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19636793-DS-9
| 19,636,793 | 20,890,087 |
DS
| 9 |
2175-06-06 00:00:00
|
2175-06-09 19:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
makeral fish / Statins-Hmg-Coa Reductase Inhibitors / Iodine and
Iodide Containing Products
Attending: ___
Chief Complaint:
Hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx AF/AFl (c/b SSS, s/p PPM), ___ edema, urinary
retention (self caths BID), chronic MSK pain (shoulders, back)
who had a recent ablation procedure for AFl and now presents
with R hip pain.
On ___, patient had uncomplicated flutter ablation and was
discharged home. One week PTA, he developed right hip pain which
has been persistent since. It's better with ambulation and worse
with lying down and with inactivity; it's been disrupting his
sleep. Given worsening of this pain, he presented to the ED for
evaluation.
In the ED intial vitals were: 97.7 68 145/100 17 99%. Eval
notable for:
- Labs: Hgb 9.5 -> 9.3 (down from 11.1 at discharge), no
leukocytosis; Chem notable for K 7.1 hemolyzed (K 4.5 on
repeat), Cr 0.9; INR 4.2; UA with Lg ___, Pos Nitr, WBC, few
bact, 0 epis.
- Studies:
- Interventions: acetaminophen, ceftriaxone, home meds
(oxycodone ___, furosemide, metoprolol, omeprazole, bowel
medications).
- Consults: EP has seen pt, advised admit under attending ___
___.
Vitals on transfer: 98.0 68 160/67 18 99% RA.
On the floor, he recounts the history above. Additionally, he
reports several days of feeling "not quite himself" at home,
thought he had a fever so took a temp (apparently 99.x, not sure
of exact value). He denies cough, dysuria (though UA as above in
stg of self-cath), or skin changes that he's noticed.
Furthermore, he denies chest discomfort, SOB, heart failure
symptoms (DOE, orthopnea, PND, fatigue, weight gain), or
palpitations.
Past Medical History:
- Cardiac: HTN, HL, A Fib/Flutter w SSS s/p ___ Sci PPM ___
- Vascular: Chronic venous ___ edema
- Heme: anemia (unclear etiol, workup ongoing)
- GI: GERD
- GU: urinary incontinence w/ retention (BID self cath).
radiation proctitis in the past
- Neuro: gait disorder (?), cervical myelopathy, peripheral
neuropathy
- MSK: bilat shoulder OA (home narcotics); chronic back pain
- Other: statin intolerance (muscle weakness, incr CK)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS 98.3 138/88 65 18 100/ra
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: No JVD. No cervical or supraclav LAD
COR: RRR. Soft ___ SEM loudest at RUSB, nonradiating.
LUNGS: No incr WOB. CTAB.
ABD: NABS. Soft, NT, ND.
EXT: WWP. 2+ dp/pt pulses.
- 2+ symmetric bilat ___ edema, sacral edema. Both LEs with
changes of chronic venous stasis.
- minimal ttp over the R hip
SKIN:
- RLE erythematous over most of the R shin and wrapping around
to posterior leg, warmer than LLE, skin more ttp; no bullae or
crepitance.
- No e/o hematoma on skin surface of R flank or thigh
NEURO: A&Ox3.
DISCHARGE PHYSICAL EXAMINATION:
VS:98.2 151/67 69 20 98RA
Wt: 77.8 -> 77.0 -> 77.6
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: No JVD.
COR: RRR. Soft ___ SEM loudest at RUSB, nonradiating.
LUNGS: No incr WOB. CTAB.
ABD: NABS. Soft, NT, ND.
EXT: WWP. 2+ dp/pt pulses.
- 2+ symmetric bilat ___ edema, sacral edema. Both LEs with
changes of chronic venous stasis.
- Minimal ttp over the R hip, no e/o ecchymosis or compartment
syndrome
SKIN:
- RLE erythematous over most of the R shin and wrapping around
to posterior leg, warmer than LLE, skin more ttp; no bullae or
crepitance. Erythema receded slightly from previously marked
borders. Color appears faded slightly compared to prior
- No e/o hematoma on skin surface of R flank or thigh
- Punctate excoriations across upper back, chronic per patient
NEURO: A&Ox3.
Pertinent Results:
SELECTED LABORATORY RESULTS:
___ 12:55PM BLOOD WBC-7.3 RBC-3.55* Hgb-9.5* Hct-30.3*
MCV-85 MCH-26.7* MCHC-31.4 RDW-18.1* Plt ___
___ 05:22AM BLOOD WBC-9.1 RBC-3.29* Hgb-8.6* Hct-27.9*
MCV-85 MCH-26.1* MCHC-30.8* RDW-18.7* Plt ___
___ 12:55PM BLOOD Neuts-57.1 ___ Monos-8.3 Eos-2.9
Baso-0.5
___ 12:55PM BLOOD ___ PTT-65.8* ___
___ 07:25AM BLOOD ___ PTT-45.4* ___
___ 05:22AM BLOOD ___ PTT-36.2 ___
___ 12:55PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-135
K-7.1* Cl-99 HCO3-28 AnGap-15
___ 05:22AM BLOOD Glucose-87 UreaN-21* Creat-0.7 Na-136
K-4.1 Cl-99 HCO3-28 AnGap-13
___ 04:57PM BLOOD proBNP-___*
___ 07:25AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.3 Mg-1.9
___ 05:19AM BLOOD %HbA1c-5.8 eAG-120
___ 02:59PM BLOOD K-5.9*
___ 04:34PM BLOOD K-4.5
IMAGING STUDIES:
CT abd/pelvis ___:
Intramuscular hematoma within the adductor compartment of the
medial right upper thigh measuring approximately 9.7 x 6.8 x
11.8 cm. No intrapelvic extension.
RLE U/S ___:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Right groin hematoma.
RIGHT HIP X-RAY ___:
No acute fracture or dislocation.
ECHO ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Normal right ventricular cavity size with
normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened with
good leaflet excursion and no aortic stenosis. There is trace
aortic regurgitation. Mild (1+) 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 global biventricular systolic function.
Mild mitral regurgitation. Mild pulmonary artery systolic
hypertension. Dilated ascending aorta.
MICROBIOLOGY:
Urine culture ___:
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. ___ is a ___ hx AF/AFl (c/b SSS, s/p PPM), urinary
retention (self catheterizes BID), chronic MSK pain (shoulders,
back) who had ablation procedure ___ for AFl now presenting with
R hip pain, found to have thigh hematoma, UTI and cellulitis.
# R thigh hematoma: CT scan demonstrated a 9.7 x 7 x 11 cm
hematoma in the right pelvis. An ultrasound was notable for no
AV
fistula, pseudoaneurysm or venous thrombosis. No evidence of
compartment syndrome. Downtrending Hgb concerning for ongoing
low rate of bleeding in stg of anticoagulation. No hemodynamic
instability. ___ was notified and recommended no acute
intervention.
# Cellulitis: He presented with cellulitis of RLE. No e/o
purulence or deeper soft tissue infection. He was treated with
ceftriaxone which was subsequently broadened to vanc/CTX given
concern for community acquired MRSA. Boundaries were demarcated
and rash began to improve during his admission. He was
discharged on Bactrim/Keflex with plan to complete 14-day course
of treatment for cellulitis/UTI (last day ___.
# Urinary tract infection: Patient straight catheterizes at
baseline. On admission UA was notable for ___, +nitrites, WBCs,
few bacteria, 0 Epi. Urine culture grew Serratia. Given concern
for complicated UTI he was started on ceftriaxone with plan to
complete 14 day course of antibiotics with Bactrim/Keflex for
UTI/cellulitis.
# AF/AFL: CHA2DS2VASC = 2 (age, male). He had recent ablation
procedure as above, also had PPM for history of sick sinus
syndrome. Telemetry notable for brief episodes of tachycardia
___ beats) c/w possible breakthrough A-flutter, asymptomatic
and subsequently returns to sinus rhythm. He was restarted on
metoprolol succinate 25mg daily. Warfarin was supratherapeutic
on admission and initially held, subsequently restarted. He will
need INR check on ___.
# Edema: He was also noted to have bilateral ___ and sacral
edema, consistent iwth mild HFpEF. TTE ___ with LV wall
thickening, normal size and function. After H/H stabilized he
was resumed on home lasix 20mg daily. Repeat TTE with EF 55%,
mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function.
CHRONIC ISSUES:
# GERD: Continued omeprazole
# MSK pain: Continued home oxycodone 10 TID:PRN, oxycontin 20 PO
BID
TRANSITIONAL ISSUES:
- He was discharged on Bactrim and Keflex with plan for 14-day
total course. Last day of therapy is ___.
- He had few episodes of tachycardia lasting several seconds
which may represent breakthrough atrial flutter. This should be
further evaluated as appropriate in the outpatient setting.
- INR was supratherapeutic on admission and warfarin was held;
subsequently INR became subtherapeutic and warfarin was
restarted. He will need INR check on ___ with close followup by
PCP after discharge.
- Ezetimibe was held during this admission due to concern for
medication interactions and may be restarted if appropriate in
the outpatient setting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 10 mg PO TID:PRN pain
6. OxyCODONE SR (OxyconTIN) 20 mg PO BID
7. Warfarin 2.5 mg PO DAILY16
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID
10. melatonin 5 mg oral QHS
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Outpatient Lab Work
Please check INR on ___. (ICD-9 427.31)
Fax results to ___. MD, ___.
2. Docusate Sodium 100 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO TID:PRN pain
7. OxyCODONE SR (OxyconTIN) 20 mg PO BID
8. Warfarin 2.5 mg PO DAILY16
9. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth Three times a
day Disp #*30 Tablet Refills:*0
10. Cephalexin 500 mg PO Q12H
Last day of therapy is ___
RX *cephalexin 500 mg 1 capsule(s) by mouth Twice a day Disp
#*25 Capsule Refills:*0
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. melatonin 5 mg oral QHS
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
Last day of therapy is ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth Twice a day Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Thigh hematoma
Cellulitis
Urinary tract infection
SECONDARY DIAGNOSES:
Atrial fibrillation / Atrial flutter s/p ablation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to a large bruise (hematoma) at the
site of your recent cardiac catheterization. You were also found
to have urinary tract infection and cellulitis. You were treated
with antibiotics for infection.
After discharge, please follow up with your doctors as
___ below. Please also continue to take your antibiotics
as directed.
Followup Instructions:
___
|
19636798-DS-18
| 19,636,798 | 20,433,160 |
DS
| 18 |
2112-06-09 00:00:00
|
2112-06-09 17:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
ORIF on ___
History of Present Illness:
___ w/ hx of alzheimer's dementia, HTN, CAD w/ stents who
presents s/p unwitnessed fall. Report from ___ was that she
was found on the ground by daughter, complaining of left hip
pain, and suffered a parietal scalp lac. At ___, her lac was
stapled, and she was pan-scanned. CT head shows 3mm left
parietal SDH. CT torso shows left introch femur fx. Transferred
to ___ for further management.
Past Medical History:
PMH/PSH (per ___):
alzheimer's dementia, HTN, CAD w/ stents
Social History:
___
Family History:
NC
Physical Exam:
On Admission, per OMR:
PHYSICAL EXAMINATION:
In general, the patient is an awake, confused ___
Vitals:
98.2 98 162/88 18 96%
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Shortened and internally rotated left leg
Full, painless AROM/PROM of knee, and ankle
Painful ROM of left hip
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
On discharge:
97.7 | 158/77 | 80 | 18 | 96%RA
Gen: Calm, lying in bed, comfortable
HEENT: Laceration over left scalp, EOMI, +cataracts, clear OP
Neck: Supple
Lungs: CTAB, good air movement, unlabored
Heart: RRR, Nl S1/S2, No MRG
Abd: Soft, ND/NT, NABS
Extr: 2+ distal pulses, good capillary refill, no peripheral
edema.
Neuro: Awake and alert. Oriented to self and hospital. Not
oriented to time nor timecourse of events that brought her here.
Tangential though process. CNs II-XII were intact/symmetric.
Distal sensation is intact and symmetric. Can wiggle fingers and
toes on command.
Pertinent Results:
___ 11:11AM BLOOD WBC-13.6* RBC-3.53* Hgb-9.7* Hct-30.9*
MCV-88 MCH-
CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY; CT ABD & PELVIS
WITH
=
=
================================================================
CONTRAST ___
==================
IMPRESSION:
1. Limited evaluation secondary to thin slices with considerable
background noise. Left femoral intertrochanteric fracture. T11
compression deformity of unknown chronicity. No evidence of
other traumatic injuries within the torso.
2. Small areas of consolidation in right middle lobe and left
lower lobe, as well as centrilobular ___ opacities in
the right upper lobe. These findings could be due to
atelectasis vs aspiration vs infection, although in the setting
of trauma, pulmonary contusions cannot be excluded.
3. 12mm left breast nodular soft tissue, underlying malignancy
could be
present. Correlate with mammographic history and further
evaluation if
appropriate given patient age/history.
4. Large right hypodense thyroid lesion. Non-emergent thyroid
ultrasound
may be performed if clinically indicated.
CT HEAD W/O CONTRAST ___
===============================
COMPARISON: Reference CT from ___.
IMPRESSION:
1. Less aparent right subdural hematoma.
2. Disproportionate dilatation of the temporal horns as compared
to the
lateral ventricles, indicative of medial temporal lobe atrophy.
Brief Hospital Course:
The patient presented to the emergency department on ___ and
was evaluated by the acute care surgery team. The patient was
found to have a hip fracture and subdural hematoma and was
admitted to the Trauma surgery service with consults to both
neurosurgery and orthopaedic surgery. A repeat head CT on
___ was stable, after which neurosurgery cleared the patient
for the OR with orthopaedics.
On hospital day one the patient was transferred to the medicine
service for the remainder of her hospitalization. The patient
was taken to the operating room on ___ for a TFN, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
On ___ the patient developed hyperactive delirium and her
SBP was uncontrolled in the 190s. After downtitrating narcotics
and decreasing tethers as well as hydrating her and restarting
some of her home medications her mental status returned to her
presumed baseline and her SBPs were more controlled in the 150s.
At the time of discharge the patient was afebrile with stable
vital signs , pain was well controlled with oral medications,
incisions were clean/dry/intact, and the patient was moving
bowels spontaneously. She needs a Foley catheter for now due to
urine obstruction. The patient is WBAT on the operative
extremity, and will be discharged on heparin SC 5000U for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was attempted with the patient
regarding the diagnosis and expected post-discharge course,
nonetheless her baseline dementia complicated understanding and
retention. We attempted to reach the patient's daughter without
success and will continue trying.
TRANSITIONAL ISSUES:
====================
#L IT FEMUR FX: Got ORIF w/o complications on ___. Surgical
site is currently clean and without signs of complication. She
is scheduled for orthopedics follow-up appointment on ___.
#SDH: Found on CT at OSH. Was less apparent on CT heat on ___.
Will need to remain on seizure prophylaxis (levitiracetam 500mg
bid) until ___ and neurosurgery follow-up (with prior CT
head) in ___.
#Delirium superimposed on Dementia: Had hyperactive delirium in
the post-operative setting that improved with decrease of
tethers and deliriogenic meds. Back to baseline on discharge.
Would continue to avoid narcotics, reorient frequently and
optimize family presence.
#Urinary obstruction: Had post-operative urinary retention that
required Foley catheter. Voiding trial failed prior to
discharge. Foley catheter was placed once again. Would advise
voiding trial at rehab in 7 days. If failure of voiding trial
would consult Uro-gynecology to replace pessary.
#INCIDENTALOMAS: 12mm Left Nodular Lesion in breast and small
hypodense lesion in R lobe of thyroid may need follow-up
imaging/clinical evaluation depending on clinical correlation
and patient/family preferences.
Medications on Admission:
MEDS:
alfuzosin ER 10 mg tablet,extended release 24 hr oral
1 tablet extended release 24 hr(s) Once Daily
Lumigan 0.01 % eye drops ophthalmic
1 drops(s) , at bedtime
allopurinol ___ mg tablet oral
1 tablet(s) Once Daily
Spiriva with HandiHaler 18 mcg & inhalation capsules inhalation
1 capsule, w/inhalation device(s) , as needed
atorvastatin 40 mg tablet oral
1 tablet(s) , at bedtime
levothyroxine 75 mcg capsule oral
1 capsule(s) Once Daily
Vitamin D3 1,000 unit capsule oral
2 capsule(s) Once Daily am
Aspir-81 81 mg tablet,delayed release oral
1 tablet,delayed release (___) Once Daily
Mapap (acetaminophen) 325 mg tablet oral
2 tablet(s) Every ___ hrs, as needed
Protonix 20 mg tablet,delayed release oral
1 tablet,delayed release (___) Twice Daily
albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for
nebulization inhalation
1 solution for nebulization(s) Every ___ hrs, as needed
Dulcolax (bisacodyl) 5 mg tablet,delayed release oral
2 tablet,delayed release (___) , as needed
lorazepam 1 mg tablet oral
1 tablet(s) Three times daily, as needed
Vitamin B-12 250 mcg tablet oral
1 tablet(s) Once Daily
metoprolol tartrate 25 mg tablet oral
0.5 tablet(s) Twice Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO HS
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Cyanocobalamin 250 mcg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Pantoprazole 20 mg PO Q24H
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Calcium Carbonate 1250 mg PO TID
14. Docusate Sodium 100 mg PO BID
15. Heparin 5000 UNIT SC TID
16. LeVETiracetam 500 mg PO BID Duration: 3 Days
17. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
18. TraZODone 50 mg PO HS
19. Lumigan (bimatoprost) 0.01 % ophthalmic QPM
20. alfuzosin 10 mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
1. Delirium
2. Left intertrochanteric femur fracture
3. Left temporoparietal sub-dural hematoma
4. Left scalp laceration
SECONDARY DIAGNOSES
===================
1. Gout
2. HLD
3. CAD
4. Vitamin B12 Deficiency
5. Hypothyroidism
6. Asthma/COPD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to take care of you during your recent stay at
___. You had a fall and your thigh bone, you also hit your
head and had some bleeding there. Your broken thigh bone was
repaired through surgery and the bleed in your head improved on
its own. After the surgery you were disoriented and agitated,
this is why you were transferred to medicine. You are now better
and closer to your usual self and are ready to go to rehab to
get your strength back.
