so we did not
pursue further. We also ruled out a cardiac cause of fall given
EKG showed no ischemic changes or interval changes, pacer
interrogation was normal, and telemetry had no events. We
ultimately suspect a mechanical fall, and physical therapy
recommended rehab placement.
# Subdural hemorrhage: Pt was found to have a right subdural
hematoma after his fall in the setting of ASA and plavix use.
There was small mass effect. He had no new neuro deficits on
exam, with baseline left sided weakness and right lower facial
droop. Per his daughter, his mental status waxes and wanes but
was at baseline throughout his stay. His daughter did not desire
any surgical intervention for this SDH regardless of findings.
Neurosurgery followed him for this and decided that no surgical
intervention was warranted anyway. His anticoagulation (ASA and
plavix) were discontinued given that risk outweighs benefit.
# Brain lesion: On CT scan, he was found to have large right
intraparenchymal mass lesion with edema. He was evaluated by
neurosurgery. His daughter desired that no further workup be
done for this lesion, given the patient's age and
co-morbidities.
# Hypothyroidism: found to be severely hypothyroid, with TSH
>100 and free T4 <0.10. He was started on levothyroxine 75mcg
in case this may help improve his mental status and energy. If
it is felt to be making no difference in his clinical status or
quality of life, this could be discontinued.
# Dysphagia:
RECOMMENDATIONS:
1. PO diet: thin liquids, moist, ground solids.
2. Suggest meals consist of a combination of pureed and ground
foods to minimize fatigue.
3. 1:1 supervision with meals to assist with feeding and
maintain aspiration precautions.
4. Meds crushed or whole with applesauce as tolerated.
5. Nutrition f/u here or upon d/c for further recommendations
for oral supplements as appropriate.
6. SLP f/u upon d/c to monitor tolerance and consider further
changes as needed.
# Goals of care: Given the patient's recent decline, poor
overall health status, and new subdural hemorrhage and left
cerebral brain mass, his family decided to focus his further
medical care on keeping him comfortable. They were interested
in pursuing hospice, but in the interim he will be placed in a
___ rehab to help improve strength and mobility with the
ultimate goal of transitioning him to home with hospice care.
His medicine list was scaled back and tailored toward this goal.
He is a confirmed DNR/DNI.
INACTIVE ISSUES:
# Anemia of chronic disease: Stable. Stopped his iron
supplementation given shift in goals of care.
# CAD (coronary artery disease): known 3VD, turned down for CABG
given age, EF 20%, overall hypokinetic. Stopped aspirin and
plavix given goals of care and recent bleed.
# CHF (congestive heart failure) EF 20%: stopped carvedilol
# Dyslipidemia: stopped lovastatin
# Chronic kidney disease (CKD), stage III: stable
# BPH (benign prostatic hyperplasia): stopped terazosin given
recent fall and severe orthostatic hypotension. This could be
restarted if he re-develops issues with urinary retention.
TRANSITIONS OF CARE:
- Brain mass: no further work up, per discussion with
patient/daughter. If their goals of care change, this can be
reassessed and worked up further.
- Hypothyroidism: started on levothyroxine 75mcg here. Given
goals of care, do not recommend rechecking TSH levels unless he
is symptomatic.
- Pain: will be discharged on standing tylenol with PRN tramadol
for shoulder pain, which can be adjusted as needed at rehab
- DNR/DNI, transition to hospice care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Doxazosin 4 mg PO HS
6. Ferrous Sulfate 325 mg PO DAILY
7. Lovastatin *NF* 40 mg Oral qHS
8. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN anal
irritation
9. Ranitidine 150 mg PO DAILY
10. Acetaminophen 500 mg PO Q6H:PRN pain
11. Senna 1 TAB PO BID:PRN constipation
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
13. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Lorazepam 0.5 mg PO BID:PRN anxiety
16. Nitroglycerin SL 0.4 mg SL PRN chest pain
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Citalopram 20 mg PO DAILY
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. Ranitidine 150 mg PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Mechanical fall
Subdural hematoma
Mass lesion of unclear significance in brain
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
evaluated for your fall, with a subsequent subdural hematoma
(blood) in your brain. We did not find an alternative worrisome
cause for your fall, such as a problem in your heart. We suspect
that you most likely tripped and fell. You were evaluated by our
physical therapists who recommended that you be discharged to
rehab after your hospitalization.
Your CAT scan also showed a mass. It was ultimately decided by
all parties that nothing will be done at this time for this
mass. Our palliative care doctors were involved with your case
and with your family and yourself a priority for comfort was
made going forward.
We have made some changes to your medication list that reflect
your goals of comfort and they will be outlined by your nurse.
Thank you,
Followup Instructions:
___
|
19635303-DS-13
| 19,635,303 | 26,265,933 |
DS
| 13 |
2134-01-27 00:00:00
|
2134-01-29 19:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of B cell lymphoma diagnosed in ___
complicated by malignant pericardial effusion that was drained
recently presents with fatigue present for one day. She was
discharged from the hospital 2 days ago after a cycle of
chemotherapy. Yesterday she had nausea and vomiting, although
today the symptoms have resolved and she is currently tolerating
PO. She reports no cough, fever, dysuria, diarrhea, chest
pain, dyspnea or syncope.
In the ED, initial vitals were 99.1 120 104/51 16 100% 2L. Exam
was reported as unremarkable. Labs showed WBC count of 34.2
with 98% neutrophils, no bands, hematocrit 27.5, platelets 96K.
Lactate was 1.4. UA showed 5 WBCs, few bacteria, 0 epis. Urine
and blood cultures were sent. CXR showed possible lingular
pneumonia, and vancomycin/cefepime was started. Oxycodone 10 mg
was also administered. Bedside ultrasound showed no evidence of
pericardial effusion. 1 liter NS was administered. Vitals upon
transfer were 100.0 116 102/50 24 98% RA.
On the floor, the patient is reporting myalgias that started
gradually on the day before admission. She reports intermittent
headaches. She is occasionally short of breath on exertion, not
at rest. There is no abdominal pain or diarrhea. There is no
sick contacts at home. Patient has not received a flu vaccine
this year.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies chest
pain or tightness, palpitations. Denies diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Ten point review of systems is otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ pericardiocentesis with removal of 215 ccs of fluid and
placement pericardial drain. The pericardial fluid analysis was
notable for ___ WBCs (81% atypicals) and elevated LDH of 5850.
Flow cytometry revealed a kappa restricted B-cell population,
CD20+, CD19+, negative for CD5, CD10, CD23 and CD138. Cytology
and cell block pathologic examination showed a uniform
population
of large immunoblast/centroblast-like cells, which by ICH were
reactive for CD20, MUM1 and BCL-6, conistent with ABC type of
DLBCL. 60-70% of the cells expressed C-MYC by ICH. MIB-1 was
estimated > 95%. ___ in situ hybridization was negative. On
___, the patient also had a cardiac MRI which confirmed a
1.9 cm heterogenous infiltrative mass originating 2.7 cm above
the tricuspid annulus and extending 4.5 cm below the annulus to
the mid-R ventricular wall with compressive effects on the R
atrium and ventricle. BM aspiration and biopsy were negative for
involvement by lymphoma. A staging torso CT from ___ showed
no evidence of extrathoracic sites of disease.
TREATMENT HISTORY:
- ___ Started on prephase steroids (prednisone 100mg daily)
- ___ C1D1 EPOCH (Doxorubicin, Vincristine and
Cyclophosphamide with 50% dose reduction), with Neupogen support
- ___ C1 Rituximab
- ___ C2D1 EPOCH
- ___ C2 Rituximab
- ___ C3D1 EPOCH
- ___ C3 Rituximab
- ___ c3 EPOCH
-___ EPOCH-R
PAST MEDICAL/SURGICAL HISTORY:
- Osteoarthritis
- Neuropathy
- Chonic hepatitis B infection
- HSV2 reactivation ___
- DCIS, s/p lumpectomy ___
Social History:
___
Family History:
Mother has a history of myocardial infarction in her ___ but
died at an old age.
Physical Exam:
ADMISSION EXAM
--------------
Vitals: T: 100.1 BP: 110/60 P: 108 R: 22 O2: 100%RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing and slightly uncomfortable, no acute signs of
distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, o/p
clear, MM slightly dry.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, tachycardic, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing
noted.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
DISCHARGE EXAM
--------------
Vitals: T99.6, BP 101/46, P ___ (113-121), RR 20, SPO2 98% RA
GEN: Alert and conversant. NAD.
HEENT: MMM.
NECK: No JVD, no LAD.
CV: S1S2, regularly tachycardic, no murmurs, rubs, or gallops.
RESP: Breathing comfortably without accessory muscle use. Good
air movement bilaterally, no rhonchi or wheezing noted.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
Pertinent Results:
ADMISSION LABS
--------------
___ 04:30PM BLOOD WBC-34.2*# RBC-3.14* Hgb-10.2* Hct-27.5*
MCV-88 MCH-32.4* MCHC-37.0* RDW-20.6* Plt Ct-96*
___ 04:30PM BLOOD Neuts-98.1* Lymphs-0.6* Monos-0.8*
Eos-0.4 Baso-0.1
___ 04:30PM BLOOD Glucose-134* UreaN-12 Creat-0.5 Na-140
K-3.3 Cl-109* HCO3-22 AnGap-12
___ 12:40PM BLOOD ALT-17 AST-20 AlkPhos-65 TotBili-0.7
___ 04:40PM BLOOD Lactate-1.4
DISCHARGE LABS
--------------
___ 05:54AM BLOOD WBC-11.4*# RBC-3.38*# Hgb-10.5*#
Hct-31.8*# MCV-94 MCH-31.0 MCHC-33.0 RDW-20.2* Plt ___
___ 05:54AM BLOOD Neuts-53 Bands-10* Lymphs-10* Monos-17*
Eos-2 Baso-0 Atyps-1* Metas-2* Myelos-5*
___ 05:54AM BLOOD Glucose-91 UreaN-5* Creat-0.8 Na-143
K-4.4 Cl-110* HCO3-24 AnGap-13
___ 04:05AM BLOOD ALT-13 AST-18 AlkPhos-70 TotBili-0.7
___ 05:54AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
IMAGING
-------
___ CXR:
Findings compatible with lingular pneumonia.
___ Cardiac MRI:
IMPRESSION:
Normal right ventricular cavity size with mild free wall
hypokinesis. Previously noted right ventricular mass is
no longer present. Normal left ventricular cavity size
with mild global hypokinesis. Mitralregurgitation (not
quantified).
Compared to the prior CMR of ___, RV mass is no
longer seen, there is mild global LV dysfunction
(Previously hyperdynamic with LVEF 76%; however, study on
___ LV function more similar to today's with LVEF
noted to be 60%)
Brief Hospital Course:
Ms. ___ is an ___ with cardiac B cell lymphoma c/b
malignant pericardial effusion on C5D16 (as of ___ of EPOCH
who presented with fatigue and was found to have
healthcare-associated pneumonia.
# Fatigue: Likely related to infection, as well as to recent
chemotherapy and Neulasta administration on ___. Symptoms
suggestive of influenza-like illness, given fever, myalgias,
headaches and non-productive cough; however, respiratory viral
screen and cultures were negative. Leukocytosis to 34.2 on
admission, felt to be attributable to Neulasta with superimposed
infection, has downtrended as would be expected in the setting
of chemotherapeutic nadir. Patient received Neupogen daily
beginning ___ until her ANC was > 1000 for 4 consecutive days.
HCAP treated as described below.
# Healthcare-associated pneumonia/pulmonary sepsis: Lingular
infiltrate seen on admission CXR in conjunction with
influenza-like illness symptoms as above. She met sepsis
criteria on admission on the basis of fever, leukocytosis
(though confounded by Neulasta administration), and tachycardia
(though confounded by baseline tachycardia in the setting of
cardiac lymphoma). Following initiation of vancomycin/cefepime
on admission, she continued to experience intermittent fevers,
prompting addition of azithromycin for atypical coverage
___, with fever on the nights of ___ but no
other signs of clinical decompensation, including no worsening
shortness of breath or hypoxia or hemodynamic instability
distinct from baseline and no other localizing signs or symptoms
of infection. Patient was treated with a full 8 day course of
vancomycin/cefepime, and a 5 day course of azithromycin. She
was discharged with a 6 day course of levofloxacin.
# Diffuse large B-cell lymphoma: Lymphoma is cardiac-limited,
with interval response to treatment on most recent cardiac MR in
___ and TTE in ___. She is on C5D16 of EPOCH as of
___ and s/p dose-reduced Neulasta on ___ due to
myalgias at that time. Patient underwent cardiac MR for routine
surveillence which showed improvement in her cancer. The full
report is listed in the results section.
Patient was continued on ___ TMP/SMX prophylaxis and acyclovir
prophylaxis in place of home valcyclovir.
# Pancytopenia: Likely due to recent chemotherapy, followed by
dose-reduced Neulasta as above. There is no known marrow
infiltration, and there are no signs of active bleeding. She
received 1 unit pRBCs and 1 unit of platelets during this
admission. She also received daily Neupogen x 4 days due to
severe neutropenia. Her counts have since recovered.
# Sinus tachycardia: Heart rate has ranged from 100s-140s
throughout admission, with multiple EKGs confirming sinus
tachycardia. Baseline heart rate is 100s-110s in the setting of
cardiac lymphoma, with likely superimposition of hypovolemia,
healthcare-associated pneumonia, and pain. There is low
suspicion for recurrent pericardial effusion/tamponade, given
negative bedside echo in the ED, or pulmonary embolism in the
absence of hypoxia or peripheral edema. Her heart rate returned
to baseline upon time of discharge.
# Atypical chest pain: Patient noted atypical chest pain
involving right upper chest and left lower chest, responsive to
morphine and exacerbated by cough and upper extremity movement.
Multiple EKGs without acute ischemic changes or evidence of
right heart strain. Pain likely reflects pleurisy in the setting
of healthcare-associated pneumonia as above. Her pain improved
upon time of discharge.
# Hepatitis B: Continued home lamivudine.
# Depression: Continue home sertraline. Pt reports this was
recently decreased from 50mg daily to 25mg daily.
TRANSITIONAL ISSUES:
- HCAP treated with vancomycin, cefepime, and azithromycin.
Patient to continue levofloxacin x 6 days after discharge.
- Patient received Neupogen x 4 days for severe neutropenia. Her
white count has since recovered.
- Patient received 1 unit pRBC and 1 unit platelets during
hospitalization.
- Cardiac MRI for routine surveillance showed improvement in
patient's cancer.
- Patient continued to be in sinus tachycardia during
hospitalization. Baseline HR 110-120s.
- Next chemotherapy cycle: ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
3. LaMIVudine 100 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
9. Senna 1 TAB PO BID constipation
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. ValACYclovir 1000 mg PO Q12H
12. Sertraline 25 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
3. LaMIVudine 100 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
9. Senna 1 TAB PO BID constipation
10. Sertraline 25 mg PO DAILY
11. 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
12. ValACYclovir 1000 mg PO Q12H
13. Levofloxacin 750 mg PO Q24H
Please continue through ___.
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Healthcare-associated pneumonia
Febrile neutropenia
Chemotherapy-induced nausea/vomiting/fatigue
SECONDARY DIAGNOSIS:
Cardiac B-cell lymphoma
Sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You came with fatigue, nausea, and vomiting. A
chest xray showed pneumonia. We believe your symptoms are from
your recent chemotherapy, as well as the pneumonia. We treated
you with IV antibiotics, and you should continue oral
antibiotics for another 6 days post-discharge, concluding
___.
Your blood counts also were found to be low after chemotherapy.
You received red blood cells, platelets, and other medications
to help boost your counts.
We also performed a cardiac MRI for restaging, which showed
improvement in your cancer. Please see below for follow up with
your oncologists as below. You will be readmitted for your next
cycle of chemotherapy on ___.
Please see the attached sheet for specific medication changes.
Followup Instructions:
___
|
19635323-DS-12
| 19,635,323 | 29,430,709 |
DS
| 12 |
2142-10-05 00:00:00
|
2142-10-05 13:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Leaking ostomy appliance
Major Surgical or Invasive Procedure:
Gastrograffin enema
History of Present Illness:
___ recent sigmoid colectomy with diverting ileostomy on
___ with Dr. ___ divericulitis. Postop she recovered
well and was discharged home on ___. Was re-admitted
___ for leaking appliance and midline wound infection.
She was on vanco a few days, had her wound partially opened, and
was discharged home on Bactrim. She presents again tonight with
the same problem, that is, stool leaking out of the ostomy and
contaminating the laparotomy incision. There was increased
erythema around the incision today so she presented to an
outside
hospital and was subsequently transferred here for evaluation.
Ostomy output has been normal, no change.
Past Medical History:
diverticulitis ___ hospitalized for 4 days at ___ for a
3cm abscess), high cholesterol, HTN, migraines, asthma,
depression
PSH: Bilateral tubal ligation; C-Section; Bilateral ___ Vein
Stripping; ___ drainage of abcess ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: T 99.5 P 96 BP 134/85 RR 18 O2 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, nontender, no rebound or guarding,
Incision: moderate erythema surrounding the length of the
incision, more pronounced at each staple. Stoma pink, peristomal
skin with excoriation but no cellulitis.