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 Heparin SC as prescribed for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
If draining, may change daily.
ACTIVITY AND WEIGHT BEARING:
- WBAT
Followup Instructions:
___
|
19636818-DS-11
| 19,636,818 | 25,589,113 |
DS
| 11 |
2200-09-30 00:00:00
|
2200-09-30 15:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ is a ___ woman who was recently admitted to
the
neurosurgery service for elective embolization of an AVM earlier
this month. Her course was complicated by intraventricular
hemorrhage, thalamic infarcts, and hydrocephalus. She presents
in
status epilepticus from her SNF.
Per EMS, she was found unresponsive at her SNF today. She then
had 3 witnessed GTCs and EMS was called. When they arrived she
had another seizure described as a GTC. She was given intranasal
midaz first, the IV midaz once an IV was established for a total
of 12.5mg total. With the midaz the seizure continued but
evolved
into just right sided shaking. Upon arrival to the ED the
seizure
had lasted ~20 minutes and she was immediately intubated and
sedated. She was given 1000mg of Keppra. NCHCT was done and is
stable. Infectious workup revealed a UTI and she was given a
dose
of CTX in the ED. Propofol was kept at 20.
Per her discharge paperwork, she presented ___ for
embolization of an AVM. After the procedure she had right sided
weakness and right gaze deviation. Head CT showed IPH with IVE
and MRI later also showed a thalamic infarct. Her course was
complicated by hydrocephalus. Upon discharge from ___ ___ she
was nonverbal, tracked the examiner but did not follow command.
Her right pupil was 3mm and left 5mm, both non-reactive. She
withdrew to noxious, though more on the left side.
Review of Systems: unable to obtain given mental status
Past Medical History:
- Thalamic AVM complicated by Intraparenchymal Hemorrhage
___, requiring R frontal EVD placement and R frontal VP shunt
- Chronic Respiratory Failure requiring Trach/PEG ___
- Sarcoidosis
- HTN
- Arthritis
- Gout
- Cervical DDD
- Obesity
Social History:
___
Family History:
Adopted, NC
Physical Exam:
# Admission #
Vitals: 98.3 ___ 21 100%
General: intubated, sedated
HEENT: right scalp shaved with scar c/d/I
Pulmonary: on the vent
Cardiac: regular, tachycardic
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
On brief initial evaluation prior to intubation, the patient was
in sinus tachycardia to 140 and was on supplemental O2. She had
depressed mental status, not regarding the examiners. Her eyes
were open with intermittent right gaze deviation. She had
rhythmic right eyelid twitching and right mouth jerking. Her
head
had rhythmic shaking toward the right. Her right arm had
rhythmic, low frequency, high amplitude shaking. Her right foot
had subtle twitching as well.
Further examination after intubation/sedation:
-Mental Status: Sedated on 20 prop (continued for concern of
recurrence of seizures pending EEG placement). Eyes closed, not
following commands.
-Cranial Nerves: Left eye hypotropic with 5mm non-reactive
pupil.
Right eye with roving movements and pupil 3mm and sluggish.
+corneals bilat. Face appears symmetric w/in the limits of the
ETT. No BTT.
-Motor/Sensory: Increased tone in finger flexors bilaterally. No
movement to light nox stimuli throughout.
-DTRs: no clonus at the ankles. toes mute bilat
DISCHARGE EXAM
Eyes open, nonverbal, not following commands, blinks to threat.
Localizes to noxious stimuli with bilateral upper extremities
and RLE, intermittently crosses midline to localize to pain.
Pertinent Results:
IMAGING:
___ ___
Limited examination secondary to streak artifact from presumed
coils from
prior AVM intervention. Moderate enlargement of the ventricles
is of unknown
chronicity given lack of prior examinations for comparison.
Otherwise, no
acute intracranial abnormalities identified.
NCHCT ___:
Severe streak artifact from the known prior embolization coils,
exacerbated by increased patient head rotation, severely limits
this study, rendering this study nearly nondiagnostic.
1. No apparent change in the course of the right
ventriculostomy catheter.
The visualized left temporal horn appears significantly
decreased in size from
prior examination (series 4, image 9) when compared to
examination of ___ on series 3, image 18). The lateral ventricles are not
visualized.
Repeat examination is recommended.
2. No evidence of new hemorrhage.
___ Shunt series
No discontinuity along the right frontal approach
ventriculoperitoneal shunt catheter.
EEG ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of
(1) rare epileptiform discharges in the left mid-temporal region
which are
less frequent than the previous day, indicative of an area of
potentially
epileptogenic cortex; (2) diffuse slowing of the background
activity in the delta and theta frequency range, indicative of a
moderate severe
encephalopathy, which is etiologically nonspecific. There are no
electrographic seizures. Compared to the previous day's
recording, theleft
temporal discharges are less frequent.
Recent MRI Brain ___:
"1. Study is moderately degraded by motion, and susceptibility
artifact at the coiled vein ___ fistula which obscures
adjacent structures.
2. Medial right thalamic acute to subacute infarct, without
associated hemorrhage.
3. Large parenchymal hemorrhage extending from posterior left
thalamus anteriorly along medial left lateral ventricular body
ependymal surface.
4. Extra-axial hemorrhage layering within the left and right
lateral
ventricles occipital horns and at superior vermis.
5. Right frontal approach ventriculostomy catheter with tip at
right lateral ventricle anterior horn.
6. Ventricular dilatation mildly increased compared to ___,
concerning for hydrocephalus."
___ 03:33AM BLOOD WBC-6.8 RBC-2.73* Hgb-8.2* Hct-26.1*
MCV-96 MCH-30.0 MCHC-31.4* RDW-14.6 RDWSD-50.8* Plt ___
___ 03:33AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-140
K-4.1 Cl-105 HCO3-25 AnGap-14
___ 03:33AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
Brief Hospital Course:
HOSPITAL COURSE
# Status epilepticus
- She presented following 4 GTCs and prior to hospitalization
received Nasal midaz, IV midaz, with continuation of seizure.
In the ED, event lasted roughly 20 minutes and she was
intubated. She was loaded with 1G Keppra, with standing dose
increased to 1g BID. Infectious evaluation revealed UTI for
which she was started on antibiotics. EEG was established, but
following intubation without evidence of seizure. She was taken
to the ICU and extubated the following day. EEG revealed (1)
rare epileptiform discharges in the left mid-temporal region
that decreased in frequency and diffuse slowing of the
background activity in the delta and theta frequency; no
electrographic seizures. She was transferred to the floor and
her exam remained at its baseline (withdraws to pain in RLE and
bilateral upper extremity, blinks to threat, pupils sluggishly
reactive, nonverbal and does not follow commands). Repeat head
CT difficult to interpret given coil artifact but showed
decreased size of R temporal horn. Her Keppra was increased to
1000mg BID.
#Urinary Tract Infection
- U/A on admission was dirty with concern for MDR organism based
on recent urine cultures. She was started on Zosyn pending
cultures and at time of discharge urine cx revealed GNR pending
speciation.
Transitional Issues:
--Urine cx GNR, pending speciation. Please call to follow-up
results. Continue on Zosyn until ___ for 7 day course given
patient has indwelling foley. ___ narrow as able pending urine
culture. A foley is currently in place given incontinence and
coccyx ulcer; please trial removal of foley pending wound
healing and s/p antibiotic treatment.
--Stage 3 ulcer on coccyx, please follow wound care RN
instructions below:
Pressure relief measures per pressure ulcer guidelines.
Turn side to side off coccyx
Limit sit time to 1 hr and sit on a pressure redistribution
cushion
Cleanse the sacral wound with Commercial wound cleanser, pat dry
Apply wound gel into the wound
Cover with Mepilex Sacral foam border dressing
Change every 3 days or as needed.
Support nutrition/hydration.
--Discharged with foley catheter in place given incontinence and
coccyx ulcer; PICC also in place
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Amlodipine 5 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. LeVETiracetam Oral Solution 500 mg PO BID
8. Senna 8.6 mg PO QHS
Discharge Medications:
1. Acetaminophen 325-650 mg NG Q6H:PRN fever or pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. LevETIRAcetam 1000 mg PO BID
4. Piperacillin-Tazobactam 4.5 g IV Q8H
End date ___
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. Amlodipine 5 mg NG DAILY
7. Docusate Sodium 100 mg NG BID
8. Famotidine 20 mg NG BID
9. Senna 8.6 mg NG QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Status Epilepticus, UTI
Discharge Condition:
Stable
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a prolonged seizure called
status epilepticus that required you to have a breathing tube.
You were found to have a urinary tract infection and are being
treated with an antibiotic. You will go back to rehab and follow
up otuaptient with Neurology and Neurosurgery.
Followup Instructions:
___
|
19636818-DS-9
| 19,636,818 | 21,757,194 |
DS
| 9 |
2200-03-25 00:00:00
|
2200-03-25 14:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Decanulated Trach, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of sarcoid, thalamic AVM s/p trach and PEG living
at rehab who presents to the hospital after decannulation of
trach at rehab on the day of presentation. She was also noted
to have bleeding at the trach site. Additionally, she
desaturated to 90% and was tachycardic.
In the ED, VS: 100.0 110 122/64 22 94%RA
She was found to be febrile while in ED to Tmax 102.6
Her neurological status was at baseline.
She received 1L NS, APAP 1 g, Vancomycin 1 gm,
Piperacillin-Tazobactam 4.5 gm IV.
Notable labs: WBC 18.1 (81% PMN), hgb 10
Imaging: CXR pending
Consults: ACS
On arrival to the FICU, Pt was afebrile and HDS. Pt was
nonverbal (baseline), but responded to commands bilaterally.
Past Medical History:
- Thalamic AVM complicated by Intraparenchymal Hemorrhage
___, requiring R frontal EVD placement and R frontal VP shunt
- Chronic Respiratory Failure requiring Trach/PEG ___
- Sarcoidosis
- HTN
- Arthritis
- Gout
- Cervical DDD
- Obesity
Social History:
___
Family History:
Adopted
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.8 BP: 147/85 P: 107 R: 34 O2: 96%
GENERAL: Nonalert, eyes closed, responds to voice, responds to
b/l commands
HEENT: AT/NC, PERRL, trach site c/d/i,
NECK: supple
LUNGS: CTAB
CV: RRR, S1 + S2 present no mrg
ABD: SNTND, +BS, PEG site c/d/i
EXT: WWP, PPP, no edema b/l
NEURO: AOx0. Not alert. Nonverbal at baseline. Wiggles toes b/l
and squeezes hands b/l to command
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
====================================
___ 01:25AM BLOOD WBC-18.1*# RBC-3.14* Hgb-10.0* Hct-30.3*
MCV-97 MCH-31.8 MCHC-33.0 RDW-13.5 RDWSD-48.1* Plt ___
___ 01:25AM BLOOD Neuts-81.3* Lymphs-11.1* Monos-6.6
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.74*# AbsLymp-2.02
AbsMono-1.19* AbsEos-0.01* AbsBaso-0.04
___ 01:25AM BLOOD ___ PTT-31.6 ___
___ 01:25AM BLOOD Glucose-143* UreaN-21* Creat-0.5 Na-133
K-4.5 Cl-92* HCO3-25 AnGap-21*
___ 08:15AM BLOOD ALT-56* AST-19 AlkPhos-141* TotBili-0.6
___ 08:15AM BLOOD Albumin-3.8
___ 01:52AM BLOOD ___ Temp-39.2 pO2-86 pCO2-35
pH-7.51* calTCO2-29 Base XS-4 Intubat-NOT INTUBA
___ 01:52AM BLOOD O2 Sat-96
___ 01:38AM BLOOD Lactate-1.6
___ 01:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG
___ 01:45AM URINE RBC-8* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
DISCHARGE LABS
====================================
___ 06:30AM BLOOD WBC-10.8* RBC-2.95* Hgb-9.2* Hct-29.5*
MCV-100* MCH-31.2 MCHC-31.2* RDW-13.4 RDWSD-48.6* Plt ___
___ 08:15AM BLOOD Neuts-78.1* Lymphs-14.4* Monos-6.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-14.05* AbsLymp-2.58
AbsMono-1.17* AbsEos-0.01* AbsBaso-0.05
___ 06:30AM BLOOD Glucose-118* UreaN-15 Creat-0.4 Na-139
K-4.3 Cl-99 HCO3-25 AnGap-19
___ 06:30AM BLOOD ALT-101* AST-29 AlkPhos-194* TotBili-0.4
___ 06:30AM BLOOD Calcium-10.0 Phos-4.1 Mg-1.9
IMAGING AND DIAGNOSTICS
======================================
CXR ___:
IMPRESSION:
Right middle lobe pneumonia.
RUQ US ___:
IMPRESSION:
Extremely limited examination. Patient can be re-scanned when
more clinically stable.
CT head ___:
IMPRESSION:
Further decrease in ventricular size since the previous CT. The
ventricles are small and slit-like. Clinical correlation
recommended.
MICROBIOLOGY
=======================================
Urine Culture: No Growth
Tracheostomy Site:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
___ 11:09 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
Brief Hospital Course:
This is a ___ year old female with past medical history of
sarcoid, recent admission ___ for thalamic IPH complicated by
chronic respiratory failure requiring tracheostomy and PEG tube,
discharged on ___ to acute rehab, who was admitted
following decannulation of her tracheostomy with sepsis
secondary to pneumonia, course complicated by transaminitis, now
resolved.
# Sepsis / Acute Bacterial Pneumonia:
Patient presented with tachycardia, fever, tachypnea and
leukocytosis. She was seen by neurosurgery, who did not feel
that this was related to her recent neurosurgical procedure. CXR
showed a right middle lobe pneumonia. Patient was started on
broad antibiotic therapy. She was eventually narrowed to
cefepime, for which she completed a 7 day course. The patient
clinically improved, and was breathing comfortably on room air
at the time of discharge.
# Transaminitis / LFT abnormality:
Course was complicated by onset of elevated LFTs, with peak at
ALT 255 AST 156 AP 251 Tbili 1.0 on hospital day 3. RUQ
ultrasound without signs of cholestasis or obstruction.
Transaminitis was most likely due to med effect now removed
versus acute hypotensive insult in setting of her initial
sepsis. LFTs were trended and improved with no further
intervention.
# Hypertension:
Patient's anti-hypertensives were held in the setting of sepsis.
These can be restarted, but consider holding one or decreasing
them, as she remained mostly normotensive even without these
medications.
# Intraparenchymal Hemorrhage:
- Continued keppra
# GERD:
- Continued famotidine
TRANSITIONAL ISSUES:
[ ] Monitor blood pressure and consider decreasing or stopping
one or more anti-hypertensives if patient remains normotensive.
[ ] Make sure to keep head of bed elevated at all times to
reduce the risk of aspiration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN fever/pain
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Docusate Sodium (Liquid) 100 mg PO BID constipation
7. Famotidine 20 mg PO BID
8. HydrALAzine ___ mg PO Q4H:PRN SBP >160
9. LeVETiracetam 500 mg PO BID
10. Senna 5 mg PO BID:PRN constipation
11. Sodium Chloride 2 gm PO TID
12. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID constipation
4. Famotidine 20 mg PO BID
5. Heparin 5000 UNIT SC TID
6. LeVETiracetam 500 mg PO BID
7. Senna 5 mg PO BID:PRN constipation
8. Acetaminophen 650 mg PO Q6H:PRN fever/pain
9. HydrALAzine ___ mg PO Q4H:PRN SBP >160
10. Hydrochlorothiazide 25 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Sodium Chloride 2 gm PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Transaminitis / LFT abnormality
# Sinus Tachycardia
# Sepsis / Acute Bacterial Pneumonia
# Intraparenchymal Hemorrhage
# Hypertension
# GERD
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:
Ms ___:
It was a pleasure caring for you at ___. You were admitted
with a serious infection from a pneumonia. You were treated
with antibiotics and improved. You are now ready to return to
rehab.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19637707-DS-21
| 19,637,707 | 27,986,466 |
DS
| 21 |
2138-01-09 00:00:00
|
2138-01-09 15:40:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Influenza Virus Vacc,Specific
Attending: ___.
Chief Complaint:
L distal femur fx
Major Surgical or Invasive Procedure:
___: ORIF L distal femur fx
History of Present Illness:
___ year old female with a history of left unicondylar knee
arthroplasty done at ___ in ___ who
states that she has had intermittent left thigh pain for the
past few weeks with working with physical therapy. Last night
while attempting to go to the bathroom, her leg suddenly gave
way and she collapsed. She was subsequently unable to bear
weight on her left leg and had to crawl to a phone to call for
help. An ambulance initially took her to ___, where
she was found to have a left distal femur fracture on imaging
and was transferred to ___ for further care. She arrived in a
posterior slab long-leg splint and was relatively comfortable.
She also hit her face during the fall but work-up for additional
trauma in the ED did not reveal any injuries.
Past Medical History:
Bipolar d/o
Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: AFVSS
Left lower extremity:
Splint removed, Skin intact
Soft, non-tender thigh and leg
Unable to range knee due to pain, holds knee in flexion
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Discharge Physical Exam:
Left lower extremity:
Soft, non-tender thigh and leg
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
XR Femur - Displaced fracture of distal third of femur, just
proximal to unicondylar knee arthroplasty. Anterior angulation
of fracture from outside images.
___ 09:45AM BLOOD WBC-15.4* RBC-3.49* Hgb-10.5* Hct-33.6*
MCV-96 MCH-30.2 MCHC-31.4 RDW-14.5 Plt ___
___ 02:00PM BLOOD WBC-16.4* RBC-3.30* Hgb-10.2* Hct-31.8*
MCV-96 MCH-30.8 MCHC-32.0 RDW-14.8 Plt ___
___ 07:30AM BLOOD WBC-12.9* RBC-2.86* Hgb-8.5* Hct-27.5*
MCV-96 MCH-29.7 MCHC-30.9* RDW-14.8 Plt ___
___ 05:35AM BLOOD WBC-11.4* RBC-2.82* Hgb-8.5* Hct-27.2*
MCV-97 MCH-30.2 MCHC-31.3 RDW-14.9 Plt ___
Brief Hospital Course:
___ year old female with presents with a left distal third femur
fracture, several months after a unicondylar knee arthroplasty.
She was admitted to orthopedics service and underwent ORIF of
the L femur on ___ by Dr. ___.
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. Physical therapy
saw the patient and recommended discharge to a rehab facility
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is Touch down weightbearing in the
Right lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 90 mg PO DAILY
2. Lithium Carbonate 300 mg PO DAILY
3. Levothyroxine Sodium 175 mcg PO DAILY
4. LaMOTrigine 200 mg PO DAILY
Discharge Medications:
1. Duloxetine 90 mg PO DAILY
2. LaMOTrigine 200 mg PO DAILY
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Lithium Carbonate 300 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H
6. Diazepam 5 mg PO Q6H:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC Q24H Duration: 30 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc q24 Disp #*30 Syringe
Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth q4-6
Disp #*40 Tablet Refills:*0
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
q4-6 Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
ORIF L distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
-Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
TDWB
Physical Therapy:
TDWB
hip strengthening and quad strengthening
Treatments Frequency:
Dressing changes daily
TDWB
Staples removal on first postop visit or POD14
Followup Instructions:
___
|
19637978-DS-12
| 19,637,978 | 28,257,720 |
DS
| 12 |
2164-11-01 00:00:00
|
2164-11-01 17:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ hx scoliosis and restrictive lung disease, now s/p lap
cholecystectomy for gangrenous cholecystitis. Readmitted with
subjective fever and tachycardia, CT scan negative for RUQ
pathology or pulmonary embolus, nontender on exam. Wean
supplemental oxygen. Continue regular diet. Continue VTE
chemoprophylaxis.
Past Medical History:
PMH:
- restrictive lung disease ___ scoliosis and prior severe PNA
- HTN
-OSA on CPAP
- Arthritis
-Asthma and sinusitis
-s/p spinal fusion
- GERD
Social History:
___
Family History:
Daughter with h/o choledocolithiasis s/p CCY
Physical Exam:
Admission Physical Exam:
Vitals: T 99 HR109 BP 152/70 RR 23 sat 95% 2L nasal cannula
GEN: A&O, nontoxic/anxious, appears comfortable
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: respirations unlabored
ABD: Soft, nondistended, nontender, no rebound or guarding,
no palpable masses, abdominal incisions healing well with no
purulence fluctuance or erythema. Moderate old/healing
ecchymoses around periumbilical port port site
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.6 PO 118 / 66 R Lying 94 16 95 0.5l Nc
GEN: well appearing. pleasant and interactive.
HEENT: PERRL, EOMI. nares patent.
CV: RRR
PULM: Clear bilaterally.
ABD: Soft, non-tender, non-distended. Laparoscopic sites CDI
with steri strips in place.
EXT: Warm and dry. No edema.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 05:29AM BLOOD WBC-7.2 RBC-3.93 Hgb-10.1* Hct-34.1
MCV-87 MCH-25.7* MCHC-29.6* RDW-19.8* RDWSD-63.2* Plt ___
___ 02:20AM BLOOD WBC-10.9* RBC-4.21 Hgb-10.8* Hct-36.2
MCV-86 MCH-25.7* MCHC-29.8* RDW-19.9* RDWSD-62.4* Plt ___
___ 05:29AM BLOOD Glucose-98 UreaN-4* Creat-0.7 Na-143
K-3.8 Cl-104 HCO3-30 AnGap-9*
___ 02:20AM BLOOD Glucose-112* UreaN-4* Creat-0.8 Na-141
K-3.6 Cl-103 HCO3-28 AnGap-10
___ 02:20AM BLOOD ALT-35 AST-37 AlkPhos-179* TotBili-0.4
___ 05:29AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.7
___ 02:56AM URINE Color-Straw Appear-Clear Sp ___
___ 02:56AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
Cultures:
___ 3:00 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending): No growth to date.
___ 2:56 am URINE SOURCE: ___.
URINE CULTURE (Pending):
Brief Hospital Course:
Ms. ___ is a ___ yo F with history of restrictive lung
disease and scoliosis who presented from home POD8 from
laparoscopic cholecystectomy for gangrenous cholecystits with
subjective fevers and tachycardia. White blood cell count was
slightly elevated at 10.9, liver enzymes where normal, and CT
scan of the chest, abdomen/pelvis showed no pulmonary embolism
or new fluid collections. The patient was given IV fluids and
admitted to the surgical floor for further monitoring.
Her vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. She was initially given IV
fluids, which were discontinued when she was tolerating PO's.
Her diet was advanced on HD1 to regular, which she tolerated
without abdominal pain, nausea, or vomiting. She was initially
on 2 L oxygen via nasal cannula and was able to wean down to .5
L. 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. Pathology report was reviewed
with the patient.
On ___ she was discharged home with instructions to follow
up in the ___ clinic as needed given that she was POD9 at that
point and the patient was agreeable with this plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 50 mg PO BID
2. Theophylline SR 300 mg PO BID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Ipratropium-Albuterol Inhalation Spray 2 INH IH DAILY
6. Aspirin 81 mg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ipratropium bromide 42 mcg (0.06 %) nasal BID:PRN congestion
3. Wixela Inhub (fluticasone propion-salmeterol) 250-50
mcg/dose inhalation BID
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shotness of breath/wheeze
8. Losartan Potassium 50 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Theophylline ER 300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Post operative fever
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with fever and were found to have an increase in your white
blood cell count. You had a CT scan of your chest and abdomen
that did not show any new infections or blood clots. Your
symptoms improved and you are now doing better, tolerating a
regular diet, and ready to be discharged home.
Please make sure to follow up with your pulmonologist for
further assessment of your lung function.
Your surgical wounds are healing well and your CT scan was
negative for any post operative complications and therefore you
do not need to follow up in the outpatient clinic next week as
long as you continue to do well. If you want to be seen in
outpatient clinic, please call the number listed below to
schedule.
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. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19638386-DS-13
| 19,638,386 | 21,213,741 |
DS
| 13 |
2165-04-20 00:00:00
|
2165-04-20 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ y.o M with history of heavy alcohol use, prior ED visits for
alcohol intoxication, presenting with epigastric pain radiating
to his back that started this morning. He describes this pain as
identical to his episodes of prior pancreatitis. He states that
he was here a few days ago and given Librium, however, because
of tremors, he continued to work. He endorses significant nausea
and vomiting. He reports that he can not keep fluids/food down
without vomiting. He reports only keeping down alcohol. He
attributes these symptoms to his withdrawal. He is from ___
___, and here on a business trip.
He states that he has a constant pain in his LUQ, radiating
toward his back, and causing pressure in his chest, which began
this morning. He states this feels like his typical pain when he
is having acute pancreatitis. He reports his last pancreatitis
episode was approximately 2 weeks ago while he was in ___.
He denies recent Tylenol use. He endorses marijuana use, as well
as the use of an herbal supplement called moringa, however
denies other illicit drug use.
Of note, his last drink was this morning. He has withdrawal
symptoms of tremors, nausea, vomiting, cold sweats, but denies
history of prior withdrawal seizure.
In the ED, initial VS were 99.3 ___ 20 100% RA.
He received 1L NS, 4 mg Zofran and .5 mg IV dilaudid.
Labs were significant for normal CBC, with WBC 5.3, H/H
16.7/49.2, Plt 172; BMP WNL with BUN/Cr ___, ALT/AST
1153/2255 Lipase 97. Lactate 2.7. Toxicology screen with an
ethanol level of 239, with positive benzos.
CXR without acute abnormality. RUQ ultrasound showed a patent
portal vein and a heterogenous liver. He was subsequently
admitted to ___ for alcoholic hepatitis.
ROS: per HPI, denies fever, chills, night sweats, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Upon arrival to the floor, the patient reports that he is
extremely uncomfortable and asking for "dilaudid." He stops the
interview multiple times stated that he is in too much pain to
answer these questions.
Past Medical History:
- EtoH abuse
- Prior acute pancreatitis
Social History:
___
Family History:
+ DM (father)
+ alcoholism
Physical Exam:
Admission Exam:
VITALS: 98.5, 157 / 89, 82 18 100 RA
General: Alert, oriented, no acute distress, however, appears
uncomfortable, and gets up and begins pacing asking for pain
medications
HEENT: Sclera anicteric, mucus membranes very dry, oropharynx
clear, EOMI, PERRL, neck supple
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, tenderness in epigastric, LUQ regions,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding; no CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Discharge Exam:
VITALS: 97.8, 150 / 93, 78, 18, 100 RA
General: Alert, oriented, no acute distress, however, appears
uncomfortable, and gets up and begins pacing asking for pain
medications
HEENT: Sclera anicteric, mucus membranes very dry, oropharynx
clear, EOMI, PERRL, neck supple
CV: normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, improved tenderness in epigastric, LUQ regions,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding; no CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Pertinent Results:
Admission Labs:
___ 07:31PM BLOOD WBC-5.3 RBC-5.20 Hgb-16.7 Hct-49.2 MCV-95
MCH-32.1* MCHC-33.9 RDW-12.0 RDWSD-42.2 Plt ___
___ 07:31PM BLOOD Neuts-69.9 ___ Monos-7.0 Eos-0.4*
Baso-0.8 Im ___ AbsNeut-3.72 AbsLymp-1.15* AbsMono-0.37
AbsEos-0.02* AbsBaso-0.04
___ 08:56PM BLOOD ___ PTT-29.2 ___
___ 07:31PM BLOOD Glucose-114* UreaN-12 Creat-1.2 Na-137
K-4.8 Cl-98 HCO3-25 AnGap-19
___ 07:31PM BLOOD ALT-1153* AST-2255* CK(CPK)-544*
AlkPhos-97 TotBili-0.7
___ 07:30AM BLOOD ALT-910* AST-1360* LD(LDH)-683*
AlkPhos-102 TotBili-1.3
___ 07:30AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.4*
___ 07:31PM BLOOD Lipase-97*
___ 07:31PM BLOOD Albumin-4.1 Iron-PND
___ 07:31PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 07:32PM BLOOD Lactate-2.7*
___ 08:22AM BLOOD Lactate-4.0*
Discharge Labs:
___ 05:31AM BLOOD WBC-5.2 RBC-4.45* Hgb-14.3 Hct-43.3
MCV-97 MCH-32.1* MCHC-33.0 RDW-11.9 RDWSD-42.8 Plt ___
___ 05:31AM BLOOD Plt ___
___ 05:31AM BLOOD Glucose-79 UreaN-5* Creat-0.9 Na-133
K-4.0 Cl-96 HCO3-22 AnGap-19
___ 05:31AM BLOOD ALT-341* AST-218* AlkPhos-85 TotBili-1.8*
___ 05:31AM BLOOD Lipase-76*
___ 05:31AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.2
___ 11:44AM BLOOD ___ pO2-48* pCO2-53* pH-7.38
calTCO2-33* Base XS-4 Comment-GREEN TOP
___ 11:44AM BLOOD Lactate-1.6
Imaging:
CXR: No acute intrathoracic process.
RUQUS:
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Main portal vein is patent.
CT Abd/Pelvis/Chest
FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal
and hilar lymph nodes are not enlarged. Aorta is normal size.
Main pulmonary artery is top normal limits measuring 3 cm.
Cardiac configuration is normal and there is no appreciable
coronary calcification. The lungs are clear. There is no
pleural or pericardial effusion. Please refer to the concurrent
abdomen CT for complete description of the intra-abdominal
findings. There are no bone findings of malignancy.
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneously decreased
attenuation throughout. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. Peripancreatic fat stranding is seen surrounding
the entirety of the pancreas, most apparent around the
pancreatic tail and head (02:59, 68) with fluid tracking along
the left retroperitoneal pericolic space. There is no organized
peripancreatic fluid collection. Parenchymal enhancement
appears uniform. The adjacent vasculature is normal in course
and caliber.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia and oral
contrast within the esophagus, suggesting reflux. The stomach
is otherwise unremarkable. There is approximately 11 cm of
jejunojejunal intussusception with mild upstream jejunal
dilatation without frank obstruction (601b:30). Oral contrast
is seen distal to these loops suggesting transient etiology. No
focal lead point is identified. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
normal.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. There is moderate right hip dysplasia, presumed
congenital, with acetabular uncoverage and mild superolateral
subluxation of the right femoral head. There is associated
flattening of the femoral head with subchondral sclerosis and
cyst formation of both the right acetabulum and the right
femoral head consistent age advanced degenerative changes
(601b:32, 1bF: 2).
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Acute interstitial edematous pancreatitis without vascular
complication or acute peripancreatic fluid collection.
2. Hepatic steatosis.
3. Right-sided hip dysplasia with age advanced degenerative
changes as described above.
4. Approximately 11 cm of jejunojejunal intussusception without
evidence of upstream obstruction and with passage of oral
contrast into distal small bowel loops, likely transient in
nature.
5. Please see the separately submitted report of the same day CT
Chest for findings above the diaphragm.
6. No acute finding in the chest.
Brief Hospital Course:
___ y.o M with history of heavy alcohol use, prior ED visits for
alcohol intoxication, prior acute pancreatitis, presenting with
epigastric pain and elevated ALT/AST and imaging consistent with
acute pancreatitis.
#Acute mild pancreatitis: patient presented with epigastric pain
and CT findings consistent with acute pancreatitis without local
or vascular complications. His lipase was 97 on admission. His
course was uncomplicated and improved with NPO, IVF and pain
control. He began advancing his diet on day 3 to clears and was
back to a regular diet prior to discharge without complication.
Of note, pain control was achieved with Maalox, ibuprofen,
intermittent oxycodone, simethicone, and sucralfate, which he
received for a short course after discharge.
#Alcoholic vs ischemic hepatitis: presented with ALT 1150 and
AST 2250. Given increasing lactate in the setting of
pancreatitis, etiology felt to be a combination of ischemic
(low-flow; not portal vein thrombosis as portal vein patent in
RUQUS) and alcoholic-induced injury. Liver chemistries improved
during hospital course and there were no acute complications
with this issue during the hospitalization. He was seen by
hepatology who recommended no further inpt w/u. RUQUS notable
for hepatic steatosis, seen on CT as well.
#Alcohol withdrawal: patient was maintained on CIWA scale but
did not require significant diazepam during hospital stay.
Continued on MVI, thiamine, and folate. He was seen by social
work and was planned for outpatient substance abuse rehab
facility. Please review transitional issues below as patient
plans to establish care in ___ after discharge.
================================
Transitional Issues:
- Patient is non-hepB immune on serology this admission; please
consider vaccination in the outpatient setting.
- Hepatitic steatosis newly noted on abdominal ultrasound and
CT; please establish care with hepatologist both for known
recurrent acute pancreatitis, alcoholic hepatitis, and concern
for evolving cirrhosis.
- Of note, patient is visiting from ___ and has no PCP. He plans
to move to ___ on the day of discharge (flight booked while
inpatient) to establish care with PCP and hepatology in ___.
He will provide the contact information of new PCP and
hepatologist after arrival in ___. He was provided
prescriptions for a short <1 week course until he can follow up.