Ext: 1+ ___ edema, ___ warm and well perfused
Pertinent Results:
GASTROGRAFIN ENEMA: Gastrografin contrast was instilled through
an 18 ___ flexible catheter into the rectum. Contrast flowed
freely into the rectum, past the colorectal anastomosis and into
the distal colon. There is no evidence of leaks or strictures.
The patient tolerated the procedure well.
IMPRESSION: No evidence of leaks at the colorectal anastomosis.
Brief Hospital Course:
She was admitted to the Acute Care Surgery team for management
of her leaking ostomy appliance and treatment for fungal skin
infection. Due to the location of the stoma and patient's body
habitus the ostomy location was very close to her mid-line
incision. The wound itself was not infected. Wound ostomy
nursing was consulted and were able to make adjustments in her
appliances to new equipment which adhered over 24 hour period
without leakage. Miconazole powder was ordered for the fungal
irritation which showed signs of improvement during her stay.
She remained on her home medications during her stay and is
being discharged to home with services. She will follow up in
Acute Care Surgery clinic as instructed.
Medications on Admission:
1. levothyroxine 50 mcg Daily
2. atenolol 25 mg Daily
3. furosemide 80 mg Daily
4. simvastatin 80 mg Daily
5. aspirin 81 mg Daily
6. hydromorphone ___ mg Q4H as needed for pain
7. butalbital/acetaminophen/caffeine 50mg/325mg/40mg as needed
for headache
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
Disp:*1 bottle* Refills:*2*
9. Ostomy supplies
ConvaTec Surfit Moldable Large Convex it ___: # ___
10. Ostomy supplies
ConvaTec Drainable Pouch ___: ___ ___
11. Ostomy supplies
Ostomy Belt: manf # ___
12. Dressing/Wound supplies
Aquacel AG rope
Sig: Commercial wound cleanser, pat dry.
Aquacel AG rope, dry gauze, change daily.
Disp: 1 tube
Refills: 4
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Leaking ostomy appliance
Candidiasis skin infection
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 non adherent ostomy due
to leaking. As a result you developed a fungal skin rash that is
beingtreated with an anti-fungal powder. A new ostomy appliance
has been used - you will be given prescriptions for the new
supplies.
DO NOT use the old ostomy appliance that you have at home.
You may resume your home medications as prescribed.
Return to the Emergency room if your ostomy appliance leaks
again.
Followup Instructions:
___
|
19635406-DS-12
| 19,635,406 | 25,560,426 |
DS
| 12 |
2170-10-29 00:00:00
|
2170-10-29 14:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Traumatic ankle injury, ?cellulitis
Major Surgical or Invasive Procedure:
ORIF R ankle ___
History of Present Illness:
Ms. ___ is a ___ with past medical history of osteoarthritis,
hypertension, ascending aortic aneurysm status post surgical
repair in ___, post-operative atrial fibrillation with
restoration of sinus rhythm, typical atrial flutter status post
radiofrequency ablation in ___, transient mild LV systolic
dysfunction in the setting of atrial flutter, seronegative
rheumatoid arthritis followed by rheum, moderate to severe
tricuspid regurgitation, and moderate pulmonary hypertension (by
TTE) who presents with right ankle pain, found to have acute
fractures of her right tibia, fibula, ankle and RLE erythema and
swelling with concern for cellulitis.
At her baseline, she uses a walker. She lives in an independent
living facility and has home aide services 3x per week. The
patient is unable to describe the specific details of what
occurred. She indicates that she was getting up from the commode
when she felt that she twisted her right ankle. She indicates
that she was unable to bend her leg and developed sudden onset
right ankle pain. However, she denies any fall, head strike,
loss
of consciousness. She was subsequently brought to the ED via EMS
for evaluation.
In the ED she was resting comfortably, in no acute distress and
reported no pain anywhere else apart from her right lower
extremity. Her right lower extremity was noted to be warm,
edematous, tenderness to palpation and she was thus admitted to
medicine for management of cellulitis.
She denies any shortness of breath, palpitations, chest
pain or dizziness.
ED COURSE:
Initial Vitals: Temp 97.5, HR 60, BP 112/63, RR 18, O2 sat 97%
RA
Initial Labs:
WBC 7, Hgb 9.6, Ht 31.6, PC 224
Na 129, K 7 (hemolyzed), Cl 98, Bicar 26, BUN 19, Cr 0.6, Gluc
92
Urine Na 68, Urine Cr 27, Urine osm 311
Interventions:
IV ceftriaxone 1g
PO tylenol 1g x2
PO atenolol 50mg
PO furosemide 20mg
PO ibuprofen 400mg
PO aspirin 81mg
IMAGING:
ANKLE (AP, MORTISE & LAT) RIGHT ___
IMPRESSION: Acute fractures through the distal right tibia and
fibula. Secondary widening of the ankle mortise.
ANKLE (AP, MORTISE & LAT) RIGHT ___
IMPRESSION: Trimalleolar fractures with persistent mild lateral
subluxation of the tibiotalar joint.
On admission to the floor, the patient confirms the above
history. She indicates that she is unsure when her right lower
extremity first became erythematous but believes this has been
present proceeding the event involving her ankle.
Past Medical History:
Osteoathritis
Seronegative rheumatoid arthritis
Lumbar spondylosis
Lumbar canal stenosis
Atrial flutter/Atrial fibrillation
Hypertension
HFpEF
?SIADH
Aortic aneurysm s/p ascending aorta repair ___
Anemia of chronic disease
Osteoporosis
Social History:
___
Family History:
No premature CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: Temp 97.3, HR 63, BP 100/64, RR 20, O2 sat 96% RA
General: Pleasant, comfortable appearing.
HEENT: Moist mucous membranes.
Neck: No elevated JVP.
Lungs: CTAB with no crackles or wheezing.
CV: RRR, normal S2 with physiologically split S2, II/VI
holosystolic murmur heard at left sternal border
ABD: Soft, nontender, nondistended, normoactive bowel sounds.
MSK: No tenderness to palpation of spinous processes or
paraspinal muscles.
Ext: 2+ RLE pitting edema up to dependent thighs, 1+ LLE pitting
edema to knee. Significant ecchymosis and erythema up to right
knee (worse in lateral RLE). RLE is warm and tender to
palpation.
No skin breakdown. 1+ DP and ___ pulses palpable bilaterally.
Left
lower extremity with mild erythema proximal to ankle.
Neuro: CN ___ intact.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: ___ 0021 Temp: 97.6 PO BP: 128/73 L Lying HR: 64
RR:
18 O2 sat: 92% O2 delivery: Ra
I/O ___: I: 720 PO + ~684mL IV; O: 1300; net: +100
General: Interactive and pleasant, laying in bed wearing
hospital
gown, appears comfortable.
HEENT: EOMI. Moist mucous membranes.
Lungs: Breathing comfortably on room air. CTAB.
CV: Regular rate, S1 and S2 present, II/VI
holosystolic murmur heard at left sternal border
ABD: Soft, nontender, nondistended, normoactive bowel sounds.
Ext: RLE in ace wrap/splint. 1+ RLE pitting edema up to
thighs, 1+ LLE pitting edema to knee. Healing ecchymoses on RLE
(back of leg), erythema up to right knee, smaller than marked
borders. RLE is non tender to palpation and there is no warmth.
Feet are warm and well-perfused bilaterally.
Neuro: Awake and alert. motor function grossly normal (not
moving
RLE).
Pertinent Results:
ADMISSION LABS:
===============
___ 11:58AM GLUCOSE-148* UREA N-15 CREAT-0.8 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-12
___ 11:58AM URINE HOURS-RANDOM CREAT-27 SODIUM-68
___ 11:58AM URINE OSMOLAL-311
___ 02:58PM ___ COMMENTS-GREEN TOP
___ 02:58PM K+-4.5
___ 01:44PM GLUCOSE-92 UREA N-19 CREAT-0.6 SODIUM-129*
POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-26 ANION GAP-5*
___ 01:44PM estGFR-Using this
___ 01:44PM WBC-7.0 RBC-3.57* HGB-9.6* HCT-31.6* MCV-89
MCH-26.9 MCHC-30.4* RDW-15.9* RDWSD-51.8*
___ 01:44PM NEUTS-87.2* LYMPHS-7.3* MONOS-4.7* EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-6.12* AbsLymp-0.51* AbsMono-0.33
AbsEos-0.01* AbsBaso-0.01
___ 01:44PM PLT COUNT-224
IMAGING:
========
ANKLE (AP, MORTISE & LAT) RIGHT ___
IMPRESSION:
Acute fractures through the distal right tibia and fibula.
Secondary widening of the ankle mortise.
ANKLE (AP, MORTISE & LAT) RIGHT (S/P Reduction) ___
IMPRESSION:
Trimalleolar fractures with persistent mild lateral subluxation
of the
tibiotalar joint.
ANKLE (AP, MORTISE & LAT) RIGHT ___
IMPRESSION:
In comparison with the study of ___, the overlying cast again
greatly
obscures detail of the prior malleolar fracture with continued
mild
subluxation about the ankle mortise with narrowing laterally.
Otherwise,
little change.
ANKLE (AP, LAT & OBLIQUE) RIGHT ___
FINDINGS:
The available images show surgical fixation of the medial
malleolus with
percutaneous pins, an anchor screw and cerclage wires. In
addition there
appears to be an intramedullary rod extending through the talus,
calcaneus and tibia. A moderate displaced lateral malleolus
fracture is also noted. Soft tissue swelling around the ankle
persists. Please see the operative report for further details.
INTERIM LABS:
=============
___ 11:58AM BLOOD Glucose-148* UreaN-15 Creat-0.8 Na-132*
K-4.4 Cl-97 HCO3-23 AnGap-12
___ 05:25AM BLOOD Glucose-75 UreaN-23* Creat-0.8 Na-135
K-5.0 Cl-100 HCO3-23 AnGap-12
___ 06:10AM BLOOD Glucose-87 UreaN-22* Creat-0.7 Na-127*
K-4.6 Cl-92* HCO3-22 AnGap-13
___ 09:20AM BLOOD Glucose-110* UreaN-21* Creat-0.8 Na-125*
K-4.4 Cl-90* HCO3-22 AnGap-13
___ 02:40PM BLOOD Glucose-104* UreaN-21* Creat-0.8 Na-127*
K-5.0 Cl-90* HCO3-23 AnGap-14
___ 05:53AM BLOOD Glucose-74 UreaN-20 Creat-0.7 Na-129*
K-4.7 Cl-93* HCO3-20* AnGap-16
___ 06:15AM BLOOD Glucose-83 UreaN-20 Creat-0.7 Na-129*
K-4.8 Cl-95* HCO3-23 AnGap-11
___ 06:23AM BLOOD WBC-4.6 RBC-3.00* Hgb-8.0* Hct-26.2*
MCV-87 MCH-26.7 MCHC-30.5* RDW-16.1* RDWSD-51.3* Plt ___
___ 06:23AM BLOOD ___ PTT-29.4 ___
___ 06:23AM BLOOD Glucose-82 UreaN-20 Creat-0.6 Na-131*
K-4.9 Cl-98 HCO3-22 AnGap-11
___ 06:23AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0
DISCHARGE LABS:
===============
___:06AM BLOOD WBC-5.9 RBC-3.07* Hgb-8.2* Hct-27.2*
MCV-89 MCH-26.7 MCHC-30.1* RDW-16.0* RDWSD-52.1* Plt ___
___ 06:06AM BLOOD Glucose-92 UreaN-23* Creat-0.6 Na-128*
K-5.5* Cl-94* HCO3-23 AnGap-11
___ 06:06AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
___ 09:32AM BLOOD K-4.7
MICRO:
======
NONE
Brief Hospital Course:
Ms. ___ is a ___ with past medical history of osteoarthritis,
inflammatory arthritis, hypertension, paroxysmal atrial
flutter/fibrillation (not on anticoagulation) who presented to
the hospital with right ankle pain, found to have an acute
trimalleolar fracture and RLE erythema and swelling with concern
for cellulitis.
Hospital Course:
================
# Trimalleolar ankle fracture
Ortho evaluated the patient and initially recommended
nonoperative management with non-weight bearing status and
splint of RLE. Repeat ankle xrays obtained 6 days post injury
were notable for possible displacement of fracture and minimal
interval improvement. She went for ORIF on ___, which Ms.
___ tolerated well and resulted in significant pain relief.
Her pain was initially managed with Tylenol 1g TID and tramadol
60mg Q6H. This was transitioned to Tylenol ___ QID and
standing oxycodone 2.5mg q4hrs given the severity of her pain
and ultimately discharged on Tylenol and oxycodone 2.5mg q6hrs.
She is scheduled to be seen with ortho for follow up with repeat
x-rays and she will continue subcutaneous lovenox for 4 weeks
for DVT ppx.
# ?Cellulitis
# RLE bruising
# Chronic venous stasis changes
Her RLE on admission was notable for extensive bruising but
there was also underlying erythema, swelling, warmth, and
tenderness to palpation. Difficult to assess time course of this
erythema and swelling but given its extent, it was predicted
that it preceded her recent ankle insult. Per the patient, she
has had erythema and swelling in both legs for years. She does
not endorse that there was a recent change in the R leg prior to
her fall. Her RLE erythema was marked ___, and remained within
the markings. US was deferred given that she was in a splint,
though there was concern for hematoma. S/p 2 days 1g IV
ceftriaxone and 3 days Keflex ___ TID (5-day total antibiotic
course ___. She remained afebrile during hospital stay.
# Hyponatremia
Na 129 on admission (sample with significant hemolysis), up to
135 on ___, which was possibly inappropriately normal. She has
a history of mild hyponatremia (low 130s). She was fluid
restricted to 1.5L, with fluids other than free water
encouraged. Continued on home PO Lasix 20mg. Na 128-129
stabilized pre discharge. She was asymptomatic. Recommended
repeat Na monitoring to ensure stabilization. Of note, she had
K to 5.5 on discharge BMP, with whole blood K of 4.7, reassuring
against hyperkalemia.
# Concern for falls/stability
Followed by ___, who recommended ___ rehab.
CHRONIC ISSUES:
===============
# HFpEF (EF>55%)
The patient has predominantly right heart failure from atrial
remodeling, likely contributing to her moderate TR. From her
visit with Dr. ___ in ___, good dry weight is 142-145lbs,
and she stayed below that. She had 2+ edema on RLE and 1+ on
LLE, with improvement to 1+ bilaterally. She had 20mg IV Lasix
on ___. Continued home PO Lasix 20mg.
# Paroxysmal Atrial Tachycardia
Not on any anticoagulation. Stayed in sinus. Continued home
atenolol 50mg.
# Hypertension
Continued home atenolol 50mg.
# Seronegative rheumatoid arthritis
Followed by rheum (Dr. ___. Not currently on
hydroxychloroquine 200mg due to possible side effect (diarrhea)
- stopped in ___.
TRANSITIONAL ISSUES:
====================
[ ] F/u with orthopedics for further fracture management - at
time of discharge had follow-up scheduled on ___ with
repeat Xray at that time.
[ ] Recommend strong bowel reg, as required dulcolax PR in
addition to standing senna bid and miralax while on opioid pain
medications.
[ ] Rx for oxycodone prescription on discharge short course,
taper down as able.
[ ] Please repeat BMP for Na monitoring; consider
discontinuation of Lasix. Currently on 1.5L free water fluid
restriction.
[ ] Continue lovenox ppx for 30 days post operatively (date of
ankle surgery ___ unless otherwise specified by orthopedics.
[ ] Activity: NWB in RLE splint.
[ ] Orthopedics recommending against NSAID usage.
Emergency contact: ___ (nephew): ___
Code: DNR/DNI (MOLST signed ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800 MG
oral daily
Discharge Medications:
1. Acetaminophen 650 mg PO QID
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: If no BM following oral,
can give PR
3. Enoxaparin Sodium 40 mg SC Q24H
Continue for 4 weeks
4. OxyCODONE (Immediate Release) 2.5 mg PO Q6H
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID pt may refuse, hold for loose stool
7. Aspirin 81 mg PO DAILY
8. Atenolol 50 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800 MG
oral daily
10. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Trimalleolar ankle fracture, right
Cellulitis, right ankle
SECONDARY DIAGNOSIS:
====================
Hyponatremia
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for pain management of an ankle fracture and
treatment of a possible soft tissue infection around your ankle.
What was done for me while I was in the hospital?
X-rays were taken which showed a right ankle fracture, so you
had a splint placed. Your pain was managed with Tylenol and
Oxycodone. Your possible soft tissue infection of your right leg
was treated with 5 days of antibiotics. You had surgery on ___ to repair your right ankle fracture, which you tolerated
well and improved your pain.
You also were found to have low sodium in your blood, which was
monitored and the amount of water you drink was limited to 1.5L
per day.
What should I do when I leave the hospital?
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for new/or worsening symptoms (fever, chills,
notably increased swelling or pain around your ankle, increased
pain). If you do not feel like you are getting better or have
any other concerns, please call your doctor to discuss or return
to the emergency room.
- Please note any new medications in your discharge worksheet.
- Your appointments are as below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19635420-DS-5
| 19,635,420 | 26,204,311 |
DS
| 5 |
2119-08-21 00:00:00
|
2119-08-21 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of hypothyroidism, ulcerative colitis, adrenal
insufficiency on hydrocort who presents with abdominal pain and
diarrhea x1 week.
Per report she was in her usual state of health until 1 week
prior to presentation. She initially noted that her stomach was
distended and hard. She states this sometimes happens when she
self increases her hydrocortisone but not to this extent. Later
she developed abdominal pain, low grade fevers (100.2) and
nausea. She gave herself stress dose steroids with no benefit.
She has be awaken from sleep with urge to have bowel movement.
She notes that this is different than prior UC flares. Her son
has a cold but no one in family has GI illness. In addition to
distension, pain and diarrhea, she has noted increase fatigue,
nausea but no emesis. She did not some blood in stools. She
takes ibuprofen/acetaminophen with improved pain. She also notes
some myalgias which she states are chronic. No sore throat.
In the ED, initial vitals were: 3 99.8 83 131/87 16 96% RA. They
did u/s without ascites. Guaiac was negative. She was given IVF,
dilaudid, zofran for symptom control. She was given stress dose
steroids. She was tolerating some food and drink but was
admitted for pain control.
Currently, she feels like her cortisol is too low. She cannot
describe why other than nausea and she feels very fatigued. She
wants to eat a pizza and pepsi that she brought in from
admission.
ROS: per above. Positive for low grade fevers, malaise, nausea,
abdominal pain, bloating, blood in stool, some back pain. She
denies emesis, chest pain, shortness of breath, lightheadedness,
headache, vaginal discharge, urinary symptoms or other symptoms.
Of note, she reports allergic reaction to PIV. The reaction was
redness and subjective lip swelling and hives.
Past Medical History:
Ulcerative colitis - per report controlled off medications
Adrenal insufficiency
Hypothyroidism
Lichen planus
ADHD
Cardiomyopathy of pregnancy, per report resolved
Breast augmentation
tubal ligation
CCY
Social History:
___
Family History:
HTN, CHF, CAD
Physical Exam:
Exam on Admission:
Vitals: 98.7, 120/83, 99, 19, 97% RA
Pain: ___
HEENT: MMM
Neck: low JVD
Cardiac: rr, nl rate, no murmur
Lungs: CTAB
Abd: soft, lower quadrant tenderness bilateral, no r/r/g, no
masses
Ext: wwp, no edema
Psych: at times odd affect
Neuro: Alert and oriented, symmetric exam, ambulates without
difficulty
Exam at discharge:
Vitals: AVSS, BM x1 (formed)
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: very benign, soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Somewhat odd affect. Very bubbly at times, at times
tearful.
GU: No foley
Pertinent Results:
___ 02:40PM BLOOD WBC-11.3* RBC-4.66 Hgb-15.7 Hct-44.1
MCV-95 MCH-33.7* MCHC-35.6* RDW-13.4 Plt ___
___ 02:40PM BLOOD Neuts-65.5 ___ Monos-5.0 Eos-4.4*
Baso-0.7
___ 02:40PM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
___ 02:40PM BLOOD ALT-32 AST-34 AlkPhos-71 TotBili-0.2
___ 02:40PM BLOOD Lipase-108*
___ 02:40PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.0 Mg-2.1
___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Stool cultures NGTD
CTAP: 1. No evidence of small or large bowel thickening to
suggest colitis. 2. Fluid-filled ascending colon, given this
finding a mild gastroenteritis would be difficult to excluded in
the correct clinical setting. 3. Status post cholecystectomy,
mild intrahepatic biliary duct dilation is postsurgical.
Brief Hospital Course:
___ with history of UC, adrenal insufficiency who presents with
abdominal pain, nausea, diarrhea. She was admitted to the
medicine service. She had no diarrhea here, and in fact had a
mild constipation requiring bowel regimen for stool. Stool
studies were sent on admission and are NGTD (C diff was refused
given formed specimen). Her CT scan was finalized as no specific
findings. Of note, lipase was mildly elevated but she did not
meet any criteria for pancreatitis (inconsistent symptoms, no
stranding on CTAP, and lipase<3x ULN). Given continued abdominal
pain, and at the patient's request, GI consult was obtained.
Their note is in OMR, but overall conclusions were that she
might have gastroenteritis with post-infectious IBS, versus an
entirely functional process. She was given Bentyl with marked
improvement, tolerated a regular diet, and requested to be
discharged today.
She also endorsed some epigastric discomfort, and it was thought
that this might reflect some NSAID and steroid induced
gastritis; she was advised to avoid NSAIDS.
Though CT was negative, given nonspecific symptoms with
abdominal distension, she was advised to followup with her GYN
doctor to make sure there was no gynecologic process
contributing to her symptoms; she told me she had a followup
appointment for next week scheduled.
# Abdominal pain
# Diarrhea
# Nausea without vomiting: As above
- Continue Bentyl QID
- Minimize NSAIDs
- Continue PRN bowel regimen
- Outpatient followup with PCP scheduled at ___ as below
- Outpatient followup with GI as needed
# Adrenal insufficiency: She was seen by the endocrine service,
who adjusted her steroid dosing. She was not thought to be in
adrenal crisis.
# Hypothyroidism: Continue home levothryoxine.
Transitional:
- Followup as below
- Followup with GYN per her schedule
- She was full code while here
Billing: >30 minutes spent coordinating her discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Hydrocortisone 5 mg PO TID
3. Escitalopram Oxalate 20 mg PO DAILY
4. Adderall XR (dextroamphetamine-amphetamine) 20 mg oral daily
5. Calcium Carbonate 1000 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
oral daily
8. DHEA (prasterone (dhea);<br>prasterone (dhea)-calcium carb)
unknown units oral daily
9. coenzyme Q10 unknown units oral daily
10. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Hydrocortisone 5 mg PO TID
___, take 12.5mg in AM, 7.5mg at noon, and 5mg at 4PM.
___, please take your usual doses.
3. Levothyroxine Sodium 75 mcg PO DAILY
4. TraZODone 100 mg PO QHS:PRN insomnia
5. DiCYCLOmine 20 mg PO QID
RX *dicyclomine 20 mg 1 tablet(s) by mouth four times daily Disp
#*60 Tablet Refills:*0
6. Adderall XR (dextroamphetamine-amphetamine) 20 mg ORAL DAILY
7. B Complex (vit B2-niac-B-6-B12-D-panth;<br>vitamin B complex)
0 ORAL DAILY
8. Calcium Carbonate 1000 mg PO DAILY
9. coenzyme Q10 0 units ORAL DAILY
10. DHEA (prasterone (dhea);<br>prasterone (dhea)-calcium carb)
0 units ORAL DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Diarrhea
Adrenal insufficiency
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and diarrhea. You were
seen by Endocrinology, and treated for adrenal insufficiency
with extra steroids given the extra stress on your body. You
were seen by GI, and were given Bentyl, which improved your
symptoms. No obvious cause of your abdominal pain or diarrhea
was found, but your symptoms had mostly resolved and you were
eating a regular diet by the time of discharge. You should
follow up with your PCP and ___. You also told me
you have a followup with your GYN to make sure there is no GYN
reason for your symptoms.
Followup Instructions:
___
|
19635420-DS-6
| 19,635,420 | 23,276,256 |
DS
| 6 |
2121-01-14 00:00:00
|
2121-01-14 14:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with type 2 polyglandular autoimmune syndrome (___'s
thyroiditis, Addison's, type 1 DM), Raynaud's syndrome,
ulcerative colitis presents with hypoglycemia. She was recently
diagnosed with DM1 without DKA a few weeks ago by antibody
testing (A1C in ___ was 6%), and was on Lantus 10U daily and
Novolog SSI. Her sugars would run as high as ___ to low
200s but in the late afternoon would drop to ___ with symptoms.
She usually starts getting symptoms with sugar <80. She has
proven exquisitely sensitive to SSI (with 1U novolog will go
from "270 to 71, or 176 to 129, or ___ to 99") So she stopped
her SSI Novolog, but has not stopped her Lantus. She takes 17.5
- 20mg hydrocortisone daily (10mg AM, 5mg mid-day, 2.5mg ___,
and 2.5mg 9p ish). She has a pet, ___, who is a low cortisol
sensing dog, and he is trained to lick her hand when he senses
her cortisol is running low. He will often do this about 30 min
prior to her sugar dropping. She is here for monitoring of
blood sugar.
ROS: She reports weight gain (40lb), and has had intermittent
abdominal pain, nausea, non-bloody diarrhea at times, with
normalish stool other times, without chest pain, SOB. She has
chronic HA without visual field disturbance. She is amenorrheic
s/p hysterectomy due to uterine fibroids. She feels her hands
and face are larger ("fatter") and reports jewelry no longer
fits her about the fingers (rings) or wrist (bracelet). She
feels her breasts are larger and engorged (as if I were
pregnance) though denies galatorrhea at any time.
In the ER her VSS without fever. Chem 7 was normal except for
gluc 62. She was given 12.5gm of D50, IVNS, and hydrocortisone
100mg IV. A CBC was normal. UA was normal without ketones.
Her Gluc in ER:
___ 18:47 96 (___)
___ 20:20 62 (serum)
___ 21:03 63 (___)
___ 22:09 83 (___)
She ordered a pizza in the ER and had a few bites. She also had
a pepsi. She states she needs something for her abdominal pain.
Past Medical History:
- Type 2 polyglandular autoimmune syndrome
* Adrenal insufficiency
* ___'s thyroiditis
* Type 1 DM
- Ulcerative colitis - per report controlled off medications
- Raynaud's
- Lichen planus
- ADHD
- Cardiomyopathy of pregnancy, per report resolved
- Breast augmentation
- Tubal ligation
- CCY
Social History:
___
Family History:
HTN, CHF, CAD
Physical Exam:
Exam on admission -- unchanged at discharge
Vitals - AVSS
HEENT - Anicteric, OP clear, neck supple, no ___
LUNGS - CTA bilat
COR - RRR no MRG
ABD - soft, NT/ND no HSM, no masses, no R/G
EXT - no edema, no C/C
SKIN - no rash
NEURO - alert, oriented, fluent speech, nl cognition, CN2-12
intact, no sensorimotor deficits,
PSYCH - calm, odd affect
Pertinent Results:
Labs on admission:
___ 08:20PM WBC-9.4 RBC-4.46 HGB-14.4 HCT-42.1 MCV-94
MCH-32.3* MCHC-34.2 RDW-12.8 RDWSD-43.8
___ 08:20PM PLT COUNT-282
___ 08:20PM NEUTS-54.2 ___ MONOS-8.0 EOS-5.1
BASOS-1.4* IM ___ AbsNeut-5.09 AbsLymp-2.84 AbsMono-0.75
AbsEos-0.48 AbsBaso-0.13*
___ 08:20PM GLUCOSE-62* UREA N-7 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 10:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:13PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-4
___ 10:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:13PM URINE UCG-NEGATIVE
Labs at discharge
___ 06:30AM BLOOD WBC-6.3 RBC-3.76* Hgb-12.1 Hct-37.2
MCV-99* MCH-32.2* MCHC-32.5 RDW-13.2 RDWSD-48.3* Plt ___
___ 06:30AM BLOOD ALT-53* AST-28 AlkPhos-101 TotBili-<0.2
___ 06:55AM BLOOD Albumin-3.8 Calcium-8.6 Phos-2.8 Mg-2.2
___ 06:55AM BLOOD FSH-3.0 LH-3.6 Prolact-17
___ 06:55AM BLOOD CRP-2.1
___ 06:55AM BLOOD GROWTH HORMONE-HUMAN-PND
___ 06:30AM BLOOD Glucose-104*
Imaging studies
KUB
1. Air and food debris distending the stomach with a large air
fluid level, which is displacing the transverse colon.
2. Moderate stool in the large bowel. No evidence of
obstruction.
Abdominal ultrasound
Normal abdominal ultrasound
Pelvic ultrasound
Status post hysterectomy. Normal ovaries bilaterally.
Brief Hospital Course:
___ with a complicated PMH purported type 2 polyglandular
autoimmune syndrome (___'s thyroiditis, Addison's, RECENT
diagnosis of type 1 DM), Raynaud's, reported ulcerative colitis
on no medications, who presents with hypoglycemia on daily
Lantus (but off SSI).
Regarding her hypoglycemia, it was felt due to overly high doses
of insulin in the context of the DM1 Honeymoon period. She was
noted to be particularly sensitive to Novolog insulin, with 1U
leading to nearly 200 point glucose drop by around 2 hours.
Endocrinology was consulted and recommended Lantus 4U daily with
Novolog 1U when FSBG >300 and 2U when FSBG >500; she did very
well with this regimen.
She additionally manifest numerous other complaints, including
nausea with vomiting, diarrhea, abdominal pain, abdominal
distension, weight gain, breast enlargement, and ovarian pain.
She demonstrated no episodes of emesis nor diarrhea here (in
fact had hard stool), and a workup for these complaints with
labs and imaging was generally negative, though note was made of
moderate fecal loading on KUB. This parallels a similar
presentation several months ago when I cared for her; refer to
my discharge summary from that stay for additional detail. She
was comfortable with deferring further workup for these issues
to the outpatient setting.
It was thought that some of her abdominal complaints could
reflect gastritis in setting of NSAID overuse, and she was
encouraged to withhold NSAIDS and take PPI.
Diagnoses/problems
# Hypoglycemia
# DM type 1
# Chronic adrenal insufficiency
# Hypothyroidism
# Ulcerative colitis
# Anxiety
# Abdominal pain
# Weight gain
Billing: >30 minutes spent coordinating discharge from hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 10 Units Breakfast
2. Hydrocortisone 5 mg PO ASDIR
3. Tirosint (levothyroxine) 75 mcg oral DAILY
4. Vitamin D 5000 UNIT PO DAILY
5. Liothyronine Sodium 50 mcg PO ASDIR
6. ClonazePAM 1 mg PO BID:PRN anxiet
7. Escitalopram Oxalate 30 mg PO DAILY
8. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
9. TraZODone 100 mg PO QHS
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Promethazine 25 mg PO Q6H:PRN nausea
Discharge Medications:
1. ClonazePAM 1 mg PO BID:PRN anxiet
2. Escitalopram Oxalate 30 mg PO DAILY
3. Hydrocortisone 5 mg PO BID
4. Hydrocortisone 10 mg PO DAILY
5. Glargine 4 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Liothyronine Sodium 50 mcg PO ASDIR
7. TraZODone 100 mg PO QHS
8. Vitamin D 5000 UNIT PO DAILY
9. Tirosint (levothyroxine) 75 mcg oral DAILY
10. Promethazine 25 mg PO Q6H:PRN nausea
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
Do not exceed 6 tablets/day
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
Early type I diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with hypoglycemia. You were evaluated by
Endocrinology, who adjusted your insulin dosing. You tolerated
these adjustments very well with resolution of the hypoglycemia.
You complained of various other issues while here including
diarrhea, upper abdominal discomfort, abdominal bloating,
ovarian pain, weight gain, and breast swelling. A workup
including ultrasounds of the abdomen and the ovaries, laboratory
studies, and an X ray of the abdomen was very reassuring. There
was no loose stool observed here. You are encouraged to follow
up with your PCP, ___, and gynecologist
for further evaluation of these complaints.
It was discussed that you do use a fair amount of NSAID type
medications for pain, and that these can cause irritation of the
stomach lining which can lead to nausea, upper abdominal
bloating, and pain in addition to reflux symptoms. You should
consider cutting back on these medications and try taking an
acid reducer such as Prilosec on a regular basis to see if this
improves your symptoms.
Followup Instructions:
___
|
19635798-DS-19
| 19,635,798 | 26,800,932 |
DS
| 19 |
2142-04-22 00:00:00
|
2142-04-22 10:40:00
|
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:
___ with acute onset of RUQ pain about 10 hours prior to
presentation. She has been feeling some vague RUQ discomfort
for
the past ___ weeks, as well as exacerbation of her GERD
symptoms.
She did yoga and had a small meal yesterday afternoon, after
which she developed severe epigastric pain that migrated to the
RUQ, and emesis of her meal. The epigastric pain resolved, but
the RUQ pain remained, and she presented to the ED for further
evaluation. She denies similar symptoms previously, as well as
fever, chills, diarrhea.
Past Medical History:
PMH: hypertension, GERD
PSH: none
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals: T 97.7, HR 78, BP 150/84, RR 18, O2 100 RA
Gen: a&o x3, nad
CV: rrr, no murmur
Resp: cta bilat
Abd: soft, ND, +BS; mildly ttp RUQ; -___ sign
Extr: warm, well-perfused, 2+ pulses
On discharge:
Vitals: T 96.5, HR 59, BP 120/77, RR 18, O2 99 RA
Gen: a&o x3, nad
CV: rrr, no murmur
Resp: cta bilat
Abd: soft, ND, +BS, appropriately tender at lap incision sites.
Surgical dressings c/d/i.
Extr: warm, well-perfused, 2+ pulses
Pertinent Results:
___ LIVER OR GALLBLADDER US (SINGLE ORGAN)
IMPRESSION: Gallstones, without evidence of acute cholecystitis.