- Code: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ChlordiazePOXIDE Dose is Unknown PO Q8H:PRN withdrawal
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 800 mg 1 tablet(s) by mouth q8h PRN Disp #*15
Tablet Refills:*0
3. Maalox/Diphenhydramine/Lidocaine 10 mL PO TID:PRN epigastric
pain
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL 10 mL by mouth TID PRN Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q6h prn Disp #*12 Tablet
Refills:*0
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*14
Tablet Refills:*0
7. Simethicone 80 mg PO QID:PRN bloating/gas
RX *simethicone 80 mg 1 tab by mouth QID PRN Disp #*28 Tablet
Refills:*0
8. Sucralfate 1 gm PO QID
Take 2 hours apart from pantoprazole (also called protonix)
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Alcoholic hepatitis vs ischemic hepatitis
Acute pancreatitis
Secondary diagnoses:
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
We have cared for you in the hospital for your abdominal pain
and chest pain. Your work-up showed acute pancreatitis as well
as liver injury from alcohol use as well as your pancreatitis.
Fortunately, your symptoms improved with IV fluids and pain
medication. It is very important that you stop drinking
alcohol, and we are very happy to hear that you're interested in
an inpatient program. We strongly encourage you commit to that,
as stopping alcohol intake will be the most important step to
improving your health. We have started you on a number of
medications for symptom control. Please take these as prescribed
and please follow up with your new doctors for ___. It
is important that you see a hepatologist (liver doctor). Please
give us the information of the primary care doctor and
hepatologist once you establish care in ___. We will fax
your records over at that time. The number to the floor where
you were staying is ___ if you need to reach someone
from your care team. Please return for evaluation if you develop
worsened abdominal pain, chest pain, shortness of breath, fevers
over 100.4 or shaking chills.
We have greatly appreciated taking part in your care.
Best wishes,
___ 7 Care Team
Followup Instructions:
___
|
19638438-DS-10
| 19,638,438 | 26,644,545 |
DS
| 10 |
2183-12-13 00:00:00
|
2183-12-14 07:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin / azithromycin / codeine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___: L Chest tube placement
History of Present Illness:
Ms. ___ is an ___ woman with a history of stage III
hormone receptor-positive breast cancer in ___ s/p lumpectomy
and chemo, currently on anastrazole, T1N0M0 oral squamous cell
carcioma s/p R hemiglossectomy, presenting with dyspnea. To
briefly summarize her oncologic history, she was diagnosed with
Stage III breast cancer in ___ and treated with a lumpectomy,
radiation, and chemotherapy, and continues on anastrazole daily.
In ___ she presented with a nonhealing tongue ulcer and was
found to have squamous cell carcinoma and underwent a R
hemiglossectomy in ___, notably with a positive superior
margin. Staging imaging was done and CT chest demonstrated
innumerable micronodules and nodules concerning for mets. This
was compared to a previous CT done in the late ___ which per
heme-onc was also abnormal. Because the patient was asymptomatic
and the nodules were somewhat chronic (though worsened), the
decision was made to hold off on any further workup and to
repeat
the CT in 6 months.
About a month ago, she developed dyspnea while on an
international cruise. At baseline she is very active, does lots
of walking and ballroom dancing, and noted she became winded
easily. Her dyspnea is worsened with exertion but is improved
when lying flat. She was found on the cruise to have a left
pleural effusion. She was treated with furosemide, cefuroxime,
and enoxaparin starting on ___. She returned from the boat on
___ and was seen by her primary care physician where she was
satting 90%. She denies any fever, chills, cough, chest pain,
palpitations, lightheadedness, vision changes, or loss of
consciousness.
In the ED, initial vital signs were notable for hypertension,
satting well: 97.7 88 184/102 24 96% RA. Physical exam notable
for diminished breath sounds on the left. Labs demonstrated Na
125, osms 256, normal CBC, normal UA. CXR demonstrated total
opacification of the L hemithorax concerning for a L pleural
effusion as well as lymphangitic carcinomatosis. IP was
consulted
and a ___ Fr pigtail was placed with 1800 blood-tinged amber
fluid
drained.
Upon arrival to the floor, vitals are notable for improved
hypertension (156/91), satting 99% on RA. She is well-appearing,
complains of mild pain at the chest tube insertion site but
otherwise has no complaints.
==================
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
T1N0M0 oral squamous cell carcioma s/p R hemiglossectomy
Stage III breast carcinoma: S/P lumpectomy and chemotherapy left
sides, T2 infiltrating ductal carcinoma ER/PR positive, HER-2
negative, lymphnode positive. S/P chemo and surgical removal
___.
Cataract surgery ___
Constipation
Hemorrhoids
Herpes zoster
Lactose interolance
Osteoporosis
Seasonal allergies
Hearing loss
Social History:
___
Family History:
Mother with breast cancer, brother with lung cancer, both
deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.0 PO BP: 156/91 R Sitting HR: 91
RR: 18 O2 sat: 99% O2 delivery: Ra
GENERAL: Well-appearing woman sitting up in bed, in NAD.
HEENT: Scarring at R tongue base, no erythema or swelling. Head
is NCAT. PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: Firm, immobile R posterior, inferior cervical lymphnode.
No
JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diffuse wheezes in L hemithorax, scattered crackles. No
increased work of breathing. R lung clear to auscultation.
BACK: L-sided chest tube in place, drained 2L of bloody fluid,
mild surrounding tenderness at insertion site. No spinous
process
tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 1132)
Temp: 98.2 (Tm 98.2), BP: 174/100 (146-179/84-111), HR: 90
(77-95), RR: 18 (___), O2 sat: 98% (94-98), O2 delivery: Ra,
Wt: 107.8 lb/48.9 kg
Fluid Balance (last updated ___ @ 1203)
Last 8 hours Total cumulative 240ml
IN: Total 240ml, PO Amt 240ml
OUT: Total 0ml
Last 24 hours Total cumulative 720ml
IN: Total 720ml, PO Amt 720ml
OUT: Total 0ml, Urine Amt 0ml
GENERAL: Well-appearing woman eating breakfast, in NAD.
HEENT: Scarring at R tongue base s/p partial glossectomy. PERRL,
EOMI. Sclera anicteric and without injection. MMM.
NECK: Firm, immobile R inferior cervical/sternal lymphnode. No
JVD.
CARDIAC: Regular rhythm, normal rate. +S1/S2. No
murmurs/rubs/gallops.
LUNGS: Good inspiratory effort. scattered crackles. No increased
work of breathing. decreased breath sounds in L lung. R lung
clear to auscultation. chest tube removed and wound closed.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. DP/Radial 2+
bilaterally.
SKIN: WWP. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:25PM BLOOD WBC-4.0 RBC-4.35 Hgb-13.0 Hct-37.9 MCV-87
MCH-29.9 MCHC-34.3 RDW-12.8 RDWSD-41.0 Plt ___
___ 01:25PM BLOOD Neuts-63.7 Lymphs-16.7* Monos-13.7*
Eos-4.2 Baso-1.2* Im ___ AbsNeut-2.55 AbsLymp-0.67*
AbsMono-0.55 AbsEos-0.17 AbsBaso-0.05
___ 01:25PM BLOOD ___ PTT-27.4 ___
___ 01:25PM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-125*
K-3.5 Cl-82* HCO3-27 AnGap-16
___ 07:55AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9
DISCHARGE LABS:
==============
___ 04:40AM BLOOD WBC-4.5 RBC-4.23 Hgb-12.8 Hct-37.3 MCV-88
MCH-30.3 MCHC-34.3 RDW-13.3 RDWSD-42.8 Plt ___
___ 04:40AM BLOOD Glucose-92 UreaN-12 Creat-0.6 Na-130*
K-3.7 Cl-92* HCO3-26 AnGap-12
___ 04:40AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.0
___ 04:40AM BLOOD
___ 04:33PM PLEURAL Hct,Fl-< 2.0
___ 04:33PM PLEURAL TNC-205* RBC-___* Polys-0 Lymphs-38*
___ Meso-1* Macro-48* Other-13*
___ 04:33PM PLEURAL TotProt-6.9 Glucose-77 LD(LDH)-380
Albumin-3.0 Cholest-99 Triglyc-30 proBNP-471
IMAGING:
========
+CHEST (PA & LAT) ___
IMPRESSION:
Coiled pleural catheter is seen at the left lung base. Interval
decrease in
size of left pleural effusion, now small. Small to moderate
left pneumothorax
now with subpulmonic component suggestive of an trapped left
lung.
Diffuse coarsened interstitial markings bilaterally appears
similar. Cardiac
silhouette appears unchanged.
+CT CHEST W/O ___
IMPRESSION:
Bilateral lymphangitic carcinomatosis and multiple metastatic
nodules have
progressed since ___.
Left pleural pigtail catheter posteromedial within the pleural
space where
there is a moderate left pneumothorax and small layering pleural
effusion.
CXR ___
Left pigtail catheter is in place. Left apical and basal
pneumothorax is
moderate and slightly increased compared to previous
examination. Widespread
parenchymal opacities are unchanged. No appreciable pleural
effusion is
demonstrated. Cardiomediastinal silhouette is unchanged.
Brief Hospital Course:
Ms. ___ is an ___ F with a history of stage III
hormone receptor-positive breast cancer in ___ s/p lumpectomy
and chemo, currently on anastrazole, T1N0M0 oral squamous cell
carcioma s/p R hemiglossectomy in ___, who presents with acute
onset dyspnea, found to have a large L pleural effusion,
re-demonstrated pulmonary nodules c/w lymphangitic
carcinomatosis, and hyponatremia.
ACUTE ISSUES:
=============
#L pleural effusion
#Lymphangitic carcinomatosis: The cause of the patient's
exudative effusion is not clear, however ddx includes malignancy
(most likely) or infectious infusions. The patient has a history
of prior malignancy and swollen LN in the supra
clavicular/sternal region. Cytology and cultures revealed **.
Oncology advised following up the cytology labs and follow up
with outpt oncologist. s/p chest tube, with 2.2L of
serosanguinous fluid, and significant improvement in dyspnea.
Chest tube was temporarily clamped out of concern for
reexpansion pulmonary edema. The chest tube was removed on ___
with no complications
#Hyponatremia: The patient is euvolemic on exam, and with no ___
to suggest hypovolemia. Most likely diagnosis is SIADH from
malignancy. No pain. Urine lytes revealed low solute
hyponatremia. The patient was fluid restricted to 1500 cc and
encouraged to increase her food intake.
# Hypertension: slightly elevated during her hospital stay.
Deferred anti-HTN medications to the outpatient provider.
TRANSITIONAL ISSUES:
====================
- Chest tube was placed on ___ and removed on ___. Please
reassess the site for wound healing.
- Remove ___ placed at the chest tube site on ___
___
- Please recheck her blood sodium levels on follow up visit.
- Consider starting her on ACE-I or CCB for blood pressure
control if elevated blood pressure persists.
- Follow up cytology report for a complete report on the
phenotyping of her malignant cancer cells.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anastrozole 1 mg PO DAILY
2. Alendronate Sodium 5 mg PO 1X/WEEK (___)
3. cefUROXime axetil 250 mg oral QID
4. Furosemide 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Alendronate Sodium 5 mg PO 1X/WEEK (___)
2. Anastrozole 1 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. HELD- cefUROXime axetil 250 mg oral QID This medication was
held. Do not restart cefUROXime axetil until you see your
primary care provider
6. HELD- Furosemide 40 mg PO DAILY This medication was held. Do
not restart Furosemide until you see your primary care provider
___:
Home
Discharge Diagnosis:
Primary diagnosis:
===================
Malignant pleural effusion
Secondary diagnoses:
====================
- history of T1N0M0 oral squamous cell carcioma s/p R
hemiglossectomy
- Stage III breast carcinoma: S/P lumpectomy and chemotherapy
left side, T2 infiltrating ductal carcinoma ER/PR positive,
HER-2 negative, lymphnode positive. S/P chemo and surgical
removal ___.
- Constipation
- Hemorrhoids
- Lactose interolance
- Osteoporosis
- Seasonal allergies
- Hearing loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for shortness of breath. The shortness of
breath was due to fluid accumulating around your left lung.
WHAT HAPPENED IN THE HOSPITAL?
-You were evaluated by the lung doctors.
-___ drained the fluid around your left lung using a chest tube.
-We removed the tube after knowing that there is no more fluid
left to drain.
-We sent a sample of the fluid for analysis. The fluid contained
cancer cells likely from the breast. This indicates that fluid
accumulation occurred because of your breast cancer.
WHAT SHOULD YOU DO AT HOME?
-You should continue to take your medications as prescribed.
-You should follow-up with your doctors as ___ below.
-Please report any shortness of breath, chest pain, any other
concerning symptom.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19638471-DS-4
| 19,638,471 | 26,890,625 |
DS
| 4 |
2152-01-11 00:00:00
|
2152-01-12 16:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefepime / meropenem
Attending: ___.
Chief Complaint:
Flank pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMHx notable for left testicular
cancer (initially staged as I, now stage IIIa based on
metastatic
to lung and paraaortic LN) s/p left orchiectomy ___
(mixed
germ cell tumor with 95% embryonal carcinoma and 5% yolk sac
tumor) currently C3D1 BEP ___ with plan for curative intent who
presented to the ED on ___ with right flank pain and dyspnea
with fever to 102 at home with associated chills. Reports pain
is gradual in onset and pain with inspiration starting
yesterday.
Alleviated by shallow breathing. He denies nausea, vomiting,
hematuria, dysuria, chest pain, diarrhea, constipation.
While in ED, vital signs notable for Tmax 99.8 with normal
saturations on room air and normal blood pressure and heart
rates.
His imaging was notable for CTA torso with segmental and
subsegmental right lower lobe pulmonary emboli with a linear
opacity in the left lung base, likely atelectasis with
superimposed pneumonia.
He received pushes of IV morphine 4mg and IV dilaudid for pain
control. He received IV levofloxacin and IV clindamycin. He
was
started on lovenox for therapeutic dosing of pulmonary embolism.
On arrival to floor, ___ seems to be in significant pain
especially with inspiration. The IV dilaudid alleviated his
pain
from a ___ to ___. His current pain is a ___ and it is hard to
focus. He additionally denies headache, visual changes, hearing
changes, mouth pain/sores, difficulty swallowing, changes in
appetite. He notes fatigue from chemotherapy.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- Small mass noted left testis ___, initial CT scans no
metastatic disease, initial AFP 35 and normal hCG
- Left orchiectomy ___ (pathology mixed germ cell tumor
with 95% embryonal carcinoma and 5% yolk sac tumor) -> initially
AFP downtrended but then rose and hCG rose as well suspected to
be secondary to embryonal cells
- ___ C1 D1 BEP
- ___ admission neutropenic fever
- ___ C2 D1 BEP
- ___ C3 D1 BEP (initially for ___ but held given
neutropenia)
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.9 SBP 129 L Sitting 86 18 96 RA
GENERAL: ___ male, appears mildly distressed from pain, laying
on left side
HEENT: EOMI PERRL MMM
NECK: no LAD
LUNGS: shallow breaths, left base crackles
HEART: RRR no murmurs/gallops
ABD: soft nt nd
EXT: no calf tenderness, no swelling, wwp
SKIN: no lesions
NEURO: alert and oriented, moving all extremities
spontaneously,
no focal deficits
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 431)
Temp: 97.8 (Tm 98.7), BP: 106/68 (106-120/68-82), HR: 85
(71-85), RR: 18 (___), O2 sat: 98% (97-100), O2 delivery: Ra
GENERAL: ___ male, appears mildly distressed from pain, laying
on left side
HEENT: EOMI PERRL MMM
NECK: no LAD
LUNGS: CTAB, no wheezing, rales, rhonchi
HEART: RRR no murmurs/gallops
ABD: soft nt nd
EXT: no calf tenderness, no swelling, wwp. 6 cm mildly
erythematous area on medial aspect of R forearm
SKIN: no lesions
NEURO: alert and oriented, moving all extremities
spontaneously,
no focal deficits
ACCESS: PIV
Pertinent Results:
ADMISSION LABS:
==============
___ 10:54PM BLOOD WBC-1.0* RBC-3.46* Hgb-10.9* Hct-30.8*
MCV-89 MCH-31.5 MCHC-35.4 RDW-13.6 RDWSD-41.0 Plt ___
___ 10:54PM BLOOD Neuts-53 Bands-0 ___ Monos-3* Eos-1
Baso-0 Atyps-2* ___ Myelos-0 NRBC-1* AbsNeut-0.53*
AbsLymp-0.43* AbsMono-0.03* AbsEos-0.01* AbsBaso-0.00*
___ 10:54PM BLOOD Hypochr-OCCASIONAL Anisocy-1+* Poiklo-1+*
Macrocy-1+* Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+* Tear
Dr-1+*
___ 11:48PM BLOOD ___ PTT-28.1 ___
___ 10:54PM BLOOD Glucose-151* UreaN-17 Creat-1.0 Na-138
K-4.3 Cl-99 HCO3-24 AnGap-15
___ 10:54PM BLOOD ALT-11 AST-18 AlkPhos-71 TotBili-0.4
___ 10:54PM BLOOD Albumin-4.1
___ 11:55AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
___ 10:57PM BLOOD Lactate-0.9
DISCHARGE LABS:
===============
___ 05:47AM BLOOD WBC-4.6 RBC-3.45* Hgb-10.8* Hct-31.3*
MCV-91 MCH-31.3 MCHC-34.5 RDW-14.4 RDWSD-46.7* Plt ___
___ 05:47AM BLOOD Neuts-30* Bands-1 Lymphs-18* Monos-35*
Eos-2 Baso-0 ___ Metas-6* Myelos-7* Promyel-1* NRBC-2*
AbsNeut-1.43* AbsLymp-0.83* AbsMono-1.61* AbsEos-0.09
AbsBaso-0.00*
___ 05:47AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-1+* Microcy-NORMAL Polychr-1+* Ovalocy-1+*
Schisto-OCCASIONAL
___ 05:47AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:47AM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-142
K-4.9 Cl-102 HCO3-27 AnGap-13
___ 05:47AM BLOOD Calcium-9.6 Phos-5.3* Mg-1.8
MICRO:
======
___ urine culture: no growth
___ blood culture x2: no growth
___ respiratory viral panel: negative
___ urine legionella antigen: negative
___ Strep pneumo antigen: negative
___ MRSA screen: negative
IMAGING AND STUDIES:
===================
___ CT abd & pelvis w/ and w/o contrast, CTA chest:
CHEST:
HEART AND VASCULATURE: There are segmental and subsegmental
right lower lobe
filling defects, consistent with pulmonary emboli. The thoracic
aorta is
normal in caliber . No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Linear opacity in the bilateral lung bases likely
represent
atelectasis with superimposed pneumonia given the regions of
hypoenhancement.