___ 01:00AM WBC-7.6 RBC-5.36 HGB-12.1 HCT-39.6 MCV-74*
MCH-22.6* MCHC-30.5* RDW-14.2
___ 01:00AM NEUTS-83.6* LYMPHS-13.2* MONOS-2.3 EOS-0.4
BASOS-0.5
___ 01:00AM PLT COUNT-151
___ 01:00AM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-2.7
MAGNESIUM-1.9
___ 01:00AM cTropnT-<0.01
___ 01:00AM LIPASE-15
___ 01:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-84 TOT
BILI-0.6
___ 01:00AM GLUCOSE-121* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
___ 01:23AM K+-3.7
___ 03:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:05AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:40AM ___ PTT-26.5 ___
Brief Hospital Course:
Ms. ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. She
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She we subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Overnight after surgery, she had
borderline urine output, as well as some mild nausea. She was
bolused 500 ml of IVF and given IV antiemetics for this. Her
urine output responded well and remaianed adequate thereafter
and her nausea resolved. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain
or vomiting. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
Her pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic on ___.
Medications on Admission:
HCTZ 25', lisinopril 20', omeprazole 20'
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Vicodin ___ mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: may cause sedation
.
Disp:*30 Tablet(s)* Refills:*0*
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incisions will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19635953-DS-6
| 19,635,953 | 22,671,153 |
DS
| 6 |
2180-11-03 00:00:00
|
2180-11-03 18:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
Ms. ___ is a ___ y/o female with a hx of UGIB ___ duodenal
ulcers and EtOH liver disease who was transferred from ___
___ due to altered mental status.
.
As per her sister, she was recently admitted to ___
___ for an upper Gi bleed. She was discharged to ___
___ facility for a couple of days. When she came home from
detox, she was mildly confused. over the next few ___ she
become progressively more confused and had significant decrease
in her functional status. Also having frequent diarrhea. Her
sister took her to her PCP who promptly sent her to the ED. In
the ED at ___ (per report) it was thought her mental status
may be related to her liver disease and she was transferred to
___.
.
In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT
which was negative for an acute process. There was no ascitic
fluid that was visulized therefore could not perform a
diagnostic tap. She was given lactulose and ceftriaxone. ? given
narcan with improvement of mental status.
.
Overnight, Cr was found to be 5.1 with BUN of 15. WBC 22. U/A
suggestive of UTI. She was given 100g albumin for HRS and
ceftriaxone for UTI, ? SBP. This morning on rounds, she was
thought to be acutely confused, and transfer to the MICU
transfer was requested for altered mental status and possible
endoscopy. On evaluation this morning, she was confused and
unable to give a history. She denied having any discomfort. She
oriented to self but not to place and time.
.
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.
Past Medical History:
Alcohol abuse
Social History:
___
Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 132/74 96 20 99/ra
GENERAL - NAD, drowsy, confused
HEENT - scleral icterus
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, mild
expiratory wheezing, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - several punctures in volar arms with surround
erythmea, ? injection drug sites vs. prior IVs. bilateral ___ 3+
edema
NEURO - AAOx1, mild left facial droop, speech fluent, no
pronator drift
.
Discharge Exam:
Afebrile, HD stable, on RA
GENERAL: Well appearing ___ M. Comfortable, appropriate and in
good humor. Mildly Jaundiced.
HEENT: Sclera icteric though improved. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normoactive BS. Distended but Soft, non-tender to
palpation, Tympanic to percussion, No HSM or tenderness.
EXTREMITIES: WWP, trace LLE (reduced from baseline).
NEURO: A and O x 3; approrpiately mentating; motor and sensory
grossly intact
Pertinent Results:
ADMISSION LABS:
___ 05:40PM BLOOD WBC-22.4* RBC-3.18* Hgb-10.4* Hct-33.0*
MCV-104* MCH-32.9* MCHC-31.7 RDW-19.2* Plt ___
___ 05:40PM BLOOD Neuts-74* Bands-0 Lymphs-16* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1*
___ 05:40PM BLOOD ___ PTT-44.8* ___
___ 05:40PM BLOOD Glucose-81 UreaN-15 Creat-5.2* Na-131*
K-3.2* Cl-97 HCO3-16* AnGap-21*
___ 05:40PM BLOOD ALT-52* AST-150* AlkPhos-265*
TotBili-4.8* DirBili-4.0* IndBili-0.8
___ 05:40PM BLOOD Lipase-23
___ 05:40PM BLOOD Albumin-2.3* Calcium-8.5 Phos-3.6 Mg-2.2
___ 02:37PM BLOOD Ammonia-147*
___ 06:20AM BLOOD Osmolal-288
___ 06:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
___ 05:40PM BLOOD HCG-<5
___ 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:20AM BLOOD HCV Ab-NEGATIVE
___ 03:06AM BLOOD Type-ART pO2-90 pCO2-26* pH-7.42
calTCO2-17* Base XS--5 Intubat-NOT INTUBA
___ 05:51PM BLOOD Glucose-77 Lactate-1.7 Na-132*
___ 03:06AM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-96
___ MetHgb-0
___ 03:06AM BLOOD freeCa-1.14
.
Discharge Labs:
___ 07:15AM BLOOD WBC-26.7* RBC-2.46* Hgb-7.8* Hct-25.5*
MCV-104* MCH-31.6 MCHC-30.6* RDW-18.4* Plt ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD Glucose-92 UreaN-36* Creat-1.3* Na-136
K-4.3 Cl-105 HCO3-17* AnGap-18
___ 07:15AM BLOOD ALT-25 AST-88* AlkPhos-151* TotBili-3.5*
___ 07:15AM BLOOD Albumin-2.7* Calcium-8.1* Phos-5.5*
Mg-1.7
.
MICRO:
BCx negative x4
UCx negative x2
C.DIFF NEGATIVE
.
IMAGING:
___ CT HEAD TECHNIQUE: Axial MDCT images were acquired of the
head without contrast and reformatted into coronal and sagittal
planes.
FINDINGS:
The exam is somewhat limited by patient motion, although repeat
scans were
performed. There is no intracranial hemorrhage, extra-axial
collection, or
mass effect. The ventricles and sulci are normal in size and
configuration. Gray matter/white matter differentiation is
preserved. The orbits are normal appearing. The soft tissues are
unremarkable. There is an air-fluid level within the left
maxillary sinus, and mucosal thickening of ethmoid air cells.
The frontal sinuses are clear. An air-fluid level is seen in the
sphenoid sinus with aerosolized debris. The mastoid air cells
and middle ear cavities are clear. There is no osseous
abnormality.
IMPRESSION:
1. No acute intracranial process.
2. Air-fluid levels in multiple paranasal sinuses.
.
___ LIVER ULTRASOUND: FINDINGS: The liver is diffusely coarse
and echogenic consistent with history of liver disease. No focal
lesions are seen. The gallbladder appears normal. The common
bile duct is mildly dilated measuring up to 8 mm. No definite
stone is seen within the common bile duct. To and fro flow is
seen within the main portal vein. There is no ascites. The right
kidney measures 13.9 cm in the long axis and is normal in
appearance without hydronephrosis or stones.
IMPRESSION:
1. Diffusely echogenic liver consistent with history of
alcoholic hepatitis.
2. To and fro flow within the main portal vein without portal
vein
thrombosis.
3. Common bile duct measures up to 8 mm and is thus dilated.
MRCP/ERCP could better evaluate for an obstructing cause.
.
___ RENAL ULTRASOUND: The right kidney measures 12.1 cm. The
left kidney measures 12.5 cm. There is no hydronephrosis, stones
or masses. The bladder is only minimally distended and cannot be
assessed. Small portion of a urinary catheter is seen.
IMPRESSION: Normal renal sonogram
.
___ HIDA SCAN: RADIOPHARMACEUTICAL DATA: 4.2 mCi Tc-99m DISIDA
___ HISTORY: Common duct dilation, leukocytosis, and
right upper quadrant pain. Evaluate for biliary pathology.
METHODS: Following the intravenous injection of tracer, serial
one-minute images of tracer uptake into the hepatobiliary system
were obtained for 75 minutes. A delayed static image was
obtained at 5.5 hours. Images of the injection site were also
acquired.
INTERPRETATION: Serial images over the abdomen show poor uptake
of tracer into the hepatic parenchyma in a homogeneous pattern.
At 15 minutes, the small bowel is visualized, although no tracer
uptake is seen within the gallbladder throughout the first 75
minutes. The patient returned to the nuclear medicine suite
after 5.5 hours for additional imaging, which revealed tracer
activity within the gallbladder.
IMPRESSION:
1. Diffusely poor tracer uptake throughout the liver is
consistent with poor hepatocellular function.
2. Tracer activity within the gallbladder on delayed images
excludes the
diagnosis of acute cholecystitis.
2. Excretion of tracer into the small bowel excludes the
diagnosis of complete biliary obstruction.
.
___ CXR HISTORY: Alcoholic hepatitis. Aspiration event.
IMPRESSION: AP chest compared to ___:
Consolidation in the perihilar left lung and in the right upper
lung extending to the apex is readily explained by massive
aspiration. A smaller region of consolidation may be present in
the right lung projecting behind the lower pole of the right
hilus. Mild cardiomegaly and mediastinal vascular engorgement
have increased suggesting cardiac decompensation. Dr. ___
was paged.
.
CXR ___ Bilateral upper lobe consolidation is slightly more
pronounced today than yesterday. Whether this is due to
progression of pneumonia or deposition of early edema in a
region of pre-existing pneumonia is difficult to say since the
mediastinal veins are dilated in the supine position. Heart size
is top normal, and there may be mild pulmonary vascular
engorgement, but no clear edema elsewhere. There is no
appreciable pleural effusion. Nasogastric tube passes into the
stomach and out of view
.
Sigmoidoscopy ___
- Polyp at 8cm in the rectum
- Polyps at the ranging distance from 18 cm to 28 cm in the
distal sigmoid colon
- Grade 2 internal hemorrhoids
- Otherwise normal sigmoidoscopy to splenic flexure
- Recommendations: Patient will need colonoscopy for removal of
polyps when her alcoholic hepatitis improves and her INR is less
than 1.5.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of upper GI
bleed (UGIB) secondary to duodenal ulcers and alcoholic liver
disease who was transferred from ___ due to
altered mental status.
.
ACTIVE PROBLEMS BY ISSUES:
.
# Alcoholic Hepatitis: Hepatic encephalopathy, jaundice, LFTs
with alcoholic picture, viral studies were negative. She has
signficant synthetic dysfunction as well with a discriminant
function of 51 on admission. Steroids were deferred initially
for possible acute hepatitis since her LFTs and bilirubin were
improving in the MICU with fluids. Hepatitis B and C virus
serologies negative. On floor tube feeds were started to augment
nutrition and improve hepatitis. NGT was accidentally self
removed. Nutrition reconsulted and felt she could take adequate
caloric intake to treat alcoholic hepatitis and so NGT was not
replaced. Discriminant function 36 on discharge but patient
clinically much improved, walking around floor, jaundice
improving, POing well with downtrending T.Bili <4 on discharge.
Patient discharged in improved condition agreement with plan to
abstain from alcohol completely. She was discharged home with
outpatient alcohol rehabilitation.
.
# Encephalopathy: The patient was transferred to the MICU for
altered mental status (AMS); likely due to hepatic
encephalopathy. A lumbar puncture was attempted, but
unsuccessful. She received Narcan in the ED to which there was
a questionable improvement in her mental status. She was given
lactulose and rifaxamin, aiming for 4 bowel movements/day and
was also started on empiric antibiotic coverage since she had a
leukocytosis with the AMS including acyclovir, vancomycin,
ampillicin, and ceftriaxone. The patient then had a right upper
quadrant ultrasound that showed dilated common bile duct, so she
underwent a HIDA scan which ruled out cholangitis as a cause of
her AMS and leukocytosis. At that point, ampicillin was
discontinued and the patient was continued on vanc/acyclovir,
flagyl/ceftriaxone was added for intra abdominal pathology.
Antibiotics were changed to Vanc/Zosyn after she developed PNA.
The patient also has a drinking history and was started on
thiamine. As the patient's mental status slowly improved, the
acyclovir was stopped, as the concern for encephalitis lessened.
On arrival to the floor her mental status continued to improve
with lactulose and Rifaximin. He encephalopathy was attributed
to alcoholic hepatitis and continued to improve throughot
duration of stay.
.
# Acute Renal Failure: The patient was found to be in ARF
(baseline creatinine is around 0.9) and presented with creat
5.2. FeNa of 0.22 consistent with prerenal etiology and muddy
brown casts were found in the urine sediment suggesting acute
tubular necrosis (ATN). With significant liver dysfunction
hepatorenal syndrome (HRS) was of concern. Renal consulted but
thought that the etiology was pure ATN. She underwent a renal
ultrasound which was normal and an albumin challenge which ruled
out hepatorenal syndrome. Creatinine continued to improve after
albumin was given and with improvement in hepatitis.
.
# Aspiration pneumonia: She developed aspiration pneumonia on
___ with a rising leukocytosis. She was fed with a
___ tube and continued on vanc/zosyn. She completed an
HCAP course with Vanc/Zosyn and she remained on RA throughout
duration of floor stay.
.
# Leukoctosis: Patient with profound leukocytosis which
uptrended initially and remained elevated. Initial concern was
for HCAP which was adequately treated. C.Diff returned negative
multiple times. Leukocytosis remained elevated despite HCAP
treatment and so WBCs thought most likely related to alcoholic
hepatitis rather than infectious etiology. Cultures negative
otherwise in work up.
.
# Upper GI bleed (UGIB): Presented with bright red blood per
rectum (BRBPR), and a Hematocrit trending down 33 -> 30. Upon
further questioning, she reported that she was having her
menses. Her hematocrit remained stable and she did not recieve
any blood transfusions. This was initially stable until 2 days
prior to discharged when on the floor she began having GIB.
Patient again felt this was menses though rectal exam with
internal hemorrhoids. Flex Sig was completed given concern for
rectal bleed which showed grade 2 hemorrhoids and multiple
recto-sigmoid polyps. Polyps were not removed because of
elevated INR and tenuous Alc Hep. Repeat colonoscopy deferred to
outpatient after improvement in hepatitis and coagulopathy.
.
# Anion Gap Acidosis: She is noted to have a gap of 18 upon
admission labs. Her lactate was within normal limits, no osmolar
gap. Given BUN unlikely to be uremia, but possible contribution
of acute renal failure. Also possible alcoholic/starvation
ketosis. Gap closed and remained stable after transfer to floor
from MICU.
.
# Sodium imbalance: She likely had hypervolemic hyponatremia due
to liver dysfunction. She was maintained on a fluid restricted
diet. She later developed hypernatremia while she was on tube
feeds only for aspiration. This was treated with free water
flushes through the NG tube. After hepatitis and HCAP
improved/resolved her Na remained stable requiring no further
intervention.
.
# Macrocytic Anemia: With significant alcohol use she is likely
either folate or B12 deficient.
.
# Peptic ulcer disease (PUD): she has a history of duodenal
ulcers and was continued on pantoprazole.
.
TRANSITIONAL ISSUES:
- Colonoscopy needs to be completed as an outpatient with
removal of colonic polyps after INR improves
- Patient counseled extensively on the importance of alcohol
abstainence and she is agreeable with plan. Should continue
reinforcing abstinence
- Consider Baclofen for alcohol abuse prophylaxis
Medications on Admission:
Oxycodone 5mg
Vitamin B12
Ondansetron 4mg
Pantoprazole 40mg daily
Discharge Medications:
1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for rectal irritation.
Disp:*1 tube* Refills:*0*
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1800 ML(s)* Refills:*1*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every twelve (12) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
hepatic encephalopathy
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the hospital because you were more confused
than your baseline and there was concern that you had bleeding
from your intestines. We did not find that there was any
significant bleeding in your intestines and the levels of your
blood stayed steady. You do have a hemorrhoid which bleeds a
little bit when you have bowel movements. Flex Sigmoidoscopy
performed showed polyps in your sigmoid colon which should be
followed up after you are discharged.
.
For your confusion, we think that it relates to your liver
disease. When your liver disease progresses, a condition called
cirrhosis, your body builds up toxic substances. You were
treated with lactulose to make you have bowel movements which
will remove these toxic substances.
.
Finally, you developed a pneumonia because when you swallow the
food sometimes goes into your lungs. This is called aspiration.
You have to eat very slowly to help the food go into your
stomach not your lungs.
.
The following changes were made to your medications:
- START Folic Acid 1mg Daily
- START Thiamine 100 mg DAILY
- START Vitamin D 400 UNIT DAILY
- START Hydrocortisone cream: apply rectally as needed for
irritation
- CONTINUE Pantoprazole
- START Lactulose 30 mL Twice daily
- START Rifaximin 550 mg twice daily
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It is also very important that you have a colonoscopy to
evaluate polyps in your colon.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
___
|
19636128-DS-19
| 19,636,128 | 29,716,107 |
DS
| 19 |
2197-01-19 00:00:00
|
2197-01-20 00:27:00
|
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 ___ w/ h/o HTN, HLP, stomach adenocarcinoma s/p
total gastrectomy ___ who presents with severe upper abdominal
pain x 2 days. Came on gradually and worsened with meals. Some
nausea but no vomiting, diarrhea, or constipation and has been
able to maintain some PO intake. She had a bowel movement today
and continues to have flatus. She denies melana, hematochezia,
dysphagia. Denies fevers, chills, sick contacts, unusual foods.
.
In the ED initial VS were 10 97.1 78 173/94 16 100%. Labs
significant for leukocytosis and lipse of 175. ABD CT with PO/IV
contrast was significant for hazy appearance of peripancreatic
fat suggesting pancreatitis. Patient treated with IVF and
morphine with improvment but recurrent pain with PO intake so
transferred to medicine for further evaluation.
.
On the floor, patient reports feeling well with resolution of
pain following morphine in ED. Minimally nauseous.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-hypertension
-stage IB stomach adenocarcinoma status post total gastrectomy,
-hyperlipidemia
-migraine headaches
-Varicose veins (symptomatic), venous stasis ulcerations,
-vertigo
-osteoarthritis
- multinodular goiter.
Social History:
___
Family History:
Mother with thyroid disease, early MI
Physical Exam:
ADMISSION
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, somewhat cachectic appearing woman in
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, minimal TTP
largerly in epigstrium no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE
98.0 143/68 59 18 100RA
General: Alert, oriented in no acute distress
HEENT: MMM
Neck: JVP not elevated
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
tenderness, rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION
___ 05:50AM BLOOD WBC-14.8*# RBC-4.03* Hgb-13.2 Hct-40.6
MCV-101* MCH-32.7* MCHC-32.4 RDW-12.9 Plt ___
___ 05:50AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-142
K-3.6 Cl-106 HCO3-28 AnGap-12
___ 05:50AM BLOOD Albumin-4.2 Calcium-9.1 Phos-2.9 Mg-1.8
.
PERTINENT
___ 05:50AM BLOOD ALT-33 AST-27 AlkPhos-84 TotBili-0.7
___ 05:50AM BLOOD Lipase-175*
___ 05:59AM BLOOD Lactate-0.9
___ 07:54AM URINE Color-Straw Appear-Clear Sp ___
___ 07:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 07:54AM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
.
DISCHARGE
___ 06:40AM BLOOD WBC-8.9 RBC-3.56* Hgb-11.4* Hct-35.8*
MCV-101* MCH-32.1* MCHC-31.8 RDW-12.9 Plt ___
___ 06:40AM BLOOD Glucose-75 UreaN-8 Creat-0.6 Na-143 K-3.4
Cl-104 HCO3-32 AnGap-10
___ 06:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
.
CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
1. Hazy appearance of fat suggesting ill-defined fluid and
inflammation about
the pancreas, duodenum and mesenteric root most suggestive of
pancreatitis;
correlation with other clinical factors is recommended.
2. No definite evidence for disease recurrence or metastases.
3. Small cystocele.
4. Widespread vascular calcifications and cardiomegaly.
Brief Hospital Course:
Ms ___ is a ___ w/ h/o HTN, HLP, stomach adenocarcinoma s/p
total gastrectomy ___ who presented with severe upper abdominal
pain x 2 days.
# Pancreatitis
The patient presented with epigastric abdominal pain with
leukocytosis, mildly elevated lipase, and ___
inflammation on CT consistent with pancreatitis. While there was
some concern for perforated ulcer given aberrant anatomy s/p
gastrectomy, this seemed unlikely based on CT scan results. In
addition, there was no note of gallbladder pathology on CT.
Ultimately the definite cause of her pancreatitis remained
unclear. Review of medications revealed no potential causative
agents, and no note of hypercalcemia or hypertriglyceridemia.
Nonetheless, the patient was treated with supportive care,
including IV fluids, pain control and bowel rest. She improved
rapidly and was tolerating a regular diet without abdominal pain
prior to discharge.
.
# HTN
BP was initially ranging in low 100s/50-60s. Her
antihypertensive was held in this setting. Her blood pressures
subsequently normalized and she was discharged on her home
Verapamil.
.
# GERD
Continued omeprazole.
.
# B-12 deficiency
Due to gastrectomy. H/H was at baseline. Continued cobalamine.
.
TRANSITION OF CARE
-Patient will follow up with PCP upon discharge.
-Patient maintained Full code status throughout her course.
-No studies pending at the time of discharge.
Medications on Admission:
CYANOCOBALAMIN (VITAMIN B-12) [NASCOBAL] - 500 mcg Spray,
Non-Aerosol - 1 spray to a single nostril once a week
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 Tablet(s) by mouth three
times a day as needed for anxiety, sleeplessness
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
VERAPAMIL - 80 mg Tablet - 3 Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN - 160 mg/5 mL Suspension - 4 teaspoon by mouth
every 6 hours for pain
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth daily
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth dailt
Discharge Medications:
1. cyanocobalamin (vitamin B-12) *NF* 500 mcg NU 1/week
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety, insomnia
3. Omeprazole 20 mg PO DAILY
4. Verapamil 240 mg PO ONCE Duration: 1 Doses
5. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN pain
6. Ferrous Sulfate 325 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital for abdominal pain. You were
found to have some mild inflammation of your pancreas. We
treated you with some pain medications and gave you IV fluids,
and you improved. You were gradually able to eat without having
pain and continued to feel well. You should avoid fatty foods
for the next few days to avoid any pain, but you may continue
with your regular diet thereafter. Please follow up with your
primary care doctor to ensure that you continue to do well.
No changes were made to your medications. Please continue taking
all of your medications as previously prescribed. It was a
pleasure taking care of you.
Followup Instructions:
___
|
19636128-DS-22
| 19,636,128 | 21,696,977 |
DS
| 22 |
2202-05-17 00:00:00
|
2202-05-17 18:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain x24 hours
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of total gastrectomy for adenocarcinoma
in ___ without evidence of disease recurrence, hypertension,
migraines, multinodular goiter, pancreatitis ___ presenting
with
abdominal pain ×24 hours.
History is obtained from pt's daughters at bedside. She
described
abdominal bloating the day prior to presentation. She describes
abdominal pain as bloating, which interfered with sleeping the
night prior to presentation, "like a gas attack." She has had
intermittent diarrhea, not daily, one episode in a day only.
Stools were not bloody. She denied F/C, nausea, vomiting. She
had
a similar episode years ago, diagnosis was not clear.
In the ___ ED:
Vital signs 97.7, 67, 141/72, 100% on room air
Exam remarkable for marked tenderness with involuntary guarding
and rebound tenderness
Labs notable for WBC 19.2->14.8, hemoglobin 9.5->7.5, platelets
259->221, lactate 1.4, creatinine 0.6, lipase 441, ALT 35, AST
31, alk phos 83, T bili 1.4, INR 1.2
UA with trace leuk esterase, positive nitrites, 15 WBC, few
bacteria, ___bdomen and pelvis with contrast raise concern for distended
gallbladder with mild amount of nonspecific surrounding free
fluid and possible hyperenhancement of the adjacent liver
parenchyma, recommend clinical correlation for possibility of
acute cholecystitis.
Right upper quadrant ultrasound was without cholelithiasis or
acute cholecystitis, stable moderate intrahepatic biliary
dilation, 3 mm nonobstructing left kidney stone
Case was reviewed with ERCP service, recommended consideration
of
CC Y, no indication for ERCP, may consider MRCP
Discussed with surgery, low suspicion for acute cholecystitis or
cholelithiasis
She received vancomycin, Zosyn, morphine sulfate, Zofran,
Tylenol, IV fluids
On arrival to the floor, she reports feeling "better." She
describes improvement in abdominal pain, which has now resolved.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
HTN
T2aN0 adenocarcinoma s/p total gastrectomy ___
migraines
vertigo
OA
multinodular goiter
pancreatitis ___
Social History:
___
Family History:
Mother with thyroid disease, early MI
Physical Exam:
ADMISSION EXAM
VS: 97.8 PO 120 / 67 62 18 99 RA
GEN: pleasant, elderly female, lying in bed, alert and
interactive, comfortable, no acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, dentures in place
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, TTP at RLQ, without rebounding or guarding,
nondistended with hypoactive bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: A&O to person, place, and date, strength and sensation
grossly intact
PSYCH: normal mood and affect
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
SKIN: No rashes or ulcerations noted
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 08:40AM WBC-19.2*# RBC-2.69* HGB-9.5* HCT-29.1*
MCV-108* MCH-35.3* MCHC-32.6 RDW-14.5 RDWSD-55.2*
___ 08:40AM NEUTS-82.6* LYMPHS-9.4* MONOS-6.5 EOS-0.4*
BASOS-0.2 NUC RBCS-0.1* IM ___ AbsNeut-15.83*#
AbsLymp-1.81 AbsMono-1.24* AbsEos-0.07 AbsBaso-0.04
___ 08:40AM PLT COUNT-259
___ 08:40AM ___ PTT-30.3 ___
___ 07:00AM BLOOD WBC-4.7 RBC-2.33* Hgb-8.3* Hct-25.5*
MCV-109* MCH-35.6* MCHC-32.5 RDW-14.6 RDWSD-56.7* Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-146
K-3.7 Cl-106 HCO3-31 AnGap-9*
___ 07:15AM BLOOD ALT-27 AST-32 AlkPhos-84 TotBili-0.6
___ 08:40AM BLOOD Lipase-441*
___ 07:50AM BLOOD Lipase-96*
___ 8:40 am URINE (___).
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 CFU/mL. ___ MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ 4 S 8 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
___ y/o woman with a history of total gastrectomy for
adenocarcinoma in ___ without evidence of disease recurrence,
hypertension, migraines, multinodular goiter, pancreatitis ___
presenting with abdominal pain ×24 hours, with elevated lipase
suggestive of recurrent acute pancreatitis.
ACUTE/ACTIVE PROBLEMS:
#Abdominal pain/elevated lipase c/f acute pancreatitis:
Clinically improved without any current symptoms. RUQ u/s
negative for cholecystitis. Lipase improved from 400 to ___.
Patient tolerated regular diet x 2 days prior to discharge.
# Bacteruria c/f UTI - urine culture positive for E.coli, given
patient's initial abdominal pain, she was given Ceftriaxone for
2 days and is being discharged to complete 3 additional days of
Ciprofloxacin (end date ___ to finish 5 days total
CHRONIC/STABLE PROBLEMS:
# History of gastric cancer: no e/o disease recurrence at
outpatient f/u, though h/o early satiety concerning. Will defer
to outpatient follow-up.
# Hypertension:
-Continue home verapamil
#GERD:
-Continue home omeprazole
Transitional issues -
- Ciprofloxacin (new med) ___
- follow up on reports of early satiety and weight loss
>30 minutes spent on discharge related activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO QHS:PRN anxiety
2. Multivitamins 1 TAB PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Verapamil 60 mg PO Q24H
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 250 mg 1 (One) tablet(s) by mouth every
twelve (12) hours Disp #*6 Tablet Refills:*0
2. Cyanocobalamin 500 mcg PO DAILY
3. LORazepam 0.5 mg PO QHS:PRN anxiety
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Verapamil 60 mg PO Q24H
7. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until you complete the
antibiotics
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Mild pancreatitis
HTN
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for pain in your stomach. Your
pancreas was slightly inflamed, which improved after resting
your stomach for a short time. You were also found to have an
infection in the urine; you received antibiotics in the hospital
and will need to finish the antibiotics from ___ to ___.
Please follow up with Dr. ___ as listed below.
Wishing you the best,
Your ___ team
Followup Instructions:
___
|
19636128-DS-23
| 19,636,128 | 22,697,287 |
DS
| 23 |
2203-03-18 00:00:00
|
2203-03-18 12:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
afferent loop obstruction
abdominal pain
Major Surgical or Invasive Procedure:
___, PLACEMENT OF JEJUNOSTOMY
History of Present Illness:
ACS Consult H&P ___
Hx obtained from chart, daughter (who translated), and Ms.
___.
HPI: ___ is a ___ w/ hx of total gastrectomy w/ RNY
esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy
(since removed) ___ for T2aN0 gastric adenoCA who is
presenting here to the ED for a <1 day hx of acute onset lower
abd pain i/s/o a ~1 wk hx of intermittent epigastric pain. She
has had similar sx before, being hospitalized for pancreatitis
___. She also had a remote hospitalization in ___ for
SBO
(?closed loop obstruction) that was managed non-operatively.
Yesterday she also noted some nausea, no vomiting. She is
continuing to have BMs and is passing gas. She denies f/c/s,
lightheadedness and/or dizziness, chest pain, SOB, blurry
vision,
h/a's, change in BMs, BRBPR, melena, difficulty urinating,
myalgias, arthralgias, or skin changes; ROS is o/w -ve except as
noted before. A CT A/P was obtained which showed dilated small
bowel thought to be from the biliary limb, c/f afferent loop
obstruction, for which we were consulted.
Past Medical History:
HTN
T2aN0 adenocarcinoma s/p total gastrectomy ___
migraines
vertigo
OA
multinodular goiter
pancreatitis ___
macrocytic anemia
PSHx:
total gastrectomy w/ RNY esophagojejunostomy and D2
lymphadenectomy ___
diagnostic lap ___, RFA of L GSV ___
Social History:
___
Family History:
Mother with thyroid disease, early MI
Physical Exam:
Admission PEx:
VS - 97.8 67 139/63 16 100% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
Abd - soft, mild to mod distension, mild
periumbilical/epigastric
ttp w/ no guardine or rebound
MSK & extremities/skin - no leg swelling observed b/l
Discharge PEx:
VS - 97.8 67 139/63 16 100% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
Abd - soft, nodistended, J tube in place
MSK & extremities/skin - no leg swelling observed b/l
Pertinent Results:
Admission Labs:
___ 11:00PM BLOOD WBC-7.9 RBC-2.74* Hgb-9.4* Hct-30.5*
MCV-111* MCH-34.3* MCHC-30.8* RDW-21.2* RDWSD-86.4* Plt ___
___ 11:00PM BLOOD Plt ___
___ 06:18AM BLOOD ___ PTT-28.8 ___
___ 11:00PM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-142
K-5.0 Cl-106 HCO3-23 AnGap-13
___ 11:00PM BLOOD ALT-19 AST-23 AlkPhos-72 TotBili-0.7
___ 11:00PM BLOOD Lipase-834*
___ 11:00PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.4*
___ 12:52AM BLOOD Lactate-1.1
Discharge Labs:
Imaging:
CT A/P ___
1. Findings concerning for small bowel obstruction, potentially
of the
afferent limb near the jejunojejunostomy, although no definite
transition
point is identified. No obvious evidence of ischemia or
perforation within
the limitations of paucity of intra-abdominal fat. Surgical
consultation
recommended. Additionally, small-bowel follow-through series
with
Gastrografin may be obtained for further assessment.
2. Slight increase in mild-to-moderate intrahepatic biliary
ductal dilatation,
which is nonspecific, could further suggest afferent limb
obstruction.
CT Head ___
1. Small posterior falx subdural hematoma extending to the
tentorium and
adjacent small subarachnoid hemorrhage.
2. Large right occipital parietal scalp hematoma without
fracture.
CXR ___
Hyperinflated lungs compatible with emphysema with no acute
cardiopulmonary process.
CT Head No Contrast ___
Interval increase in size of a posterior falx subdural hematoma
extending to the tentorium and now the anterior falx. There has
been interval increase in the degree of posterior left parietal
subarachnoid hemorrhage as well as new left frontal lobe and
possibly posterior right parietal lobe subarachnoid hemorrhage.
No midline shift.
CT Head No Contrast ___
1. Prominent subdural hemorrhage along the superior falx and
left tentorial leaflet and multiple areas of subarachnoid
hemorrhage involving in the left frontal and temporal lobes are
not significantly changed.
2. Several areas of subarachnoid hemorrhage in the right frontal
and temporal lobes are new or increased in prominence.
CT Head No Contrast ___
1. No evidence of infarction or new intracranial hemorrhage.
2. Redemonstration of prominent subdural hemorrhage along the
superior falx and left tentorial membrane, minimally decreased
in size compared to prior study.
3. Several areas of subarachnoid hemorrhage in the bilateral
frontal and
temporal lobes appear slightly less conspicuous than on prior
study.
4. Large right parietal subgaleal hematoma appears significantly
increased in size compared to prior study, now measuring up to
1.6 cm.
Hip XR ___
No comparison. A pelvis over view as well as 2 projections of
the left hip are provided. Moderate degenerative changes at the
level of both hip joints. No evidence of fracture. Multiple
phleboliths project over the pelvis. Mild degenerative changes
at the level of the sacroiliac joints.
US Abd Limited ___
5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the
midline
laparotomy site, differential diagnosis includes hematoma or a
complex seroma.
Unilat Lower Ext Veins ___
Moderate to severe soft tissue swelling overlying the right
posterior knee.
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
Ms. ___ ___ yo F with hx of total gastrectomy with RNY
esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy
(since removed) ___ for T2aN0 gastric adenoCA who presented
on ___ to ___ ED for acute epigastric pain. CT A/P was
obtained which revealed dilated small bowel thought to be
consistent with afferent loop obstruction. Acute care surgery
was consequently consulted in the ED. Patient was admitted under
ACS on ___ for further evaluation and management.
Overnight ___ patient fell unwitnessed while getting out of
bed, striking head. Non-contrast HCT revealed small left sided
subarachnoid and parafalcine subdural hemorrhage. She was
evaluated by neurosurgery who did not recommend operative
management. The patient had a repeat fall with head strike
without associated changes on imaging later in her hospital
course. She fortunately did not sustain any ongoing neurologic
deficits from either fall.
On ___ patient underwent uncomplicated ___
enteroenterostomy and placement of jejunostomy with EBL of 20
mL. She was noted to be stable in the PACU s/p 1 unit pRBC. She
was ___ transferred to the floor. On discharge her tube feeds
were at goal and she tolerating a (small) clear liquid PO diet.