The airways are patent to the level of the segmental bronchi
bilaterally.
ABDOMEN: The liver, pancreas, spleen and adrenal glands are
unremarkable.
There is cholelithiasis, as on prior.
URINARY: There is no evidence of focal renal lesions or
hydronephrosis. There
is no perinephric abnormality. There is no nephrolithiasis.
GASTROINTESTINAL: There is no bowel obstruction or ascites. The
appendix is
normal. There is no free intraperitoneal fluid or free air.
PELVIS: There is no free fluid in the pelvis. Patient is status
post left
orchiectomy.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES AND SOFT TISSUES: There is no evidence of worrisome
osseous lesions.
The abdominal and pelvic wall is within normal limits
IMPRESSION:
1. Segmental and subsegmental right lower lobe pulmonary emboli
2. Linear opacity in the left lung base, likely atelectasis
with
superimposed pneumonia.
3. No acute intra-abdominal or intrapelvic process.
___ NIVS:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
SUMMARY:
___ with PMHx notable for left testicular cancer (initially
staged as I, now stage IIIa based on metastatic to lung and
paraaortic LN) s/p left orchiectomy ___ (mixed germ cell
tumor with 95% embryonal carcinoma and 5% yolk sac tumor) s/p 3
cycles BEP on ___ with plan for curative intent who was
admitted for low risk PE and LLL PNA, course c/b febrile
neutropenia, treated with vanc/aztronam/levaquin and lovenox.
ACTIVE ISSUES:
# Left lower lobe pneumonia
The patient presented with flank pain, fever and chills. CT
chest showed linear opacity in the left lung base, likely
atelectasis with superimposed pneumonia. He had no risk factors
for MDR organisms, but was neutropenic. His O2 saturation
remained appropriate on room air during this admission. He was
initially treated with Levaquin and clindamycin in the ED, which
was broadened to vanc/meropenem, which was subsequently switched
to vancomycin, aztreonam and Levaquin following development of a
fever of 100.5 (of note though, this was likely a drug fever,
given his allergic reaction (skin redness) to meropenem). RVP
was obtained and was negative. Strep and legionella antigen
tests were negative. The patient was maintained on
vanc/aztreonam/levo for 24 hours after his ANC rose above 500,
and then he was trantioned to PO levofloxacin. Outpatient
allergy skin testing was set up to clarify his antibiotic
allergies, given his known cefepime allergy and reaction to
meropenem this admission. The patient was discharged on PO
levofloxacin.
# Pulmonary embolism,
The patient presented to the ED with right flank pain, fever and
chills. CTA showed segmental and subsegmental right lower lobe
pulmonary embolism, which was thought to be the likely etiology
of his pain. Risk factors for PE include his active malignancy.
___ NIVS showed no DVT. He received therapeutic anticoagulation
with Lovenox, and his pain was controlled with PO and IV
Dilaudid. He was provided with an incentive spirometer and
instructed to use it every hour. His pain subsided during the
hospitalization, and his breathing improved. He should continue
Lovenox 90 mg SQ Q12H following discharge.
# Neutropenic fever
The patient developed a fever of 100.5, and was also neutropenic
during this admission. CTA during this admission was remarkable
for pneumonia. He was felt to be high risk, given the lung
infiltrate noted on imaging and his history of high dose chemo.
The etiology of his neutropenia is likely secondary to marrow
suppression from chemotherapy. His ANC was monitored daily
during this admission and improved. He was not given GSF given
his history of receiving bleomycin therapy. His ANC rose above
500 prior to discharge, and the patient's most recent fever was
0007 on ___.
# Left testicular cancer - (initially staged as I, now stage
IIIa
based on metastatic to lung and paraaortic LN). He is s/p left
orchiectomy ___ (mixed germ cell tumor with 95% embryonal
carcinoma and 5% yolk sac tumor) currently C3D1 BEP ___ with
plan for curative intent. Tumor markers (AFP, Hcg) low. No
evidence of disease recurrence. Primary Oncologist team notified
of his admission.
CHRONIC ISSUES:
None
TRANSITIONAL ISSUES:
[] ___ 1430 on day of discharge
[] Will need skin testing as outpatient to determine antibiotic
allergies (Allergy clinic: ___, appointment set up
___
[] ___ consider hypercoagulability workup, though PE most likely
related to his malignancy
============
#HCP/CONTACT:
Name of health care proxy: ___
Relationship: wife
Cell phone: ___
#CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
3. LORazepam 0.5 mg PO BID:PRN nausea, anxiety
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
5. Fexofenadine 180 mg PO DAILY:PRN allergies
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
RX *enoxaparin 100 mg/mL 90 mg SC twice a day Disp #*60 Syringe
Refills:*2
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
3. Fexofenadine 180 mg PO DAILY:PRN allergies
4. LORazepam 0.5 mg PO BID:PRN nausea, anxiety
5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Left lower lobe pneumonia
Febrile neutropenia
Pulmonary embolism, segmental and subsegmental
Secondary diagnoses:
Left testicular cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had pneumonia, a blood clot in the lung (pulmonary
embolism), and a fever with a very low white blood cell count
(febrile neutropenia)
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on a blood thinner (Lovenox) for the blood
clot in the lung. Your pain was controlled with strong
medications.
- You were treated with antibiotics for the pneumonia.
- Your blood counts were watched closely, and your neutrophil
count improved.
- You improved and were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19638525-DS-4
| 19,638,525 | 27,938,465 |
DS
| 4 |
2129-07-01 00:00:00
|
2129-07-01 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___: Coronary artery bypass grafting x4 with the left
internal mammary artery to the left anterior descending artery
and reverse saphenous vein graft to the posterior descending
artery, ramus intermedius artery, diagonal artery.
History of Present Illness:
___ y/o female with PMH of medically managed likely CAD,
hypertension, hyperlipidemia, history of CAD, depression and
sleep apnea who presents with chest pain radiating presenting
with headache accompanied by neck and arm pain, and new chest
pain, found to have an NSTEMI. Patient reports having fallen
out of bed last ___, while she was dreaming that
she was in a chair. She woke up suddenly to find herself on the
floor, having hit her head on a nightstand. At the time she had
a headache, pain in her right jaw and down the left side of her
body. She does not remember falling but remembers waking up on
the floor.
Today, she called her PCP's office stating that her head was
throbbing. She denied any confusion or disorientation or visual
disturbances. Normal range of motion in all extremities. She
took Aleve last night but no pain meds during the day. Triage
advised her to go the ___ ED for a CT head. She called EMS to
arange a ride, and at that time also started to experience
dyspnea and central chest pain radiating to her back. She
reports that she has had pain like this in the past, typically
after eating food but also with climbing stairs and walking;
however, the pain has never been as bad as it was today.
On arrival to the ED, she continued to experience stuttering
chest pain radiating to her back. Initial vitals were 98.6, 88,
16, 138/80, 98% RA. Pain score ___. EKG revealed 0.5-1mm ST
depressions in V3-V6. Labs were notable for troponin of 0.11,
D-dimer 1020, anemia with Hct 33.2, otherwise unremarkable. CTA
was performed, and showed no PE or aortic dissection or other
acute pathology. CXR was unremarkable. CT head showed no acute
intracranial pathology.
She was given aspirin 325, morphine 5mg Ix1, ondansetron 4mg,
5mg metoprolol tartrate IV x2 for tachycardia, lorazepam 0.5mg
IV. She was seen by ___ Cardiology attending and then taken
to the cath lab, where she was found to have 3 vessel disease:
60-70% plaque in circ and LAD, but with acute ulcerated plaque
causing 90% obstruction of the distal left main near the
bifurcation.
Given left main disease, she was referred for CABG to
cardiothoracic surgery, and admitted to the CCU for overnight
monitoring. In the Cath lab, she was hypotensive to ___
systolic after fentanyl/versed, but pressures improved after
weaning off sedatives. She was given a heparin bolus prior to
cardiac catheterization and started on a drip that was held
during coronary angiography. Access was obtained through the
right radial artery and a TR band was left in place.
On arrival to CCU: the patient was in no acute distress. She
denied any chest pain, dyspnea, palpitations, lightheadedness/
dizziness. She was alert, and able to give a history of the
events leading up to the current point in time, although she
demostrated limited understanding of the importance of CT
surgery.
Past Medical History:
PAST CARDIAC HISTORY:
Hypertension
Hypercholesterolemia
Impaired Glucose Tolerance (but not diagnosed with diabetes
mellitus type II)
-Positive nuclear imaging study in ___:
EKG changes with adenosine: ___ mm downsloping ST segment
depression between stress and early recovery. This is similar
to the changes on a nuclear test in ___. In ___, there were
no defects on the nuclear imaging. On the current study, there
was evidence of
diagonal territory ischemia. The possibility of high-grade
stenosis was raised. The reversible ischemia was moderate with
a
summed difference score of 4.
It is of note that she had the electrocardiographic changes in
___. A baseline resting electrocardiogram on ___, is read
as showing
nonspecific ST-T wave abnormalities. To my review, these
consist
of very minor lateral T-wave flattening. She has mild atrial
conduction disturbances, no acute changes.
PAST MEDICAL HISTORY:
Hypertension
Hypercholesterolemia
Sickle Cell Trait
Obstructive Sleep Apnea
Obesity
Spinal Stenosis
Endometrial Cancer
GERD
PAST SURGICAL HISTORY:
Axillary skin tag removal
TKA
Hysterectomy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
GENERAL: Well developed female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTABL. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 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 Exam:
T: 98.8 HR: ___ SR BP: 130-140/60 Sats: 93 RA 98 2L
Wt: 96 Kg Preop: 95 Kg BS: 148/114
General: ___ year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds at bases no crackles
GI: obese, benign
Extr: 1+ edema warm
Incision: sternal no click and left lower extremity clean dry
intact no erythema
Neuro: awake, alert oriented moves all extremities
Pertinent Results:
ADMISSION LABS:
___ WBC-6.3 RBC-4.35 Hgb-12.2 Hct-36.8 MCV-85 MCH-28.0#
MCHC-33.1 RDW-13.1 Plt Ct-23
___ Glucose-154* UreaN-10 Creat-0.6 Na-138 K-3.7 Cl-104
HCO3-22
___ ALT-36 AST-59* AlkPhos-103 Amylase-49 TotBili-0.3
___ cTropnT-0.11*
___ Calcium-9.9 Phos-2.5* Mg-1.6
___ %HbA1c-6.0* eAG-126*
___ Triglyc-25 HDL-65 CHOL/HD-1.7 LDLcalc-43
Discharge Labs:
___ WBC-9.7 RBC-3.35* Hgb-9.8* Hct-29.4* MCV-88 MCH-29.4
MCHC-33.5 RDW-13.4 Plt ___
___ Glucose-98 UreaN-17 Creat-0.6 Na-139 K-4.6 Cl-98
HCO3-28 AnGap-18
___ Mg-2.0
ECHO ___:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Minimal aortic
valve stenosis. Mild mitral regurgitation.
CTA CHEST ___:
1. No aortic dissection.
2. No pulmonary embolism to the segmental level. Cannot exclude
subsegmental
pulmonary embolism.
3. Coronary artery calcifications.
4. Thymic hyperplasia.
5. Evidence of prior granulomatous disease.
6. Multinodular thyroid. Consider ultrasound for further
assessment.
CXR ___:
IMPRESSION: No evidence of acute disease. Convex contour to
the right upper mediastinum, probably due to tortuosity of great
vessels; other etiologies such as lymphadenopathy are hard to
excluded, however. If prior films are not available to show
long-term stability of this appearance, then chest CT is
suggested in follow-up to assess further.
CXR ___: IMPRESSION:
1. Status post median sternotomy for CABG with stable
postoperative cardiac and mediastinal contours. Prominent right
paratracheal soft tissue is felt to likely be vascular in
etiology. There are small bilateral effusions with probable
patchy bibasilar opacities likely reflecting compressive
atelectasis. No evidence of pulmonary edema. No pneumothorax.
CT HEAD ___:
IMPRESSION: No evidence of acute intracranial process.
Cardiac Cath ___:
1. Three vessel coronary artery disease, with severe left main
involvement. Normal central aortic blood pressure
Brief Hospital Course:
The patient was brought to the Operating Room on ___ where
she underwent Coronary artery bypass grafting x4 with the left
internal mammary artery to the left anterior descending artery
and reverse saphenous vein graft to the posterior descending
artery, ramus intermedius artery, diagonal artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented, but with
some intermittent confusion, therefore narcotics were avoided.
CPAP was continued qHS without difficulty. The patient had no
focal neurologic defects and was hemodynamically stable after
being weaned from inotropic and vasopressor support. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued on POD
2 without complication.
Respiratory: continued to have low lung volumes and atelectasis.
Aggressive pulmonary toilet, nebs and incentive spirometer
continued. Oxygen saturations 98 2L NC. CPAP at night.
Cardiac: hemodynamically stable sinus rhythm. Beta-blockers
were titrated to maintain HR 60-70's. Low-dose aspirin and
statin continued. Blood pressure 133-142/70, Losartan 25 mg
started ___. Home dose 50 mg please titrate as blood
pressure tolerates.
GI: PPI and bowel regime continued. Tolerated a regular diet.
Renal: renal function normal with good out put and slow
diuresis.
Endocrine; Blood sugars 127-___ontrolled on insulin
sliding scale.
Neuro: Narcotics were avoided to prevent confusion. Her pain
was well controlled on acetaminophen and ultram.
Disposition: Seen by physical therapy who recommended rehab for
continued strength and mobility. She continued to make steady
progress and was discharge to ___ ___.
___
Medications on Admission:
1. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
2. Losartan Potassium 50 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Fluoxetine 20 mg PO DAILY
7. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral two times per day
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral two times per day
2. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral
daily
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Aspirin EC 81 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
10. Fluoxetine 20 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Furosemide 40 mg PO BID
adjust dose as needed
13. Metoprolol Tartrate 75 mg PO TID
hold HR < 50 SBP < 100
14. Potassium Chloride 20 mEq PO Q12H
15. Losartan Potassium 25 mg PO DAILY
increase to 50 mg once SBP will tolerate
16. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
18. CPAP
Autoset via Nasal cannula
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sickle cell trait
Sleep apnea
Osteopenia
Morbid obesity
Spinal stenosis
Uterine Ca
Hypercholesterolemia
Depression
CAD
impaired glucose tolerance
hypertension
constipation
hyperreactive airway
Past Surgical History
s/p bilateral TKR
s/p hysterectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+ bilateral lower extremity edema.
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 cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19638540-DS-14
| 19,638,540 | 23,656,205 |
DS
| 14 |
2171-07-05 00:00:00
|
2171-07-05 17:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
acromycin / adhesive / morphine
Attending: ___.
Chief Complaint:
constipation, pain
Major Surgical or Invasive Procedure:
___ Imaging PARACENTESIS DIAG/THERA
History of Present Illness:
___ with a PMH of stage IVB Uterine papillary serous carcinoma (
endometrial cancer) receiving palliative Gem/avastin who was
d/c
on ___ for a DVT of LUE and saddle PE d/c on lovnenox who now
presents with abd pain.
States she's had constipation for ___ days w/ positive effect
w/
mag citrate ___ days ago and compliant w/ bowel regimen
colace/senna bid. "The senna doesn't do a damn thing." Since
then
has had increased abd distention and no BM w/ episode of
vomiting. + flatus but significant poor PO intake due to the
abdominal distention.
VS in ER 98.9 96 125/67 18 95% RA. she was treated with dilaudid
with resolution of her pain. She had a CT scan w/ oral contrast
which "really cleaned me out." Nursing noted large formed bowel
movement. She was admitted for further management of her
abdominal distention.