On ___ the renal team was consulted for progressive
hyponatremia that initially developed on ___. They felt this was likely SIADH in the setting of
subarachnoid hemorrhage and recommended fluid restriction and
appropriate workup, with expectation of improvement as
intracranial hemorrhage improves. The endocrine service was also
consulted and after workup were in agreement this was likely
SIADH. They agreed with the renal team's recommendation to
restrict PO intake to <1L and to continue trending her sodiums
at her rehab facility. There is no place for salt tabs or
vaptans at this time.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
18" CHROME GRAB BAR - 18" chrome grab bar . use for safety as
directed daily as needed dx: R26.81
18INCH CHROME GRAB BAR - 18inch chrome grab bar . use as
instructed daily Dx:
ADULT BRIEFS- SMALL - adult briefs- small . use ___ and prn for
incontinence
BEDSIDE COMMODE - bedside commode . unsteady gait 781.2
DEXAMETHASONE - dexamethasone 1.5 mg tablet. 1 tablet(s) by
mouth
daily
LORAZEPAM - lorazepam 0.5 mg tablet. TAKE 1 TABLET BY MOUTH AT
BEDTIME AS NEEDED FOR ANXIETY
MECLIZINE - meclizine 12.5 mg tablet. TAKE 1 TABLET BY MOUTH TWO
TIMES A DAY AS ___ OR USE MACHINERY WORK WHILE
ON
MEDS
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1
CAPSULE(S) BY MOUTH DAILY
SHOWER BENCH - shower bench . use when showering/bathing daily
as needed
VERAPAMIL - verapamil 40 mg tablet. 1 and ___ tablet(s) by
mouth
daily
Medications - OTC
ACETAMINOPHEN [CHILDREN\'S PAIN-FEVER RELIEF] - Children\'s Pain
and Fever Relief 160 mg/5 mL oral liquid. TAKE 4 TEASPOONS BY
MOUTH EVERY 6 HOURS FOR PAIN
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12 500
mcg tablet. 1 TABLET(S) BY MOUTH DAILY
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL ___ -
Artificial Tears (dextran 70-hypromellose) eye drops. ONE DROP
___. free tears/gel. Let warm water fall on CLOSED
lids for 2 mins in shower. Massage edges of lids/lashes for 30
secs.
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
TABLET(S) BY MOUTH DAILY
FOOD SUPPLEMT, LACTOSE-REDUCED [ENSURE] - Ensure oral liquid. 1
to 2 cans by mouth daily vanilla flavor dx: weight loss
MULTIVITAMIN [DAILY-VITE] - Daily-Vite tablet. 1 TABLET(S) BY
MOUTH DAILT
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Verapamil 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
afferent loop obstruction
abdominal pain
subarachnoid hemorrhage
subdural hemorrhage
traumatic brain injury
Discharge Condition:
Clear and coherent
Discharge Instructions:
Dear Ms. ___,
You came here with abdominal pain and were found to have a bowel
obstruction on imaging. You were taken to the OR where you
underwent an enteroenterostomy. A J-tube was placed to ensure
you are getting adequate nutrition.
You hospitalization was complicated by 2 falls. Initial imaging
demonstrated a brain bleed but repeat imaging was stable so
neurosurgery did not feel operative management was appropriate.
We do think your brain bleed did lead to low sodium levels in
the hospital (a condition called SIADH). We anticipate that your
sodium level will improve with time.
In the meantime please restrict your fluid intake by mouth to
less than 1L. The rehab facility will check your sodium levels
as well.
You should follow up with Dr. ___ our surgery clinic
in ___ weeks. You can reach his office at ___ to set
up an appointment.
Followup Instructions:
___
|
19636160-DS-11
| 19,636,160 | 23,188,055 |
DS
| 11 |
2115-02-06 00:00:00
|
2115-02-09 23:57:00
|
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:
Sigmoidoscopy w/biopsy (___)
History of Present Illness:
Mr. ___ is a ___ man with history of
hypogammaglobulinemia, hypothyroidism, Hep C s/p treatment,
Crohns disease presenting with abdominal pain and diarrhea.
The patient reports that he was diagnosed with Crohns ___ years
ago, and has had two flares since then. He estimates that it has
been ___ years since he was last treated for a Crohns flare. He
has not been on any medications for his Crohns in many years.
Beginning on at the beginning of ___, he developed cramping
bilateral lower abdominal pain and hematochezia. He had ___
episodes per day. No nausea, vomiting. No fevers, chills. He
called his gatroenterologist on ___ to report these symptoms.
Labs were sent at that time, notable for Hb 13, ESR 29, TTG-IgA
negative, IgA 335, C. diff negative.
He was seen in clinic on ___, and was ordered a colonoscopy,
which he underwent on ___ that showed aphtha in the rectum, in
the descending colon, in the transverse colon, in the ascending
colon and in the cecum. Eroded, hemorrhagic, plaque covered,
pseudopolypoid and ulcerated mucosa at 35 cm proximal to the
anus. Multiple polyps. The patient was initiated on Lialda 4.8
gm
daily and budesonide.
The patient called back on ___ to report that he continued to
have ___ bowel movements per day and abdominal discomfort. His
gastroenterologist directed him to stop budesonide and start
prednisone 40 mg daily. He was also referred to colorectal
surgery for evaluation of anal fissure.
He called again on ___ to report that he continued to wake up in
the night to have 4 liquid bowel movements. He reports that his
rectum continued to be very painful. He reports that his
appetite
has been very poor, and has lost about 20 pounds unintentionally
since last month. Patient denies any recent NSAID use. No
changes
in medications.
Given his ongoing symptoms, his gastroenterologist referred him
to the ED for IV steroids and IV fluids.
In the ED, initial vitals: 96.3 104 149/97 18 100% RA
Exam: Abd: Soft, Nontender, Nondistended
Labs: WBC 6.7, Hb 13.4, plt 199, AST 43, ALT 53, BMP wnl,
lactate
1.6
Imaging: None
Patient given: LR at 125 cc/hr
On arrival to the floor, the patient reports rectal pain. He
denies any abdominal pain at present. No nausea, vomiting. No
other complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Crohns with partial transverse colectomy
- Hypogammaglobulinemia
- HCV cirrhosis, Childs A (HCV s/p treatment)
- Hypothyroidism
Social History:
___
Family History:
No known family history of inflammatory bowel
disease.
Physical Exam:
ADMISSION
------------
VITALS: 98.5 129 / 85 80 20 100 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
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. Rectal exam with exquisite tenderness to exam,
no
clear anal fissure on external exam and limited internal exam
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
DISCHARGE EXAM
___
GENERAL: NAD, sitting up in bed
EYES: anicteric sclera
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, no TTP, ND, no R/G
RECTUM: ___ fistula with mucus discharge, perianal
erythema
is much improved today
GU: No suprapubic fullness or tenderness to palpation
SKIN: Well-healed abdominal surgical scar
NEURO: AOx3, CN II-XII intact
PSYCH: pleasant, appropriate affect
PPD on Right ARM - NO swelling, induration or redness
Pertinent Results:
ADMISSION:
==========
___ 07:33PM BLOOD WBC-6.7 RBC-5.19 Hgb-13.4* Hct-41.6
MCV-80* MCH-25.8* MCHC-32.2 RDW-14.5 RDWSD-41.7 Plt ___
___ 07:33PM BLOOD Neuts-83.8* Lymphs-11.1* Monos-4.6*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-5.58 AbsLymp-0.74*
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.01
___ 12:25AM BLOOD ___ PTT-25.6 ___
___ 07:33PM BLOOD Glucose-160* UreaN-17 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-22 AnGap-14
___ 07:33PM BLOOD ALT-53* AST-43* AlkPhos-100 TotBili-0.8
___ 07:33PM BLOOD Lipase-16
___ 07:33PM BLOOD cTropnT-<0.01
___ 05:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
___ 05:27AM BLOOD calTIBC-234* Ferritn-260 TRF-180*
___ 05:45AM BLOOD CRP-54.3*
___ 05:27AM BLOOD CRP-62.6*
___ 06:45AM BLOOD CRP-41.1*
___ 05:27AM BLOOD IgG-524*
___ 07:39PM BLOOD Lactate-1.6
DISCHARGE:
==========
CRP: 54 -> 62 -> 41 -> 10
PPD: Negative on ___
HBsAB: positive ___
Imaging:
MR pelvis (___):
RECTUM AND INTRAPELVIC BOWEL: There is an intersphincteric anal
fistula with origin at ___long the right
side into the right perianal fold measuring approximately 3.5 cm
in length consistent with Clinical History provided. Remaining
visualized rectum and intrapelvic bowel is unremarkable.
No significant free fluid or abscess.
Flex sig (___):
Fistula in the rectum (above dentate line).
Localized heaped-up and erosion with contact bleeding in the
transverse colon. Multiple cold forceps biopsies were performed.
Localized congestion, decreased vascularity, edema, erythema,
friability, and ulceration with contact bleeding in the sigmoid
(___). Multiple cold forceps biopsies performed for
histology
in the sigmoid. External exam with multiple broad based skin
tags, 1x4mm fistula at 3 o'clock in ___ area.
IgG 524
TSH ___
Ferritin 260, TIBC 234
Trop <0.01
Lact 1.6
Stool Cx (___): negative
C.diff (___): negative
BCx (___): negative
Path (flex sig ___: 1. Transverse colon, biopsy:
-Colonic mucosa with crypt distortion, and submucosa with
chronic inflammation. 2. Sigmoid colon, biopsy:
-Active colitis with extensive ulceration. See note.
Note: No granulomata or dysplasia identified in either biopsy.
___ 05:47AM BLOOD WBC-4.4 RBC-4.28* Hgb-11.0* Hct-35.4*
MCV-83 MCH-25.7* MCHC-31.1* RDW-15.0 RDWSD-45.5 Plt ___
Brief Hospital Course:
___ man with history of hypogammaglobulinemia,
hypothyroidism, HCV s/p treatment c/b cirrhosis (Child's A), and
Crohn's disease s/p partial colectomy (recently initiated on
mesalamine and budesonide) presenting with abdominal pain,
diarrhea, and hematochezia, found to have ___ fistula c/f
for flare of fistulizing Crohn's disease.
# Crohn's disease with flare:
# ___ fistula:
Patient with long hx of Crohn's disease for which he is followed
by Dr. ___ at ___. Developed abdominal pain and diarrhea ~1
month prior to admission. Colonoscopy ___ at ___ showed
multiple aphthae in rectum, multiple polyps, and eroded,
hemorrhagic, plaque covered, ulcerated mucosa in the anus with
e/o of colitis and possible ischemia/necrosis on biopsy.
Symptoms were unresponsive to initiation of mesalamine and
budesonide and subsequently a trial of oral steroids, resulting
in referral to the ED for admission on ___. Pt was treated with
IV solumedrol and Flex sigmoidoscopy performed ___ showed
multiple erosions and ulcerations with contact bleeding, most
prominently in the sigmoid (___) and a rectal fistula.
C.diff and stool cultures returned negative. Pt underwent
pelvis MRI for ___ fistula and was seen by Colorectal
surgery who did not recommend any intervention at this time but
will follow in clinic. Symptoms improved rapidly on IV
steroids with resolution of diarrhea and pt was initiated on
infliximab after PPD returned negative. Pt was followed closely
by GI and will continue getting IV infliximab through the GI
clinic at ___. Meselamine was discontinued at discharge and
pt was continued on a steroid taper as outlined by the GI team.
# Microcytic anemia:
Hgb 13.4 on admission and has been stable in ___ range since.
Suspect secondary to intermittent hematochezia with component of
anemia of inflammation (given ferritin 260). HD stable.
# Hypothyroidism:
TSH WNL. Continue home levothyroxine
# GERD
# Esophageal ring:
continued on home PPI
# Hypogammaglobulinemia:
IgG 524 (nl ___. IVIG q5weeks, last dose ___ and
would be due ___ deferring additional IVIG for now in
absence of infection.
# HCV s/p treatment:
# HCV cirrhosis, Child's A:
History of HCV infection s/p successful treatment with
interferon, ribavirin and sofosbuvir. SVR first documented in
___. Cirrhosis is Childs A with no varices (last ___ or
ascites. Outpt follow up scheduled with hematology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Nasal
congestion
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. PredniSONE 40 mg PO DAILY
5. Lialda (mesalamine) 4.8 gm oral DAILY
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg ___ tablet(s) by mouth daily Disp #*65
Tablet Refills:*0
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's colitis with flare
Perianal fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with diarrhea and abdominal
pain, concerning for a flare of your Crohn's disease. You were
started on intravenous steroids and seen by the gastroenterology
service. You underwent a sigmoidoscopy and an MRI of your
pelvis, which showed a perianal fistula without any abscess. You
were evaluated by the colorectal surgery team who did not
recommend any intervention at this time and you will be seen in
follow up with Dr. ___.
You have improved rapidly on IV steroids and were given your
first infusion of Infliximab which will be continued through the
___. The gastroenterology office will
contact you in the next few days with the details of your
appointment in ~2wks for the next infusion. If you don't hear
from them by ___, please call ___.
You have been started on a prednisone taper as outlined below.
Please continue to take your medications as shown below and
continue local wound care for your fistula.
With best wishes,
___ Medicine
Followup Instructions:
___
|
19636178-DS-11
| 19,636,178 | 28,301,149 |
DS
| 11 |
2151-12-09 00:00:00
|
2151-12-09 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed woman history of HTN, HL,
rheumatoid arthritis, obesity, hypothyroidism, and prior right
sided stroke in ___, who presents with gradual left arm and
leg
weakness noted since this morning around 3am in the setting of
nausea and emesis since that time.
Patient reports she has had headaches since last week. Started
bifrontal and then progressed to left retro-orbital which is
more
typical of her migarines. She has history of migraines that used
to be menstrual related and diminished in quantity and severity
since post menopause. Patient thinks headache now is related to
being started on Golimumab for her inflammatory arthritis.
Started it 6 months ago, and last had it one month ago.
She reports this morning around 2:30am she woke up feeling very
nauseous with upset stomach and started vomiting many times. Had
NBNB emesis several times throughout the day, unable to keep
anything down. Reports left arm and leg weakness also were noted
since the morning around 3am and gradually worsened as she got
weaker. She reports after her stroke in ___ which resulted in
left face, arm and leg weakness and altered mental status, she
has no residual weakness, but will get recurrence of left arm
and
leg weakness when she gets sick with cold or flu symptoms. This
was similar to that. Patient was so dehydrated and vomiting so
much that aroudn 5:30pm while leaning over toilet, passed out
for
about a minute. Came to and was very weak and tired. Called son
who came over and noted left arm and leg weakness and brought
immediately to ED. Code stroke called.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech.
On general review of systems, the pt denies recent fever. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Reports nausea, vomiting, diarrhea, and abdominal
pain. No dysuria.
Past Medical History:
-Hyperlipidemia
-Migraine headaches
-Hypothyroidism
-OSA
-Restless leg syndrome
-Rheumatoid arthritis
-? SLE
-Prior CVA versus lupus associated in ___ with left sided
weakness presentation
-Syncope
-Depression
Social History:
___
Family History:
No FH stroke or autoimmune disorders.
Physical Exam:
=========================
Admission Physical Exam
=========================
___ Stroke Scale - Total [5]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 1
5b. Motor arm, right - 0
6a. Motor leg, left - 2
6b. Motor leg, right - 0
7. Limb Ataxia - 1
8. Sensory - 1
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Vitals: 98.8 89 126/63 16 98% RA
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name
___
backward without difficulty. 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. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strengh.
-Motor: Normal bulk, tone throughout. Left arm with drift. Right
arm no drift. Left leg could not sustain antigravity. Right leg
no drift. No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 4+ ___- 4- 4- 4 4 4
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: Decreased light touch and pinprick in left arm and
leg.
Decreased vibratory sense and proprioception on toes
bilaterally.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Left arm dysmetria on FNF, non on right side.
Decreased RAM on left side.
-Gait: Deferred.
==============================
DISCHARGE PHYSICAL EXAM
==============================
General exam was unchanged.
Neurologic examination was normal; strength and sensation was
normal on the left side. There was no dysmetria on the left side
and gait was stable.
Pertinent Results:
======
LABS
======
___ 08:30PM BLOOD cTropnT-<0.01
___ 12:07AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:00AM BLOOD %HbA1c-5.3 eAG-105
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
==========
IMAGING
==========
___:
NECT: No acute intracranial hemorrhage. Near complete
opacification of the left sphenoid sinus.
CTA: Carotid and vertebral arteries major intracranial branches
are patent without significant stenosis or occlusion. No large
aneurysm.
CTP: No abnormality in perfusion maps.
MRI HEAD WITHOUT CONTRAST (___):
1. No evidence of acute infarction
2. Scattered T2 FLAIR hyperintense foci in the cerebral white
matter as
described above, nonspecific in appearance can be seen with
small-vessel
ischemic changes, etc. Correlate for risk factors.
3. Moderate mucosal thickening with fluid of the left sphenoid
sinus.
CXR (___):
No previous images. The cardiac silhouette is within upper
limits of normal in size and there is no evidence of vascular
congestion or pleural effusion. Specifically, no acute pneumonia
identified.
Brief Hospital Course:
Mrs. ___ is a ___ year-old right-handed woman with a past
medical history including hypertension, hyperlipidemia,
rheumatoid arthritis, obesity, hypothyroidism, and prior right
sided stroke in ___ who presented to ___ ED ___ as a Code
Stroke for acute onset left arm and leg weakness. NIHSS was 5
and examination was notable for left sided weakness and sensory
loss. Otherwise, pt did have recent nausea, abdominal pain, and
emesis. She also reported bifrontal and left retro-orbital
headache for past week similar to prior migraines. NCHCT, CT
perfusion and CTA head and neck were unremarkable. Pt did not
receive IV tPA as symptoms were suspected to be recrudescent of
prior stroke and last known normal time was unclear. She was
admitted to the neurology stroke service for further management.
While in the hospital, pt had an MRI which showed no acute or
chronic infarcts. Left sided symptoms, nausea, vomiting and
headache resolved on hospital day 2. Pt felt well and was stable
for discharge home with stroke clinic follow-up. At time of
discharge, differential for patient's transient episode included
recrudescence of old stroke symptoms in setting of viral
gastroenteritis (pt may have had an old lacunar stroke not
visible on MRI) or complex migraine.
=======================
TRANSITIONS OF CARE
=======================
-Lipid panel and TSH pending at time of discharge.
-MRI did not show any acute or old stroke; pt may have had
recrudescence of a small lacunar stroke not visible on MRI due
to her gastroenteritis. Or, she may have experienced a complex
migraine as she had reported a week of migrainous headache prior
to symptoms onset.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. cycloSPORINE 0.05 % ophthalmic BID
4. Omeprazole 20 mg PO BID
5. golimumab 50 mg/0.5 mL subcutaneous q30 days
6. Levothyroxine Sodium 50 mcg PO DAILY
7. MethylPHENIDATE (Ritalin) 10 mg PO DAILY:PRN distractibility
8. Multivitamins W/minerals 1 TAB PO DAILY
9. butalbital-aspirin-caffeine 50-325-40 mg oral TID PRN
headache
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO Q ___ AND ___
4. Levothyroxine Sodium 50 mcg PO Q ___,
___ AND ___
5. Omeprazole 20 mg PO DAILY
6. butalbital-aspirin-caffeine 50 mg ORAL TID PRN headache
7. cycloSPORINE 0.05 % OPHTHALMIC BID
8. golimumab 50 mg/0.5 mL subcutaneous q30 days
9. MethylPHENIDATE (Ritalin) 10 mg PO DAILY:PRN distractibility
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Recrudescence of prior stroke symptoms versus complex migraine
Secondary diagnoses:
-Hyperlipidemia
-Migraine headaches
-Hypothyroidism
-OSA
-Restless leg syndrome
-Rheumatoid arthritis
-Prior TIA/strokes with left sided weakness presentation
-Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of left sided weakness.
We were initially worried about an ACUTE ISCHEMIC STROKE, a
condition in which 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.
Fortunately, ___ did NOT have a stroke on our imaging study of
your brain (MRI). The blood vessels in your head and neck were
also imaged and found to be normal. It is possible that your
left sided weakness may be a reproduction of your prior stroke
symptoms in light of your stomach virus, as ___ have had nausea,
vomiting and abdominal pain. It is also possible that your
migraine headache is associated with left sided weakness; this
is called a "complex migraine".
Still, ___ do have risk factors for stroke. Your risk factors
are:
-High cholesterol
-Migraines
-Small prior stroke
We are not changing your home medications. Please take your home
medications, including aspirin, as previously prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing ___ with care during this
hospitalization.
Followup Instructions:
___
|
19636464-DS-11
| 19,636,464 | 20,476,361 |
DS
| 11 |
2130-06-19 00:00:00
|
2130-06-20 10:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Carbamazepine / methocarbamol / Cyclobenzaprine
Attending: ___
Chief Complaint:
difficulty walking
Major Surgical or Invasive Procedure:
___ Posterior fossa high volume CSF puncture
History of Present Illness:
The patient is a ___ year old ___ woman with a
history of a Chiari malformation and an unspecified connective
tissue disorder who has experienced progressive difficulty with
walking.
In retrospect, the patient thinks that her friends and also
bystanders have noticed a gradual change in the way she walks
over the past few months. In early ___, she went on a short
cruise and had a few people ask her if she was okay because of
the way she was walking. She did not particularly appreciate any
alteration in her gait at that time, but she did notice that she
had some difficulty with swimming during that trip. She
developed
pain/synovitis in her knees which her Rheumatologist was
concerned might represent a flare, so she was started on a
prednisone taper. She has a history of chronic headaches and
neck
pain treated with symptomatic pharmacotherapy such as tramadol
and naproxen, and these symptoms seemed to worsen during this
time. In late ___, she revisited Dr. ___ in the
General Neurology clinic who follows her tension headaches with
neck pain in the setting of her history of a Chiari malformation
which is status post suboccipital decompression in her twenties.
She reported "tightness" in the back of her neck and right
shoulder and arm. The pain was not accompanied by weakness or
sensory changes in that extremity. She also had left leg pain
that would coarse down the back of her leg when performing
Valsalva maneuvers, She was thought to have developed cervical
and lumbosacral radiculopathy and was prescribed baclofen as a
muscle relaxant and a soft cervical collar. However, the
baclofen
did not work for her symptoms and was switched with robaxin;
this
similarly did not work and was exchanged for diazepam. During
this time, she started to "unbalanced" and felt as though her
legs were not moving properly. She occasionally felt as though
her feet were slapping the ground, and again, coworkers or
friends would ask her if anything were wrong. She started to
walk with her feet further apart. She felt as though her legs
were too light; she wanted to wear heavier shoes or weights on
her ankles. She was in communication by phone with Dr. ___ reorder an MRI scan to reevalute her Chiari malformation
which was unchanged from prior scans. She described sensations
of
her own body moving oddly in space, felt like a bobble head
doll,
no room spinning; she was prescribed meclizine to address this
symptom. She subsequently experienced two falls, one on ___
when she standing and eating an apple and suddenly fell toward
the left and a second on ___ when she fell fowards while
walking toward her stove. Both falls were without head injury,
loss of consciousness, or preceding symptoms. She presented to
her Rheumatologist the next ___ when she was reported as having
vertical nystagmus and neck/torso dystonic movements, and she
was
then sent to the Emergency Department.
Past Medical History:
[] Neurologic - Chiari malformation s/p suboccipital
decompression ___ (Dr. ___, ___), ___ headaches
and neck pain
[] Rheumatologic - Unspecified connective tissue disorder ___
ab and RNP ab positive, dsDNA neg)
[] Gynecologic - s/p hysterectomy
Social History:
___
Family History:
Stroke (father, age ___.
Physical Exam:
Physical Examination:
General: Awake, NAD, lying in bed comfortably, tall.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Recalls a coherent
history. Registration ___ and recall ___. Concentration
maintained when recalling months backwards. Follows two step
commands, midline and appendicular. Language fluent with intact
repetition and verbal comprehension. Normal prosody. No
paraphasic errors. High and low frequency naming intact. No
dysarthria. No apraxia or neglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. Funduscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOMI, no nystagmus, normal saccades, no optic
ataxia. [V] ___ without deficits to light touch bilaterally.
[VII] No facial asymmetry. [VIII] Hearing intact to finger rub
bilaterally.
[IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength
___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk. Tone normal. No pronation, no drift. No
resting or postural tremor or asterixis. +Pseudoathetoic
movements of the hands (variable, sometimes right more than
left).
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
ADM 4+/5 bilaterally. APB ___.
- Sensory - Light touch intact. Pinprick decreased ___ on LUE,
___ on RUE, ___ on back. Proprioception diminished at the
second finger PIPs bilaterally, fifth toes bilaterally.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 0 1 0 0 0
R 0 1 0 0 0
Plantar response up on right, down on left.
- Coordination - Truncal ataxia when sitting or standing. Some
overshoot with mirrored movements. Mild dysmetria on left
greater
than right. Mild intention tremor bilaterally. RAM with change
in
cadence.
- Gait - Present Romberg. Normal initiation. Wide base.
___ stride length, posturing/limited arm swing with
stress gaits. Bilateral sway. Few steps but unsteady turn.
Pertinent Results:
___ 11:11AM ___
___
___ 11:11AM ___
___
___ 11:11AM PLT ___
___ 11:11AM ___
___ 11:11AM ___
___ 11:11AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 06:00PM URINE ___
___
___
___ 06:00PM URINE ___ SP ___
___ 08:13PM CEREBROSPINAL FLUID (CSF) ___
___
___ 08:13PM CEREBROSPINAL FLUID (CSF) ___
___ 08:13PM CEREBROSPINAL FLUID (CSF) ___
___
___ NC MRI BRAIN
FINDINGS: The patient is status post suboccipital decompression
of a
navicular Chiari malformation. The persistent CSF intensity
fluid collection
posterior and inferior to the cerebellum appears slightly
decreased in size
from prior exam. The cerebellar tonsils are located at the level
of the
foramen magnum. The imaged portions of the cervical spine and
brain stem are
unremarkable without evidence of syrinx formation.
There is no shift of the normally midline structures or
hydrocephalus. There
is no evidence for intra- or ___ hemorrhage, edema,
mass, or
infarction. There are no abnormal areas of diffusion. flow voids
are seen
within the major intracranial arteries and dural venous sinuses.
The ocular
lenses and globes are normal. The imaged paranasal sinuses and
mastoid air
cells are well aerated.
IMPRESSION: Stable ___ decompression of Chiari
malformation
with no evidence for infarction.
___ CT Torso
IMPRESSION: 21 x 7 mm lucent lesion with chondroid matrix within
the right
iliac bone may represent a cartilaginous lesion versus an
intraosseous lipoma.
Recommend MRI for further evaluation.
___ MRI C/T Spine
IMPRESSION:
1. Stable ___ changes from prior Chiari decompression
with no
interval change in the suboccipital pseudomeningocele with
stable mass effect
on the cerebellum.
2. Mild degenerative changes in the cervical spine, but no
significant spinal
canal or neural foraminal narrowing.
3. Unremarkable MRI of the thoracic spine.
___ PANOREX
Small nonaggressive ovoid lucency in the left parasymphyseal
mandible. This is
of uncertain etiology, but probably ___. Clinical
correlation and,
if indicated, ___ radiographic imaging in ___ months to
confirm
stability is requested.
MRI ___
IMPRESSION:
1. At ___, there is diffuse circumferential disc bulge with
focal central
protrusion with mild inferior migration, contacting and mildly
deforming
bilateral traversing S1 nerve roots as described above.
2. Prominent epidural fat deforming the thecal sac in lower
lumbar and upper
sacral spinal canal suggestive of epidural lipomatosis.
2. A small right iliac bone lesion is incompletely evaluated on
the present
study- may represent an atypical hemangioma. A dedicated MRI may
be
considered for further evaluation if clinically indicated.
___ MRI CINE/Flow Study
BRAIN MRI:
Again posterior fossa decompression identified. The CSF space is
identified
in the retrocerebellar region at the region of foramen magnum.
The fluid
collection has not significantly changed compared to the prior
study of
___ and ___.
There is no hydrocephalus, midline shift, or mass effect. No
acute infarct is
seen. Vascular flow voids are maintained.
The ___ imaging study demonstrates bidirectional flow
at the
foramen magnum, best visualized on series 12. The bidirectional
flow anterior
to the spinal cord is uninterrupted. However, posterior and
inferior to the
cerebellum, in the region of the fluid collection, bidirectional
flow is
visualized inferior to the fluid collection which demonstrates a
different
dynamics of the flow. Findings are indicative of likely
adhesions at the
foramen magnum with the fluid collection being separate from the
upper
cervical subarachnoid space. It appears that the fluid
collection may have
communication with the foramen Magendie and the fourth ventricle
but not with
the upper cervical posterior subarachnoid space.
IMPRESSION:
1. The fluid collection at the foramen magnum in the region of
suboccipital
craniectomy is unchanged in size.
2. The ___ imaging shows the fluid collection to be
not
communicating with the subarachnoid space in the upper cervical
region. Fluid
collection may be communicating with the fourth ventricle but
not with the
subarachnoid space.
___ positive 1:160 titer
RPR NR
B12 1456
TSH 0.86
CSF WBC 0, RBC 0, Prot 18, Glucose 65
___ negative
Anticardiolipin antibodies normal
PENDING:
___ Ab
___ Ab
Gq1b Ab
Lupus anticoagulant
Brief Hospital Course:
___ h/o Chiari malformation s/p suboccipital decompression,
connective tissue disorder p/w one month of ataxia and gait
instability with at least three months of discoordination/gait
change suggestive of a foramen magnum syndrome. Her exam is most
remarkable for truncal > appendicular ataxia and proprioceptive
loss in all limbs.
[] Ataxia - The examination was most suggestive of a foramen
magnum syndrome with mechanical compression and
___ processes being the most likely etiologies.
She was evaluated with an MRI which did not reveal any major
changes in the meningocele in the posterior fossa s/p prior
suboccipital decompression. A Flex/Ext XR did not show major
signs of subluxation. Neurosurgery was consulted and performed
an MRI CSF CINE flow study and posterior fossa high volume tap
without clear evidence of improvement in her examination.
___ antibodies were drawn and sent out; most are
still pending, but ___ was negative. A CT Torso was
performed to evaluate for occult malignancy, but no major
abnormalities were found. A small right iliac lucency was
visualized which could represent a benign hemangioma; Radiology
recommended followup/dedicated imaging. Similarly, a small left
mandibular nonaggressive lesion was visualized on Panorex for
which Radiology recommended dedicated imaging.
___ evaluated the patient and recommended acute rehab.
PENDING STUDIES:
Gq1b Ab
___ Ab
___ Ab
Lupus anticoagulant
___
TRANSITIONAL CARE ISSUES:
[] Neurology - Please f/u the ___ antibodies. Please
continue to follow the patient's symptoms.
[] PCP - ___ consider followup imaging for the left
mandibular and right iliac crest bone lesions.
Medications on Admission:
Albuterol sulfate inhaler, Amitriptyline 10 qhs,
Hydroxychloroquine 400, Naproxen 500 q12h, Tramadol 100 q12h,
Prednisone 10
Discharge Medications:
1. tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
___.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) puffs Inhalation Q6H (every 6 hours)
as needed for wheeze.
3. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. naproxen 250 mg Tablet Sig: Two (2) Tablet PO twice a ___ as
needed for pain.
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. ___ % Ointment Sig: One (1)
Appl Rectal DAILY (Daily) as needed for discomfort.
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a ___.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Ataxia
Secondary Diagnosis: ___ malformation, ___ headache,
L5 radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: No nystagmus, normal saccades, patchy decreased
pinprick sensation, truncal ataxia > appendicular ataxia,
intention tremor, wide based gait, present Romberg.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to your difficulty with walking. We
suspected that this was related to either mechanical compression
of the cerebellum due to scarring or pressure exerted by
alteration of the cerebrospinal fluid or to an ___
process wherein antibodies might be produced which damage the
cells of the cerebellum. The investigation into this process
will continue when you leave the hospital and will be directed
by Dr. ___ Neurologist.
At this time, we will not be changing your medications.
We would like you to followup with Dr. ___ your primary
care physician as listed below.
If you experience any of the following warning signs, please
seek medical attention.
It was a pleasure providing you with medical care during this
hospitalization.
Followup Instructions:
___
|
19636477-DS-8
| 19,636,477 | 21,311,090 |
DS
| 8 |
2199-02-10 00:00:00
|
2199-02-10 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
code stroke, left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ right handed woman with history of HTN who
presented with left arm clumsiness and abnormal sensation. She
was last well at 9:30pm. She was in her usual state of health
until she experienced a sudden onset cold sensation in her left
arm. She said that she was at her evening prayer meeting at the
time. Around 9:30pm, she noticed a strange cold sensation up her
left forearm. She did not think she was weak. She was holding
her prayer book but she did not notice any problem with turning
the pages although she was likely to be using her right hand to
turn the page. She did go to the bathroom and had some trouble
pulling up her pants. When asked, she said that she might have
trouble using her left hand. She then told her daughter and
husband about it. She was able to walk to the car and her
daugher drove her to the ___ ED right away.
Her blood pressure has been well controlled with BP typically
around 120's over 70's. She denies skipping medications. Denies
head trauma. No strenous exercises, coughing, or straining.
She 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.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
Social History:
___
Family History:
No FH of DM, HTN or stroke
Physical Exam:
___ Stroke Scale score was 6 in the Emergency Room:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 2
PHYSICAL EXAM ON ADMISSION:
Vitals: 98.2, 167/77 ---> 154/62, 64, 16, 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self and ___, Knows
month and year but thought it was the ___. Able to relate
history without difficulty. Grossly attentive. Language is
fluent with intact repetition and comprehension. She mumbles but
that was normal per patient. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects with error on "cactus". Able to read without
difficulty (though she clearly neglects the left side of the
page). Speech was not dysarthric. Able to follow both midline
and appendicular commands. Patient neglects the left side of the
cookie jar picture and only commented on the "curtains". She
neglected all the people in the picture.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. There is
visual extinction to DSS.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Flattening of the left NLF.
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 and tone. Positive pronator drift on the left
arm.
=[Delt] [Bic] [___] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L ___ 4+ ___ 5
R ___ 5 5
*Motor exam on the L limbs limited by left sided neglect
-Sensory: Decreased LT in LLE. Proprioception sense loss on LUE
and LLE. No deficits to pinprick, cold sensation, vibratory
sense throughout. Positive tactile extinction to DSS on the
left.