Past Medical History:
PAST MEDICAL/ONCOLOGIC HISTORY (per OMR):
1) HTN
2) HLD
3) LCIS (Dx ___, Treated with tamoxifen ___, Evista
___
4) Stage IVB UPSC (Dx ___ underwent TAH, b/l
salpingo-oophorectomy, rectosigmoid resection with primary
anastomosis, splenectomy, appendectomy, total omentectomy, right
pelvic node dissection and tumor debulking, s/p 15 cycles of
Doxil, four cycles of Taxol, two cycles of Taxotere (changed due
to peripheral neuropathy); six cycles of Carboplatin, which she
received from ___ to ___ Avastin/Gemzar for eight
cycles of Gemzar; the Avastin had been held since ___ due
to side effects of vomiting. She received three cycles of
Abraxane. Because of slight progression, treatment has changed
again to Topotecan.
PAST SURGICAL HISTORY
D&C x3
Total hip replacement (___)
Lumbar fusion (___)
Exlap, TAH, RSR, splenectomy, debulking
Social History:
___
Family History:
Maternal aunt- ___
Mother- HTN, ___ Ca
Maternal GF- colon cancer
Father- ___ Cancer
___ GM- DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 99.0 PO 126 / 71 97 16 96
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NT, distended w/ fluid wave
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
DISCHARGE
Pertinent Results:
LABS
___ 01:20PM BLOOD WBC-9.3 RBC-2.64* Hgb-8.3* Hct-25.7*
MCV-97 MCH-31.4 MCHC-32.3 RDW-15.8* RDWSD-55.2* Plt ___
___ 05:27AM BLOOD WBC-8.8 RBC-2.56* Hgb-8.1* Hct-25.2*
MCV-98 MCH-31.6 MCHC-32.1 RDW-15.9* RDWSD-55.8* Plt ___
___ 05:00AM BLOOD WBC-10.4* RBC-2.60* Hgb-8.1* Hct-25.4*
MCV-98 MCH-31.2 MCHC-31.9* RDW-16.0* RDWSD-56.6* Plt ___
___ 01:20PM BLOOD ___ PTT-35.0 ___
___ 05:27AM BLOOD ___ PTT-32.2 ___
___ 01:20PM BLOOD Glucose-92 UreaN-23* Creat-0.7 Na-133
K-5.0 Cl-98 HCO3-21* AnGap-19
___ 05:27AM BLOOD Glucose-83 UreaN-18 Creat-0.5 Na-137
K-4.9 Cl-104 HCO3-20* AnGap-18
___ 01:20PM BLOOD ALT-88* AST-81* AlkPhos-219* TotBili-0.2
___ 05:27AM BLOOD ALT-71* AST-63* LD(LDH)-568* AlkPhos-201*
TotBili-0.2
___ 01:20PM BLOOD Lipase-36
___ 01:20PM BLOOD cTropnT-<0.01
___ 01:20PM BLOOD Albumin-3.1*
___ 05:27AM BLOOD Albumin-2.8* Calcium-7.9* Phos-4.5 Mg-1.7
Iron-29*
___ 05:27AM BLOOD calTIBC-190* Ferritn-748* TRF-146*
___ 01:31PM BLOOD Lactate-1.1
MICRO
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
IMAGING
___ Imaging PARACENTESIS DIAG/THERA ___.
Approved
Technically successful ultrasound-guided diagnostic and
therapeutic
paracentesis, yielding 0.5 L of chylous ascitic fluid. Fluid
samples were
submitted to the laboratory for cell count, differential, and
culture.
___ Cardiovascular ECHO ___ ___.
Finalized
Conclusions
Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
no clear change.
___ Cytology PERITONEAL FLUID ___ ___.
Logged Only
Report not finalized.
Assigned Pathologist ___, MD, PHD
Logged in only.
CYTOLOGY # ___
___BD & PELVIS WITH CO ___
___. Approved
1. No evidence for bowel obstruction or acute intra-abdominal
process.
Moderate stool burden.
2. Slightly increased amount of intra-abdominal ascites.
Specifically
increased amount of fluid in the left upper quadrant which is
now more clearly loculated.
3. Stable retroperitoneal, mesenteric, and pelvic
lymphadenopathy.
4. Slightly larger moderate to large left pleural effusion.
Unchanged small right pleural and moderate pericardial effusion.
Brief Hospital Course:
___ with a PMH of stage IVB Uterine papillary serous carcinoma
(endometrial cancer) receiving palliative Gem/avastin who was
d/c on ___ for a DVT of LUE and saddle PE d/c on lovnenox who
now presents with abd pain and constipation. She underwent CTAP
with contrast, which showed no acute intraabdominal process
(full report below); she spontaneously had BM. We adjusted her
pain medications; she will follow up with her primary oncologist
on ___.
TRANSITIONAL
- follow up: Oncology (___)
- may require adjustment of her pain medications; in particular,
consider switching fentanyl patch to oxycontin for ease of
adjustment
- CONTACT: ___ (husband/HCP) ___
- CODE: status changed from full to DNR/DNI in conversation with
attending of record, Dr. ___, during this admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 50 mg SC Q12H
2. Acetaminophen 1000 mg PO Q8H
3. Acyclovir 400 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Citalopram 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fentanyl Patch 12 mcg/h TD Q72H
9. Lactaid (lactase) 3,000 unit oral QID:PRN
10. Lodine (etodolac) 400 mg oral QD
11. LORazepam 1 mg PO QHS anxiety/insomnia
12. Magnesium Citrate 300 mL PO EVERY THIRD DAY:PRN constipation
13. OLANZapine 10 mg PO QHS
14. Omeprazole 20 mg PO QPM
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. Ranitidine 300 mg PO QAM
17. Senna 8.6 mg PO BID:PRN cosntipation
18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
19. Calcium+D (calcium carbonate-vitamin D3) 1000 mg oral QD
20. flaxseed 1 tab oral BID
21. MethylPHENIDATE (Ritalin) 10 mg PO BID:PRN fatigue
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
2. Lactulose ___ mL PO BID:PRN constipation
use if no bowel movement for 24 hours
RX *lactulose 20 gram/30 mL ___ mL by mouth twice per day
Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*2
4. Simethicone 160 mg PO QID:PRN Bloating
RX *simethicone 125 mg 1 tablet by mouth four times per day as
needed Disp #*120 Tablet Refills:*0
5. Docusate Sodium 200 mg PO BID
RX *docusate sodium 250 mg 1 capsule(s) by mouth twice per day
Disp #*60 Capsule Refills:*0
6. Senna 17.2 mg PO BID cosntipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice per day
Disp #*60 Tablet Refills:*0
7. Acetaminophen 1000 mg PO Q8H
8. Acyclovir 400 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Calcium+D (calcium carbonate-vitamin D3) 1000 mg oral QD
12. Citalopram 10 mg PO DAILY
13. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
14. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Apply 1 patch every 72 hours Disp #*5
Patch Refills:*0
15. flaxseed 1 tab oral BID
16. Lactaid (lactase) 3,000 unit oral QID:PRN Meals with milk
products
17. Lodine (etodolac) 400 mg oral QD
18. LORazepam 1 mg PO QHS anxiety/insomnia
19. Magnesium Citrate 300 mL PO EVERY THIRD DAY:PRN
constipation
20. MethylPHENIDATE (Ritalin) 10 mg PO BID:PRN fatigue
21. OLANZapine 10 mg PO QHS
22. Omeprazole 20 mg PO QPM
23. Ondansetron 8 mg PO Q8H:PRN nausea
24. Ranitidine 300 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
uterine papillary serous carcinoma, metastatic
uncontrolled pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for cancer-related constipation and pain.
Your constipation cleared spontaneously. We increased your pain
medication to control your pain, and also performed
paracentesis.
For your pain, a fentanyl patch with PRN hydromorphone may not
be the best strategy. The hydromorphone, on the other hand, is
relatively short acting. Your outpatient physicians can discuss
your pain regimen with you.
Please see your appointments and medications below.
Sincerely,
Your ___ Oncology Team
Followup Instructions:
___
|
19638540-DS-15
| 19,638,540 | 26,520,403 |
DS
| 15 |
2171-07-17 00:00:00
|
2171-07-17 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
acromycin / adhesive / morphine
Attending: ___
Chief Complaint:
fatigue, dyspnea
Major Surgical or Invasive Procedure:
___ Abdominal fluid collection drainage and paracentesis
___ PleurX drainage catheter placement
History of Present Illness:
___ PMH of stage IVB Uterine papillary serous carcinoma
(endometrial cancer) receiving palliative Gem/avastin who has
been admitted several times in the past month for DVT of LUE and
saddle PE d/c on lovnenox and abdominal pain likely due to
constipation. She presents again after noting swelling in her
RLE for ___ days and has been experiencing worsened fatigue,
exertional dyspnea, and dry heaving induced by the sensation of
post-nasal drip. She also states her abdominal distension has
worsened slightly since discharge, but that this owes to a
self-decrease of her prescribed bowel medications.
She and her husband state they have been adherent to her Lovenox
since prescribed, and that she has had no trigger other than
activity to her shortness of breath; she does note that she
sleeps on several pillows however. She also denies sick
contacts. She does state that her post-nasal drip feels similar
to allergic rhinitis, but that she has not attempted treatment.
In the ED, initial vitals: 98.8 118 125/64 18 99% RA
Labs notable for: Plt 1050, BNP 12076
On arrival to the floor the patient stated she was not presently
nauseous. At rest, her RLE does not hurt, but that it appears
swollen. She has experienced no fever/chills, headaches, chest
pain, changes to urinary frequency/quality, or copious diarrhea.
She has noted an increase in number of BMs since resuming her 2
pills twice daily regimen of senna and Colace.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative nless otherwise noted in the HPI.
Past Medical History:
PAST MEDICAL/ONCOLOGIC HISTORY (per OMR):
1) HTN
2) HLD
3) LCIS (Dx ___, Treated with tamoxifen ___, Evista
___
4) Stage IVB UPSC (Dx ___ underwent TAH, b/l
salpingo-oophorectomy, rectosigmoid resection with primary
anastomosis, splenectomy, appendectomy, total omentectomy, right
pelvic node dissection and tumor debulking, s/p 15 cycles of
Doxil, four cycles of Taxol, two cycles of Taxotere (changed due
to peripheral neuropathy); six cycles of Carboplatin, which she
received from ___ to ___ Avastin/Gemzar for eight
cycles of Gemzar; the Avastin had been held since ___ due
to side effects of vomiting. She received three cycles of
Abraxane. Because of slight progression, treatment has changed
again to Topotecan.
PAST SURGICAL HISTORY
D&C x3
Total hip replacement (___)
Lumbar fusion (___)
Exlap, TAH, RSR, splenectomy, debulking
Social History:
___
Family History:
Maternal aunt- ___
Mother- HTN, ___ Ca
Maternal GF- colon cancer
Father- ___ Cancer
___ GM- DM
Physical Exam:
ADMISSION EXAM:
VS: 98.9 129/77 110 20 95RA
GENERAL: NAD, lying in bed, conversant
HEENT: AT/NC, EOMI, PERRL; dry oral mucosa
NECK: supple throat, no LAD
LUNGS: decreased lung sounds in bases
CV: RRR, no M/R/G
ABD: mildly distended, mildly TTP RUQ/LUQ, +BSx4
EXT: RLE>LLE edema
SKIN: no ecchymoses, petechial, or rashes
NEURO: A/Ox3, CNII-XII grossly intact, motor ___, sensory
globally intact
ACCESS: R port, accessed
DISCHARGE EXAM:
VS: 98.1 134/82 115 16 94RA
GENERAL: NAD, lying in bed, conversant, grimaces from
distension/pain, cachectic appearing
HEENT: AT/NC, EOMI, PERRL; dry oral mucosa
NECK: supple throat, no LAD
LUNGS: decreased lung sounds in bases
CV: RRR, no M/R/G
ABD: mildly distended, tympanic to percussion, mildly TTP
diffusely, soft +BSx4; PleurX drainage catheter in place
EXT: RLE>LLE edema
SKIN: no ecchymoses, petechial, or rashes
NEURO: A/Ox3, CNII-XII grossly intact, motor ___, sensory
globally intact
ACCESS: R port, accessed
Pertinent Results:
ADMISSION LABS:
___ 12:12PM BLOOD WBC-8.8 RBC-3.88*# Hgb-12.2# Hct-38.0#
MCV-98 MCH-31.4 MCHC-32.1 RDW-17.3* RDWSD-60.7* Plt ___
___ 12:12PM BLOOD Neuts-82.8* Lymphs-7.9* Monos-8.4
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.32* AbsLymp-0.70*
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.02
___ 12:12PM BLOOD ___ PTT-37.2* ___
___ 12:12PM BLOOD Glucose-116* UreaN-27* Creat-0.5 Na-135
K-4.9 Cl-100 HCO3-21* AnGap-19
___ 12:12PM BLOOD ___
___ 12:12PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.7
DISCHARGE LABS:
___ 05:18AM BLOOD WBC-16.6* RBC-2.88* Hgb-9.0* Hct-27.4*
MCV-95 MCH-31.3 MCHC-32.8 RDW-18.6* RDWSD-64.2* Plt ___
___ 05:18AM BLOOD ___ PTT-44.9* ___
___ 06:44AM BLOOD Glucose-116* UreaN-28* Creat-0.6 Na-133
K-4.4 Cl-99 HCO3-21* AnGap-17
___ 06:44AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8
MICRO:
___ 12:24 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 12:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ PARACENTESIS
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 1.0 L of turbid white free fluid was removed. Additionally,
250 cc of
clear straw-colored fluid was aspirated from a loculated left
upper quadrant
collection.
___ LENIS
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ ABD FILMS
IMPRESSION:
No free intraperitoneal air.
Mild dilatation of the transverse colon. Large amount of stool
in the
descending colon.
Moderate left pleural effusion and retrocardiac atelectasis
better appreciated on recent CT.
___ CT A/P w/ CONTRAST
IMPRESSION:
1. Increased moderate to large volume simple ascites fluid when
compared to the ___ CT abdomen and pelvis.
2. Stable bilateral external iliac and retroperitoneal
lymphadenopathy, as
described above.
3. New 2 cm soft tissue lesion within the right lower abdominal
subcutaneous fat may represent a new metastatic lesion versus an
injection site granuloma.
___ PleurX catheter placement
FINDINGS:
1. Limited grayscale ultrasound imaging of the abdomen
demonstrated
moderateascites.
2. Appropriate final position of PleurX catheter.
3. Removal of 1 L of turbulent straw-colored ascites.
Brief Hospital Course:
___ PMH of stage IVB Uterine papillary serous carcinoma
(endometrial cancer) receiving palliative Gem/avastin with
recent admits for a DVT of LUE and saddle PE d/c on lovnenox and
constipation who presents with multiple complaints including RLE
edema, fatigue w/ DOE, and nausea w/ post-nasal drip.
#ABDOMINAL DISTENSION:
#STAGE IVB UTERINE PAPILLARY SERIOUS CARCINOMA: The patient was
admitted with nausea that seemed to stem from post nasal drip,
but may also have been contributed to by persistent abdominal
ascites and loculated fluid collections. These were drained for
1.5L total, but patient had total persistent post-procedural
pain and abdominal fullness. She had repeat CT A/P which showed
increased abdominal ascites, and required more pain medication
to control her abdominal pain and discomfort. Ultimately, the
patient and husband wished to forgo further therapeutic
intervention and return home on hospice. Prior to discharge,
Pleurex drainage catheter was placed and the patient was set up
to be cared for by ___, with
delivery of medications to home on the day of discharge.
Specific changes made include increase of Fentanyl TD to 25mg
Q3days and Dilaudid to Q3H PRN. All unnecessary medications were
discontinued. MOLST was filled out and patient confirmed
DNAR/DNI/DNH. Dr. ___ was the attending of service at the time
of her discharge and agreed with the plan.
#RLE EDEMA W/ HX OF PE: Continuing Lovenox to prevent further
DVT/PE, but this can be stopped at home per patient comfort and
preferences. ___ was negative. RLE edema resolving with patient
use of TEDS.
#NAUSEA/RHINORRHEA: A presenting complaint of the patient, and
she experienced significant improvement with fluticasone and
loratadine.
CHRONIC ISSUES:
#DEPRESSION: Continued home citalopram, zyprexa, lorazepam PRN.
#PAIN: Increased fentanyl dose to 25 and Dilaudid frequency to
Q3H.
#HL: Stopped home aspirin, statin.
#FATIGUE: Wrote Rx for home Ritalin if patient requests for
comfort; did not continue Ritalin or dronabinol during stay.