-DTRs:
___ Pat Ach
L ___ 2 1
R ___ 2 1
Plantar response was flexor bilaterally.
-Coordination: + dysmetria on FNF on the left which may be
limited by decreased strength. HKS bilaterally more or less
intact but difficult to assess as patient is tired and
distracted at this point.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
___ 12:40AM BLOOD WBC-6.2# RBC-4.57 Hgb-11.4* Hct-34.9*
MCV-77* MCH-25.0* MCHC-32.7 RDW-13.6 Plt ___
___ 12:40AM BLOOD Neuts-62.3 ___ Monos-4.1 Eos-1.2
Baso-0.7
___ 11:21PM BLOOD ___ PTT-33.7 ___
___ 11:11PM BLOOD Glucose-103* UreaN-14 Creat-0.8 Na-133
K-4.2 Cl-102 HCO3-21* AnGap-14
___ 11:11PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
URINE:
___ 09:09AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:09AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
___ 09:09AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
MICRO:
___ MRSA SCREEN: POSITIVE FOR METHICILLIN RESISTANT STAPH
AUREUS.
DISCHARGE LABS: _______________
===========================================
IMAGING:
CT HEAD ___:
There is a right parietal intraparenchymal hemorrhage measuring
2.5 x 4.7 x
2.6 cm with surrounding edema. There is mild mass effect with
effacement of the overlying sulci. There is no shift of
normally midline structures. The ventricles are normal in size
and configuration. The basal cisterns appear patent and there
is preservation of gray-white differentiation. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: Right parietal intraparenchymal hemorrhage. No
shift of normally midline structures.
MRI brain wo contrast ___:
Right parietal parenchymal hemorrhage as detailed. No evidence
for amyloid angiopathy in the remaining brain. Without
contrast, it is
difficult to exclude an underlying mass. No aneurysm is seen.
MRI brain w and wo contrast ___:
Right parietal bleed is slightly smaller by a few millimeters.
There is stable surrounding edema. There is no nodular
enhancement
surrounding the lesion. However, evaluation is limited due to
intrinsic T1
hyperintensity. There is venous hyperemia and prominent vessels
abutting the hemorrhage as well as in the right cerebral
hemisphere. No large flow voids are seen to suggest an
underlying AVM, although a thrombosed AVM cannot be entirely
excluded. There is no evidence for acute territorial ischemia.
No evidence for amyloid angiopathy. Mass effect on the right
lateral ventricle is unchanged. There are scattered small vessel
ischemic changes in the white matter. IMPRESSION: Slight
interval decrease in right parietal hematoma. No definite
nodular enhancement, although evaluation would be more sensitive
after resolution of T1 hyperintense blood products.
CXR: ___:
Cardiomegaly is moderate, unchanged. Mediastinal silhouette is
unchanged
except for slightly more pronounced azygos vein that in
combination with
vascular engorgement might be consistent with mild degree of
vascular
overload. No definitive evidence of infectious process seen.
The more focal appearance of consolidation in the right lower
lung most likely related to low lung volume and again
potentially due to volume overload.
ECGStudy Date of ___ 1:33:24 AM
Sinus rhythm with premature ventricular contractions versus
premature atrial contractions with aberrancy. Compared to the
previous tracing of ___ no significant change.
Brief Hospital Course:
Ms. ___ is a ___ year-old right handed woman with HTN who
presented with sudden onset left hand clumsiness, abnormal cold
sensation and dressing apraxia. Initial NIHSS was 6 in the ED
(left neglect and extinction, left facial droop, left upper
motor neuron pattern weakness and sensory deficits). Initial
NCHCT showed right parietal intraparenchymal hemorrhage. She had
2 subsequent MRIs (first without contrast, and second with
contrast) which showed the bleed had decreased in size.
Neurological exam shows left hemiplegia, neglect and extinction
to visual/tactile stimulation. Blood pressures were controlled
with strict goal of SBP <140 while in the ICU. With regards to
etiology of her bleed, the etiology remained unclear.
Reassuringly, there was no obvious mass, amyloid angiopathy or
mass on imaging.
BP was elevated to the 160's on presentation and that may have
been the cause. There was no evidence of amyloid angiopathy on
MRI. She denies any constitutional symptoms to suggest
malignancy and there is no mass effect. She has no family or
personal history of AVM or aneurysm. She has a bed in rehab at
___, we will discharge to rehab at 1pm and arrange
follow up outpatient MRI and Neurology Clinic.
Neuro:
- Check risk factors: repeat fasting lipid panel and HBA1c
pending
- Continue close BP control with goal SBP<140 (see below)
- prn hydralazine 10mg q4h prn for sBP >140
- Consider rechecking CT head if clinical scenario worsens
- Will arrange outpatient follow up MRI in 2 months
- ___ recs for rehab services
CV:
- Continue to monitor by telemetry
- keep sBP <140
- prn labetalol 10mg q4h prn for sBP >140
- Continue propranolol 20mg BID (home med)
- Continue HCTZ 25mg (home med)
PULM: hx of asthma
- Cont proair and flovent (home meds)
ID: question of dysuria but normal UA
ENDO:
- Continue levothyroxine (home med)
-finger sticks have been at goal, okay to dc ___
FEN:
- FEN: Advance diet to nectar thick liquids and ground solids
- Sodium has been low on this admission (129-134) consistent
with hypovolemic hyponatremia. We encouraged po intake. Her
sodium was 130 at discharge. Please check another basic
chemistry within ___ days of transfer to ___
PPX:
DVT: ppx with HSQ and pneumoboots
GI: ppx with colace, senna, omeprazole (home med)
Precautions: fall and aspiration
# Transitional Issues:
1) Will need repeat MRI w and w/o contrast in 2 months, which is
scheduled.
2) Please check a repeat sodium in ___ days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
5. Propranolol 20 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Propranolol 20 mg PO BID
7. Acetaminophen 650 mg PO Q6H:PRN pain/fever
8. Atorvastatin 40 mg PO DAILY
9. Docusate Sodium 100 mg PO BID constipation
10. Heparin 5000 UNIT SC TID
11. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right parietal hemorrhagic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurological exam shows left hemiplegia, neglect and extinction
to visual/tactile stimulation.
Discharge Instructions:
Dear ___,
___ was a pleasure to take care of you at ___.
You were admitted on ___ with clumsiness of your left arm.
When you arrived a Code Stroke was called and an emergent Head
CT found evidence of a new stroke. You were admitted to the
ICU, where a number of tests were done to evaluate the cause of
your stroke. Imaging of your blood vessels showed no
significant abnormality to explain your stroke. We suspect high
blood pressure may have been one possible explanation. You came
out of the ICU and remained stable. Our physical therapists
recommended that you be discharged to a rehab facility and we
made arrangements at ___. We would like you to
obtain a follow up MRI in 2 months and we have scheduled that
for you. Please remain on all of the medications listed in your
discharge summary. Thank you for allowing us to participate in
your care.
Followup Instructions:
___
|
19636477-DS-9
| 19,636,477 | 21,449,434 |
DS
| 9 |
2200-09-29 00:00:00
|
2200-09-30 19:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
Mrs ___ is a ___ year-old lady with a history of
hypertension and hemorrhagic stroke who presents with worsening
dizziness and cough.
Two day prior to admission Mrs. ___ started feeling dizzy
and unsteady as well as well as worsening weakness in her left
upper and lower extremities. She further describes her dizziness
as a sensation that the room is spinning. This sensation has
worsened since today at noon which prompted her to come to the
ED. Of note she has been having a mild cough over the last two
day too.
Her ED course is significant for:
-Initial vitals: 98.1 | 88 | 170/74 | 18 | 100% ra, FSG 127
-Given left sided paresis worse than usual a code stroke was
called, her NIHSS was 1 given sequel from prior stroke, a CT
head without contrast revealed no acute hemorrhage and right
temporal encephalomalacia, neurology considered that there was
no stroke and that no further work-up was warranted.
-Exam by neurology resident revealed a few beats of nystagmus
with left gaze in addition to left arm deviation and extinction
(unchanged from prior)
-CBC 5.2>11.8/37.6<284
-Chemistry 137/3.6, 100/26, ___
-Serum and urine tox were negative
-UA was negative
-EKG and TnT x1 negative for ischemia
-A CXR was read as evolving LLL pneumonia
-Vitals prior to transfer: 98.1 | 77 | 142/78 | 15 | 98% RA
On arrival to the floor vitals were 97.8 | 157/68 | 61 | 18 |
100%RA
Patient endorses room spinning sensation accompanied by nausea
upon changing the position of her head laterally or vertically.
She admits additionally to having intermittent chills for four
days.
ROS: Please see HPI.
Past Medical History:
-HTN
-Right parietal hemorrhagic stroke
-Asthma
-Hyperlipidemia
-GERD
-Multinodular goiter s/p thyrodectomy
-Overactive bladder
-Vertigo
Social History:
___
Family History:
No FH of DM, HTN or stroke
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.8 | 157/68 | 61 | 18 | 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Prolonged expiratory phase.
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: AOx3, LUE drift and attenuation but normal grip and
flexor/extensor strength, LLE with paresis (can oppose gravity).
Leftward horizontal inducible nystagmus. Gait deferred due to
discomfort. No dysmetria, no dysdiadochokinesis.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 98.0, 123-140/79-87, 71-84, 20, 99-100% on RA.
General: Pleasant affect, alert and oriented, no acute distress.
HEENT: Sclera anicteric, moist mucous membranes. No nystagmus.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, decreased facial sensation on left and minimal left
facial droop, otherwise CN III-XII intact. LUE prontator drift,
left upper and lower extremity weakness, No dysmetria. ___
strength of right upper and lower extremities.
Pertinent Results:
ADMISSION LABS
==============
___ 02:30PM BLOOD WBC-5.2 RBC-4.85 Hgb-11.8* Hct-37.6
MCV-78* MCH-24.4* MCHC-31.4 RDW-14.2 Plt ___
___ 02:30PM BLOOD Neuts-56.5 ___ Monos-6.1 Eos-1.5
Baso-0.6
___ 02:30PM BLOOD ___ PTT-31.0 ___
___ 02:30PM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-137
K-3.6 Cl-100 HCO3-26 AnGap-15
___ 02:30PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.9
DISCHARGE LABS
==============
___ 06:52AM BLOOD WBC-4.6 RBC-4.49 Hgb-10.9* Hct-34.4*
MCV-77* MCH-24.3* MCHC-31.8 RDW-13.9 Plt ___
___ 06:52AM BLOOD Neuts-54.5 ___ Monos-5.8 Eos-1.6
Baso-0.4
___ 06:52AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-138 K-4.1
Cl-106 HCO3-24 AnGap-12
LIVER LABS
===============
___ 02:30PM BLOOD CK(CPK)-54
CARDIOLOGY LABS
===============
___ 02:30PM BLOOD CK-MB-1 cTropnT-<0.01
SERUM TOXICOLOGY
================
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE TOXICOLOGY
================
___ 03:06PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINALYSIS
==========
___ 03:06PM URINE Color-Straw Appear-Clear Sp ___
___ 03:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 03:06PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-5
TransE-<1
MICROBIOLOGY
============
URINE CULTURE: ___: Mixed bacterial flora, consistent with
skin and/or genital contamination.
IMAGING
=======
___: CT HEAD WITHOUT CONTRAST
FINDINGS:
No acute infarction, hemorrhage, edema, or mass effect. Right
parietal
encephalomalacia from prior hemorrhage is demonstrated with
associated ex
vacuo dilatation the posterior body and trigone of the right
lateral
ventricle. Bilateral subcortical and periventricular white
matter
hypodensities are nonspecific but likely represent sequela of
chronic small vessel ischemic disease and are similar to prior
CT and MRI exams.
Calcification of the posterior falx is noted. The
perimesencephalic cisterns are patent.
No fracture. The partially visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial abnormality, including no intracranial
hemorrhage.
2. Right parietal encephalomalacia.
___: CHEST X-RAY (PA AND LATERAL)
FINDINGS:
PA and lateral views of the chest provided.
There is increased opacity overlying the spine on lateral
projection, which is most likely due to positioning. Pulmonary
vasculature is normal. Cardiomediastinal and hilar contours are
normal. There are no pleural effusions. Prior thyroidectomy
clips are noted. S-shaped scoliosis again
seen.
IMPRESSION:
No evidence of pneumonia.
Brief Hospital Course:
___ w/hx of R hemorrhagic CVA and HTN presenting with vertigo,
cough and chills.
#Vertigo: Mrs. ___ presented to ___ with vertigo two days
after experiencing rhinorrhea, cough and chills. She noted the
vertigo was positional and occurred when she moved her head too
quickly. Given her history of hemorrhagic CVA of right parietal
region, there was concern for a central process as cause of her
vertigo. A code stroke was called in the Emergency Department.
She underwent a CT Head without Contrast which showed no acute
intracranial abnormality including no intracranial hemorrhage.
She was evaluted by Neurology in the Emergency Deaprtment who
did not believe she was having an active stroke. She was noted
to be orthostatic while in the Emergency Department and per
Neurology, the cause of the dizziness was thought to be related
to orthostasis. She was noted to have minimal horizontal
nystagmus on day of admission which resolved during
hospitalization. Although orthostasis was thought to be cause of
vertigo, likely contributing factor was her upper respiratory
tract infection approximately 2 days prior to symptoms. She
likely experienced labyrinthitis which resolved after URI
resolved. She worked with physical therapy prior to discharge
without any further episodes of dizziness. She did not require
meclizine during hospitalization. Per recommendations from
physical therapy, she will be discharged with home physical
therapy. If vertigo returns, she may benefit from vestibular
therapy.
# Upper Respiratory Tract Infection: Mrs. ___ presented
with symptoms of cough, fever, and rhinorrhea. Although initial
X-ray read mentioned increased opacity overling spine on lateral
projection, this was likely related to positioning. Final read
indicated "no evidence of pneumonia." She initially was treated
with levofloxacin for two doses until final read indicated no
evidence of pneumonia. Rhinorrhea and cough had resolved by the
time of discharge. She was not discharged on antibiotics.
# Orthostatic Hypotension: During hospitalization, Mrs. ___
was noted to have orthostatic hypotension. She was not
symptomatic. She received IVF during hospitalization with
resolution of the orthostatic hypotension. She was able to work
with physical therapy without further episodes of orthostatic
hypotension. One reason for her initial presentation of
orthostatic hypotension may have been secondary to her use of
hydrochlorothiazide. She was continued on HCTZ, with goal to
discuss with outpatient provider whether continuing with HCTZ or
switching to a different anti-hypertensive agent may be
beneficial to avoid further orthostatic hypotension.
# HYPERTENSION: During hospitalization was continued on
propanolol 20 mg PO BID and hydrochlorthiazide 12.5 mg PO daily.
Please see above regarding "Orthostatic Hypotension."
# MICROCYTIC ANEMIA: during hospitalization, patient noted to
have microcytic anemia with MCV 77 (H/H 10.9/34.4). Please
consider appropriate cancer screening and/or iron studies to
assess microcytic anemia.
# S/P Right Parietal Hemorrhagic Stroke: Left sided deficits
were baseline relative to previous physical examinations. She
was continued on atorvastatin 20 mg PO QPM. Also continued on
anti-hypertensive medication as noted above.
# HYPOTHYROIDISM: Continued with levothyroxine sodium 100 mcg PO
daily.
# ASTHMA: No exacerbations during hospitalization. Continued
with albuterol inhaler 2 puff IH Q6H:PRN wheezing, flovent HFA
220 mcg/actuation inhalation BID, fluticasone propionate nasal
spray 1 spray BID. -c/w flovent and prn albuterol
# OVERACTIVE BLADDER: Continued with tolterodien 2 mg PO daily,.
# GASTROESOPHAGEAL REFLUX DISEASE: Continued with omeprazole 40
mg PO daily.
TRANSITIONAL ISSUES
===================
-Consider discontinuation of HCTZ in place of a different
anti-hypertensive agent given that she is experiencing
orthostatic hypotension.
-during hospitalization, patient noted to have microcytic
anemia. Please consider appropriate cancer screening and/or iron
studies to assess microcytic anemia.
-if continues to have vertigo, please consider ___
rehabilitation.
-Code Status: Full Code (confirmed)
-Name of health care proxy: ___
___: Husband
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 20 mg PO BID
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral BID
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Atorvastatin 20 mg PO QPM
7. Tolterodine 2 mg PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN pain
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Omeprazole 40 mg PO DAILY
11. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Atorvastatin 20 mg PO QPM
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Tolterodine 2 mg PO DAILY
10. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
11. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Vertigo
Orthostatic Hypotension
Upper Respiratory Tract Infection
SECONDARY DIAGNOSIS
===================
Hypothyroidism
Asthma
Overactive Bladder
Gastroesophageal Reflux Disease
Right parietal hemorrhagic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after
experiencing vertigo (sensation that room spinning). You
underwent imaging of your brain to assess if you were having a
stroke. This showed you were not having a stroke. Given that you
were experiencing an upper respiratory tract infection prior to
the development of the vertigo, your presentation was likely
related the viral infection. During hospitalization you were not
experiencing further episodes of the dizziness.
While hospitalized your blood pressure was also noted to
fluctuate. Please discuss with your primary care physician your
blood pressure medication regimen.
It was a pleasure taking care of you during your
hospitalization. We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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