TRANSITIONAL ISSUES:
- appointments with PCP and oncologist as needed
- home hospice with ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. Acetaminophen 1000 mg PO Q8H
3. Acyclovir 400 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Citalopram 10 mg PO DAILY
7. Docusate Sodium 200 mg PO BID
8. Enoxaparin Sodium 50 mg SC Q12H
9. Fentanyl Patch 12 mcg/h TD Q72H
10. Lactaid (lactase) 3,000 unit oral QID:PRN Meals with milk
products
11. LORazepam 1 mg PO QHS anxiety/insomnia
12. Magnesium Citrate 300 mL PO EVERY THIRD DAY:PRN constipation
13. MethylPHENIDATE (Ritalin) 10 mg PO BID:PRN fatigue
14. OLANZapine 10 mg PO QHS
15. Omeprazole 20 mg PO QPM
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Ranitidine 300 mg PO QAM
18. Senna 17.2 mg PO BID cosntipation
19. Polyethylene Glycol 17 g PO DAILY
20. Simethicone 160 mg PO QID:PRN Bloating
21. Calcium+D (calcium carbonate-vitamin D3) 1000 mg oral QD
22. flaxseed 1 tab oral BID
23. Lodine (etodolac) 400 mg oral QD
24. Lactulose ___ mL PO BID:PRN constipation
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 2 spray intranasal once a day
Disp #*1 Bottle Refills:*1
2. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Apply 1 patch to skin every 72
(___) hours Disp #*10 Patch Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 (three)
hours Disp #*50 Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H
7. Acyclovir 400 mg PO BID
8. Calcium+D (calcium carbonate-vitamin D3) 1000 mg oral QD
9. Citalopram 10 mg PO DAILY
10. Docusate Sodium 200 mg PO BID
11. Enoxaparin Sodium 50 mg SC Q12H
12. flaxseed 1 tab oral BID
13. Lactaid (lactase) 3,000 unit oral QID:PRN Meals with milk
products
14. Lactulose ___ mL PO BID:PRN constipation
RX *lactulose 10 gram/15 mL ___ mL by mouth twice a day
Refills:*0
15. Lodine (etodolac) 400 mg oral QD
16. LORazepam 1 mg PO QHS anxiety/insomnia
17. Magnesium Citrate 300 mL PO EVERY THIRD DAY:PRN
constipation
18. MethylPHENIDATE (Ritalin) 10 mg PO BID:PRN fatigue
RX *methylphenidate [Ritalin] 10 mg 1 tablet(s) by mouth twice a
day Disp #*12 Tablet Refills:*0
19. OLANZapine 10 mg PO QHS
20. Omeprazole 20 mg PO QPM
21. Ondansetron 8 mg PO Q8H:PRN nausea
22. Ranitidine 300 mg PO QAM
23. Senna 17.2 mg PO BID cosntipation
24. Simethicone 160 mg PO QID:PRN Bloating
25.Compression stockings
R60.0 Localized swelling
8-22mm graduated compression stockings, mid-thigh length
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- stage IVB Uterine papillary serous carcinoma
- loculcated abdominal fluid collection
- ascetic abdominal fluid collection
- allergic rhinitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted with nausea, post-nasal drip, worsening
shortness of breath, fatigue, and a feeling of abdominal
fullness. Your post-nasal drip resolved with steroid nasal
spray, which likely caused your allergy symptoms including
shortness of breath. Your abdomen was drained and ___ had some
post-procedural pain, which may have been due to constipation.
___ were given additional medications to induce a bowel
movement, and after ___ moved your bowels ___ had temporary
relief from your abdominal discomfort. However, ___ had
persistent abdominal pain and fullness, and your fatigue
worsened. After a CT scan which showed a worsening abdominal
fluid collection, ___ and your husband decided ___ wished to
pursue hospice care at home. This was arranged through ___
___, and ___ were discharge home with hospice
services in place. Prior to your departure, ___ had an abdominal
drainage catheter placed to drain your abdomen if ___ become
uncomfortable.
Best regards,
Your ___ Care Team
Followup Instructions:
___
|
19638621-DS-21
| 19,638,621 | 21,108,796 |
DS
| 21 |
2183-01-04 00:00:00
|
2183-01-07 14:35:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HTN, dCHF (EF >55% ___ presenting with acute SOB.
Pt called EMS today after her husband sustained a fall at home
and EMS noted that she appeared to be in respiratory distress
with RR ___, O2 sat ___ on RA and she was transported to the ED.
In the ED, initial vitals were
Temp: 98.5 HR: 130 BP: 157/80 Resp: 40 O(2)Sat: 97 Normal
On exam, she appeared to be in respiratory distress +retracting,
unable to speak in full sentences with rales to her mid lung
fields. Labs and imaging significant for BNP > 5000 and CXR
showing pulmonary edema. Patient given IV lasix 40mg.
Past Medical History:
-?MI ___ years ago: per pt and family pt was scheduled for
angiography but this was cancelled and never done
-HTN
-colon CA s/p resection ___ ago
-s/p hysterectomy
-osteoporosis
-varicose veins
-B12 deficiency
Social History:
___
Family History:
Noncontributory to her presentation with acute ___ edema.
Physical Exam:
98.5 HR: 130 BP: 157/80 Resp: 40 O(2)Sat: 97 Normal
GENERAL - well-appearing elderly F in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no LAD
LUNGS - Kyphosis. Rales auscultated through bases, good air
movement, resp
unlabored
HEART - RRR, nl S1-S2
ABDOMEN - soft/NT/ND, no masses no rebound/guarding
EXTREMITIES - Warm. 2+ pitting edema most notable on the shins
LYMPH - no cervical LAD
NEURO - awake, A&Ox3,
Discharge exam:
Tm/Tc:98.0 HR: ___ BP:131-149/44-62 02sat:96% RA
GENERAL: Anxious in NAD. Alert and interactive.
NECK: supple without lymphadenopathy, JVD at clavivle sitting up
___: RRR. no M/R/G
RESP: BB faint crackles
ABD: soft, NT/ND, normoactive bowel sounds.
EXTR: 1+ edema left ankle, none right.
NEURO: A/O x 3. Denies pain. MAE, speech clear.
Pertinent Results:
Admission labs:
___ 07:45AM BLOOD WBC-4.8 RBC-3.13* Hgb-10.5* Hct-31.4*
MCV-100* MCH-33.6* MCHC-33.4 RDW-13.2 Plt ___
___ 07:45AM BLOOD ___ PTT-42.8* ___
___ 03:17AM BLOOD
___ 07:45AM BLOOD Glucose-201* UreaN-38* Creat-1.4* Na-143
K-4.7 Cl-107 HCO3-23 AnGap-18
___ 07:45AM BLOOD proBNP-5419*
___ 03:17AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 Cholest-184
___ 10:35AM BLOOD VitB12-529 Folate-GREATER TH
___ 03:17AM BLOOD Triglyc-137 HDL-54 CHOL/HD-3.4
LDLcalc-103
___ 07:53AM BLOOD Lactate-2.1*
Discharge labs:
___ 06:00AM BLOOD WBC-2.5* RBC-2.59* Hgb-8.7* Hct-25.6*
MCV-99* MCH-33.7* MCHC-34.0 RDW-13.2 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-88 UreaN-52* Creat-1.7* Na-141
K-5.1 Cl-106 HCO3-27 AnGap-13
CXR ___
FINDINGS: As compared to the previous radiograph, the signs of
overinflation
have minimally increased. On a background of minimal fluid
overload, there is
no evidence of new parenchymal opacities that have occurred in
the interval.
However, the patient is slightly rotated and the assessment of
the image is
minimally limited. Therefore, if the clinical complaints
persist, a
short-term radiographic followup should be performed, if
possible in frontal
and lateral projection.
No cardiomegaly. Tortuosity of the thoracic aorta. No larger
pleural
effusions. No pneumothorax.
Echo ___
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction
suggestive of CAD. Mild mitral regurgitation. Mild pulmonary
artery hypertension.
Compared with the prior study (images reviewed) of ___,
mild regional systolic dysfunciton is now identified.
Brief Hospital Course:
___ y/o F with PMH signifincat for HTN presents with shortness of
breath found to be in acute on chronic diastolic heart failure.
#Respiratory distress: Patient presented tachypnic but improved
quickly in the ED with bipap and diuresis. Likely due to a mix
of anxiety from seeing husband fall and acute on chronic heart
failure. She was discharged with celexa for anxiety and
instructed of the anticipated effects.
#Acute on chronic diastolic congestive heart failure: Patient
was clinically euvolemic following diuresis in the ED. Due to
___ and observed volume in house, her lisinopril and furosemide
were held in the hospital and she was discharged without those
two medications. Her metoprolol was uptitrated and she was
discharged with an extended release formulation. Home isosorbide
mononitrate was continued.
# CAD/Hypertension: BP elevated on arrival to 170/110. Her
metoprolol and amlodipine were continued in house but lisinopril
held due to ___. she was continued on her home aspirin.
#Bacteremia: Likely contaminant. Bcx in the ED grew coagulase
negative staph. She was covered broadly with antibiotics but was
clinically stable with no symptoms or signs of infection
throughout hospitalization. Broad coverage of antibiotics was
discontinued after repeat bcx x2 were negative for 48 hours.
# Asymptomatic bacteriuria: Initially +UA in the ED with one
dose of ceftriaxone given. GNRs grew out of Ucx when Bcx became
positive (see above) so she was covered broadly on antibiotics
although she was asymptomatic and showed no signs of infection
throughout admission. Repeat Ucx was negative.
# ___: BUN 38 and Creat 1.4 on admission, baseline Cr 1. Related
to congestion as creatinine improved with diuresis. Lisinopril
was held.
Transitional Issues
- f/u final bx result
- Changed to metoprolol xl 100 mg
- Started on celexa 10 mg daily for anxiety
- Discharged without home furosemide and lisinopril so consider
re-starting as outpatient if needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral
daily
7. Cyanocobalamin Dose is Unknown PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Citalopram 10 mg PO DAILY Duration: 1 Weeks
Stop on ___ and START 20mg daily
RX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth daily Disp
#*3 Tablet Refills:*0
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*3
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral
daily
7. Citalopram 20 mg PO DAILY
Start ___. STOP celexa 10mg daily at that time.
RX *citalopram [Celexa] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Acute on Chronic diastolic heart failure
- Acute on Chronic renal failure
- ?MI ___ years ago: per pt and family pt was scheduled for
angiography but this was cancelled and never done
-HTN
-Blood clot ___ years ago
-colon CA s/p resection ___ ago
-s/p hysterectomy
-osteoporosis
-varicose veins
-B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you were having shortness of breath.
You were found to have extra fluid in your body because the
heart was unable to help your kidneys pump out the fluid. This
compromised your breathing and is called heart failure.
We treated you with medications including lasix which helps you
get rid of the extra fluid and we provided you with supplemental
oxygen to help you breathe easier.
Another issue is that your kidney function was slightly elevated
during your hospitalization which we have been monitoring. For
the time being we are stopping your Lisinopril but we may start
this medication again when your kidney function has improved.
We have also stopped your Lasix for the time being but this may
also be resumed as an outpatient.
We have started you on a drug called celexa for your anxiety.
This medication will be slowly increased over a period of time.
You may not feel its effectiveness for three weeks.
In summary on discharge you will be taking the following
medications:
- Amlodipine 5mg daily : for your blood pressure
- Metoprolol 100mg Xl daily: to decrease the workload of the
heart
- Aspirin 81mg daily
- Celexa 10mg daily: for anxiety, take this dose until ___
at which point please INCREASE to Celexa 20mg daily
- Imdur 30mg daily: to decrease the resistance the heart needs
to pump against.
*** PLEASE STOP:
Lasix and Lisinopril for the tieme being.
Because you have been diagnosed with heart failure it is of the
utmost importance that you Wweigh yourself every morning, call
Dr. ___ your weight goes up more than 3 lbs in 2 days. It is
also important that you avoid a diet high in salt as this can
cause an exacerbation or worsening of your heart failure.
It has been a pleasure taking care of you. If you have any
questions related to your medications, or questions related to
your symptoms or concerns please call your Primary Care Dr. ___
___ the ___ at ___.
Followup Instructions:
___
|
19638656-DS-20
| 19,638,656 | 27,318,957 |
DS
| 20 |
2193-11-23 00:00:00
|
2193-11-23 10:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / sesame oil / cinnamon
Attending: ___.
Chief Complaint:
perianal pain
Major Surgical or Invasive Procedure:
I & D, ___ placement
History of Present Illness:
___ y/o M s/p proctolectomy, ileostomy and subsequent J pouch in
___ (Dr. ___ with Hx of UC, SBOx2 & pouchitis presenting
with ~3 days of worsening perianal pain and abdominal
distention. The pain is worse with defecation and patient denies
fevers, chills, nausea, vomiting, BRBPR. On ___
Dr. ___ noted altered pouch output which improved
with 2 days of liquid diet. Upon arrival to the ED patient has
received: IV 2L NS, IV morphine, Cipro/Flagyl.
Past Medical History:
Ulcerative colitis, status post colectomy with pouch in ___
SBOs conservatively managed in ___ and ___
s/p MVA with screws in right shoulder and hip
Social History:
___
Family History:
Grandfather and cousin with IBD. Father passed away from
complications of diabetes. Mother died of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.2 56 107/69 14 97% RA
Gen: AOx3, in NAD
HEENT: normocephalic, atraumatic
Abdominal: distended, soft and non-tender to palpation
Rectal Tender to palpation perianally w/o particular focus of
pain; no focal fluctuance, erythema, or induration
DRE: appropriate sphincter tone and squeeze; no palpable lesions
or hemorrhoids
DISCHARGE PHYSICAL EXAM:
VS: 98.1 69 121/76 18 96% RA
Gen: NAD
CV: RRR
Resp: non-labored breathing, no resp distress
Abd: soft, nondistended, nontender
Rectal: ___ in place on right, some serosang drainage on ABD
pad
Pertinent Results:
CT A/P ___
1.7 x 1.4 x 2.5 cm perianal intersphincteric abscess posterior
to the J-pouch anastomosis.
MR PELVIS ___
2.1 x 1.3 x 3.5 cm horseshoe shaped abscess centered in the
intersphincteric plane of the anus just distal to the J-pouch
anastomosis, from the 4 to 8 o'clock position, which splays the
internal and external sphincters. Short transsphincteric sinus
tract which traverses the external sphincter at 7 o'clock and
terminates in a 1.1 x 0.9 cm abscess within the midline to right
ischioanal fat. Phlegmonous change of the anastomosis at the
left posterolateral aspect.
Brief Hospital Course:
___ was admitted to Medicine and started on
IV cipro/flagyl. An MR pelvis revealed a 2.1 x 1.3 x 3.5 cm
horseshoe shaped abscess centered in the intersphincteric plane
of the anus just distal to the J-pouch anastomosis, from the 4
to 8 o'clock position. He was then transferred to Colorectal
Surgery and taken to the OR on ___ for I&D and ___
placement, the abscess cavity was noted, but not much pus was
drained. For details, please refer to the operative note. On
POD1, he was discharged afebrile, hemodynamically stable,
tolerating a regular diet, ambulating, with pain improved, and
instruction to schedule follow up with Colorectal Surgery in 2
weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Anaphylaxis
2. Mesalamine (Rectal) 1000 mg PR QHS
3. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six hours
Disp #*90 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth two
times a day Disp #*60 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp
#*10 Tablet Refills:*0
4. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Anaphylaxis
5. Mesalamine (Rectal) 1000 mg PR QHS
Discharge Disposition:
Home
Discharge Diagnosis:
perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for an abscess near your rectum which required
drainage in the operating room. A small incision was made near
your rectum and ___ (rubber band) was placed to allow for
continued drainage. You have tolerated the procedure well and
are ready for discharge. Please call the Colorectal Surgery
Clinic to schedule a follow up appointment in 2 weeks.
Followup Instructions:
___
|
19638873-DS-7
| 19,638,873 | 22,369,447 |
DS
| 7 |
2156-03-20 00:00:00
|
2156-03-21 19:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clarithromycin / Amoxicillin /
Doxycycline / clindamycin / Erythromycin Base / Penicillins
Attending: ___.
Chief Complaint:
groin pain, fevers, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of HIV on ART (complicated by AIDS with CMV
retinitis and PJP, now with suppressed viral load and CD4 333),
Hodgkin lymphoma s/p ABVD x 6 completed ___ and now HPV
associated anal SCC receiving concurrent ___ and XRT
___ was C2D1), transferred from OSH due to fever and
neutropenia. He has been having intermittent low grade fevers
(up
to 100.6). He also has been having skin redness, sloughing, pain
(taking oxycodone and ibuprofen), and oozing in his genital area
and buttocks from XRT, which has worsened in spite of using
aquaphor/topical lidocaine/hydrocort ointments. XRT was held
___ and ___ because of this. He also continues to have
non-bloody diarrhea despite taking both imodium and lomotil. He
is getting home IVF, 1L daily. He denies any SOB, cough, CP,
dysuria. Has had oral and esophageal candidiasis in the past,
but
denies any oral ulcers, dysphagia, or odynophagia. He has missed
a few doses of fluconazole.
He presented to ___ for eval of fevers and was noted to
be neutropenic. He received ___ and was transferred here.
ED course:
___ 74 101/61 16 97%
21:31 IVs: Start IV Fluid (Common) NS 125 mL/hr Total: 1000
mL
Review of Systems: As per HPI. All other systems negative.
Past Medical History:
(Please see OMR for full details.)
Anal SCC
- ___ Noted perianal irritation for the first time
- ___ Started to have some bleeding from the anus and pain
- ___ Presented with painful lump in the anus. Concern for
condyloma v tumor v abscess.
- ___ Underwent resection of the lesion. Path consistent
with SCC, HPV+ by report
- ___ PET CT showed Perianal and anorectal foci of FDG
avidity are nonspecific and may represent physiologic uptake.
However, can not rule out uptake secondary to the known
malignancy. No FDG-avid lymphadenopathy or distant metastases.
- ___ C1D1 ci5FU 1 g/m2/day + mitomycin C 10 mg/m2 with
concomitant XRT
- ___ PLT 96, WBC 4.8
- ___ C2D1 ci5FU 0.8 g/m2/day (dose reduced for mucositis)
+
mitomycin C 7.5 mg/m2 (dose reduced for thrombocytopenia) with
concomitant XRT
PMH/PSH:
anal SCC, as above
HODGKIN'S DISEASE s/p ABVD x 6, completed ___
CHRONIC KIDNEY DISEASE
HIV/AIDS on ART (h/o CMV retinitis, PJP treated with dapsone,
___
--___: HIV-1 RNA is not detected.
--___ CD4 count 333
MRSA ___
h/o pneumococcal pna with sepsis
h/o h. influenza pna
PULMONARY EMBOLISM with DVT
CVA in ___ with no residucal deficit
CONDYLOMA ACUMINATA
PATENT FORAMEN OVALE
Social History:
___
Family History:
Mother: small cell lung cancer
Father: unknown
No other family history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
101.6, 114/66, 94, 16, 94%RA
GEN: mild distress from pain, no respiratory distress
HEENT: PERRL, EOMI, slightly dry MM, oropharynx clear, no
cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
ABD: hyperactive bowel sounds, non-tender, not distended, no
organomegaly or masses
EXTR: Warm, well perfused. No edema. 2+ pulses.
Skin: erythematous, painful skin around entire groin (and
bilateral buttocks and ___, though patient denies pain
here) with skin sloughing, some purulent exudate, no swelling.
NEURO: alert and orientedx3, CN ___ grossly intact, motor
grossly intact
DISCHARGE PHYSICAL EXAM
Vitals: Tm98.1 HR64 (61-72) BP91/56 (sbp90-110) RR20 100%RA
GEN: gentleman lying in bed
HEENT: PERRL, EOMI, dry mmm, oropharynx clear, no
cervical ___: left sided port c/d/i, no erythema or TTP
Resp: CTAB, no rales or rhonchi.
CV: RRR without m/r/g, nl S1 S2.
ABD: normoactive bowel sounds, non-tender, not distended, no
organomegaly or masses
EXTR: Warm, well perfused. No edema. 2+ pulses.
Skin: less erythematous, mildly tender skin around the groin and
pubis, scrotal swelling decreased, bleeding around tip of penis;
faint erythema on bilateral buttocks, improved
Pertinent Results:
ADMISSION LABS
___ 09:55PM BLOOD WBC-1.1*# RBC-3.22* Hgb-11.0* Hct-32.1*
MCV-100* MCH-34.1* MCHC-34.1 RDW-14.5 Plt Ct-40*#
___ 09:55PM BLOOD Neuts-35* Bands-8* ___ Monos-34*
Eos-4 Baso-0 ___ Myelos-0
___ 06:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 09:55PM BLOOD ___ PTT-34.8 ___
___ 09:55PM BLOOD Glucose-97 UreaN-16 Creat-1.4* Na-136
K-4.0 Cl-103 HCO3-26 AnGap-11
___ 09:55PM BLOOD ALT-21 AST-29 AlkPhos-73 TotBili-0.4
___ 06:50AM BLOOD Vanco-16.4
URINE
___ 09:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:55PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:55PM URINE Mucous-RARE
MICROBIOLOGY
___ ___ 1 out of 4 blood cx with staph aureus (from
PIV), sensitivities done
- sensitive to linezolid, cipro, clinda, dapto, minocycline,
gentamicin, levofloxacin, nitrofurantoin, oxacillin,
tetracycline, bactrim, vanc; resistant to erythromycin & PCN
___ Blood cx NGTD
___ Urine culture negative
___ Stool studies neg: Neg C diff, neg O&P X 3, negative
campbylobacter, negative crypto, negative giardia
___ Neg HSV viral culture swab from groin
IMAGING
___ CXR
No signs of pneumonia.
___ TTE
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified. Mildly
dilated thoracic aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
___ CXR
Heart size and mediastinum are stable in appearance. There is
no definitive
new consolidation demonstrated. There is no pleural effusion or
pneumothorax
seen. Port-A-Cath catheter is in place. If clinically
warranted, correlation
with chest CT might be considered.
Brief Hospital Course:
___ with HIV on ART and HPV associated anal SCC receiving
concurrent ___ and XRT ___ was C2D1), transferred
from OSH due to fever and neutropenia, with persistent diarrhea
and severe skin irritation secondary to XRT.
# Neutropenic fever: Fever likely secondary to skin and soft
tissue infection from the groin and bacteremia (1 out of 4 blood
cultures with MSSA). Patient is neutropenic secondary to recent
treatment. Patient was initially on broad spectrum antibiotics
with vanc/cefipeme. This was narrowed to cefazolin on ___ after
determining sensitivities of positive blood cultures. TTE was
negative for endocarditis so patient is to complete a 2 week
course of cefazolin (last day ___. There was lower suspicion
for pulmonary source in the setting of clear chest xray and no
symptoms of cough through majority of hospital stay. Patient had
no urinary symptoms and u/a negative. Patient was given
filgrastim X 1 (administered ___ and white count improved.
Wound care team saw patient and advised patient to cleanse groin
with Domeboro soaks. Skin infection improved clinically by day
of discharge.
# Diarrhea: Likely secondary to chemo/radiation. Patient was
initially started on flagyl which was promptly discontinued once
c. diff studies returned negative. Stool cultures were otherwise
negative for other microorganisms. Diarrhea improved with
current regimen of standing imodium and PRN loperamide and
tincture of opium. Patient was discharged on oxycodone for pain
control.
# HPV -associated anal SCC, receiving concurrent ___
and ___ was C2D1). Further treatment was held while patient
was hospitalized. He has appropriate follow-up scheduled with
medical oncologist and radiation oncologist.
# HIV: last VL undetectable; CD4 count 300s. White count
improved with neupogen. Patient was continued on ART. RT
# CKD: stage III, b/l Cr 1.5. Remained at baseline during
hospitalization.
# Transitional issues
# The patient has a mildly dilated ascending aorta. Based on
___ ACCF/AHA Thoracic Aortic Guidelines, a follow-up
echocardiogram is suggested in ___ years.
# Patient had productive cough on day of discharge but resolved
over a few hours. CXR was unrevealing and had no interval
changes from imaging on day of admit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Darunavir 600 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Etravirine 200 mg PO BID
4. Fluconazole 100 mg PO Q24H
5. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
pain
6. Lorazepam 0.5 mg PO Q6H:PRN anxiety, insomnia
7. Maraviroc 150 mg PO BID
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Raltegravir 400 mg PO BID
10. RiTONAvir 100 mg PO BID
11. Ascorbic Acid ___ mg PO DAILY
12. Cyanocobalamin 1000 mcg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
15. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Darunavir 600 mg PO BID
4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Etravirine 200 mg PO BID
7. Fluconazole 100 mg PO Q24H
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Lorazepam 0.5 mg PO Q6H:PRN anxiety, insomnia
10. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
pain
11. Maraviroc 150 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Raltegravir 400 mg PO BID
14. RiTONAvir 100 mg PO BID
15. Aquaphor Ointment 1 Appl TP TID
RX *white petrolatum [Aquaphor with Natural Healing] 41 % apply
to rash three times a day Disp #*4 Bottle Refills:*0
16. Domeboro 1 PKT TP QID apply to groin
RX *calcium acetate-aluminum sulf [Domeboro] 952 mg-1,347 mg
apply 1 packet four times a day to affected arrea Disp #*20
Packet Refills:*0
17. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone [Gas-X] 80 mg 1 tab by mouth four times daily
Disp #*100 Tablet Refills:*0
18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
every 4 hours Disp #*20 Tablet Refills:*0
19. CefazoLIN 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every 8
hours Disp #*30 Bag Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: skin infection
Secondary diagnosis: staph aureus bacteremia ___ blood
cultures)
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 here at ___. You were
found to have a skin infection of the groin after receiving
radiation for your anal small cell carcinoma. You were found to
have bacteria in your blood as well. You were started on
antibiotics which you should continue through ___. We did
an echocardiogram of your heart which showed no evidence of
vegetations. You were also having persistent diarrhea which we
improved through lomotil, imodium, and tincture of opium. This
diarrhea was most likely due to the treatments of chemo and
radiation you had received. Also, your platelets were low during
hospitalization. Please come back immediately if you have easy
bruising or bleeding. We wish you all the best in your recovery.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19638873-DS-8
| 19,638,873 | 28,851,950 |
DS
| 8 |
2156-03-31 00:00:00
|
2156-04-01 14:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clarithromycin / Amoxicillin /
Doxycycline / clindamycin / Erythromycin Base / Penicillins
Attending: ___.
Chief Complaint:
port malfunction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo M with hx of HIV/AIDS on HAART as well as
hx of Hodgkin's Lymphoma s/p ABVD x 6 cycles completed in ___,
now with HPV+ anal SCC being treated with concurrent ___
mitomycin and XRT (cycle 2 day 26 today), with recent MSSA
bacteremia requiring admission ___, discharged on
cefazolin to complete a 2 week course (to complete on ___
who presented to the ER with his port malfunctioning. The port
was placed originally on ___ ___ surgery.
The patient states that problems began on ___ when he
infused his evening dose of Cefazolin and it created a bulge in
his chest wall. This bulge persisted and was still present in
the morning. It gradually subsided. The following day he was
unable to draw back blood from the port despite different
positions and went to ___. An IV nurse there
evaluated the port and stated that it had tipped. She moved the
left chest wall tissue to flatten it and was able to access it.
He received 1 dose of Cefazolin at ___ yesterday.
That evening, he was again unable to draw back from the port.
This prompted him to come into the ER on ___. He denies any
fevers, chills or night sweats. He reports chronic diarrhea
which is starting to improve. He had 5 bowel movements on
___ and 1 on ___. He takes both lomotil and loperamide
for this at home. He has been tested for C. Diff in the past
and has been negative. He does reports abdominal cramping with
the diarrhea. He denies any shortness of breath, chest pain or
palpitations. He has no pain in the shoulder or chest wall.
In the emergency department, initial vitals: 98.6 80 109/60 16
100% RA. The port had been accessed previously and was
infusing, so the patient was given his cefazolin as prescribed.
The port was noted to be mobile in the chest wall.
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,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY (anal SCC):
- ___: Noted perianal irritation for the first time
- ___ Started to have some bleeding from the anus and pain
- ___ Presented with painful lump in the anus. Concern for
condyloma v tumor v abscess.
- ___ Underwent resection of the lesion. Path consistent
with SCC, HPV+ by report
- ___ PET CT showed Perianal and anorectal foci of FDG
avidity are nonspecific and may represent physiologic uptake.
However, can not rule out uptake secondary to the known
malignancy. No FDG-avid lymphadenopathy or distant metastases.
- ___ C1D1 ___ 1 g/m2/day + mitomycin C 10 mg/m2 with
concomitant XRT
- ___ PLT 96, WBC 4.8
- ___ C2D1 ___ 0.8 g/m2/day (dose reduced for mucositis) +
mitomycin C 7.5 mg/m2 (dose reduced for thrombocytopenia) with
concomitant XRT
OTHER PAST MEDICAL HISTORY:
Hodgkin's Lymphoma, s/p ABVD x 6, completed ___
Chronic Kidney Disease
HIV/AIDS on HAART (h/o CMV retinitis, PJP treated with dapsone,
___
--___: HIV-1 RNA is not detected.
--___ CD4 count 333
MRSA ___
h/o pneumococcal pna with sepsis
h/o h. influenza pna
Hx of DVT/PE
Hx of CVA with no residual deficits
Hx of Condyloma acuminata
PFO
Social History:
___
Family History:
Mother: small cell lung cancer
Father: unknown
No other family history of cancer
Physical Exam:
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CHEST: Right sided port is in place and accessed. No erythema
or abnormalities noted.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
Pertinent Results:
___ 01:15PM BLOOD WBC-3.1* RBC-3.32* Hgb-11.5* Hct-34.4*
MCV-104* MCH-34.5* MCHC-33.3 RDW-16.0* Plt ___
___ 07:35AM BLOOD WBC-2.9* RBC-3.09* Hgb-10.5* Hct-31.2*
MCV-101* MCH-34.1* MCHC-33.7 RDW-16.5* Plt ___
___ 01:15PM BLOOD Glucose-91 UreaN-10 Creat-1.2 Na-135
K-5.9* Cl-104 HCO3-23 AnGap-14
___ 07:35AM BLOOD Glucose-93 UreaN-11 Creat-1.1 Na-138
K-4.4 Cl-104 HCO3-26 AnGap-12
___ 07:35AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.7
___ 01:19PM BLOOD Lactate-1.8 K-5.2*
CHEST (PORTABLE AP)Study Date of ___ 9:42 ___
FINDINGS: Left subclavian catheter tip terminates in the mid
superior vena
cava, with no evidence of pneumothorax. Cardiomediastinal
contours are
normal. Lungs and pleural surfaces are clear except for a focal
band-like
area of atelectasis or scarring in the periphery of the right
mid lung region.
Brief Hospital Course:
Mr. ___ is a ___ year old man with HIV/AIDS on HAART as well
as anal SCC s/p ___ + mitomycin + XRT. His course was
complicated by MSSA bacteremia requiring IV cefazolin. He
presents after several missed doses of antibiotics due to port
malfunction. He was continued on cefazolin here. He was
evaluated by ___, our port-a-cath nurse, and his port
was found to be working. He has now completed his course of
antibiotics and will be discharged home in good condition. The
port will remain in place for now but he may elect to have it
removed in the near future if not needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Darunavir 600 mg PO BID
4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Etravirine 200 mg PO BID
7. Fluconazole 100 mg PO Q24H
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Lorazepam 0.5 mg PO Q6H:PRN anxiety, insomnia
10. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
pain
11. Maraviroc 150 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Raltegravir 400 mg PO BID
14. RiTONAvir 100 mg PO BID
15. Aquaphor Ointment 1 Appl TP TID
16. Domeboro 1 PKT TP QID apply to groin
17. Simethicone 40-80 mg PO QID:PRN bloating
18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
19. CefazoLIN 2 g IV Q8H
Discharge Medications:
1. Aquaphor Ointment 1 Appl TP TID
2. Ascorbic Acid ___ mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Darunavir 600 mg PO BID
5. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Etravirine 200 mg PO BID
8. Fluconazole 100 mg PO Q24H
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety, insomnia
11. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
pain
12. Maraviroc 150 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
15. Raltegravir 400 mg PO BID
16. RiTONAvir 100 mg PO BID
17. Simethicone 40-80 mg PO QID:PRN bloating
18. Domeboro 1 PKT TP QID apply to groin
19. CefazoLIN 2 g IV Q8H Duration: 4 Doses
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV every 8
hours Disp #*4 Intravenous Bag Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
trouble accessing port-a-cath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for trouble with
your port-a-cath which led to you not being able to get your
antibiotic doses at home. You were seen by the port-a-cath nurse
here and the problem was resolved. You should finish your course
of antibiotics. You will follow up with your doctors as
previously ___.
Followup Instructions:
___
|
19638896-DS-12
| 19,638,896 | 29,913,722 |
DS
| 12 |
2132-09-21 00:00:00
|
2132-09-21 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ with h/o recurrent metastatic lung
cancer c/b malignant pleural effusion s/p TPC placement in ___
with recent pleural space infections who is admitted from the ED
with confusion and word finding difficulties
Recent medical course notable for persistent pleural space
infeciton. Pleural fluid initially grew Corynebacterium and
patient was given 14d course of Augmentin. Pleural fluid
continued to grow Corynebacterium and patient was admitted to
___ ___ for IV abx (vanc, CTX, flagyl). Pt dc'ed
with PICC to continue vancomycin for 14d, which she completed 6
days ago.
Since discharge, she reports persistent confusion. This
primarily
manifests as word finding difficulties. She also has short term
memory problems and some confusion with household objects. For
example, the other day she believed her recliner was a car seat,
and would bring her into a medical appointment. Her husband has
also noticed more difficulty ambulating, with a shuffling gait.
She does not use an assistive device and denies falls. She
denies
any localized weakness.
Otherwise, she denies any fevers, chills or rigors. No visual
changes. No dysphagia. No URTI symptoms or ILI symptoms. She has
had increasing pain with daily drainage of her pleurX, typically
only getting about 100cc before stopping due to pain. Otherwise,
she has no chest pain or pleurX discomfort. No SOB. Her cough is
improved. Appetite is fair. No nausea, vomiting, or diarrhea. No
dysuria. No new leg pain or swelling. No medication changes
aside
from the vancomycin, which she completed. She has persistent
generalized fatigue, which has been present for months.
In the ED, initial VS were pain 0, T 99.2, HR 123, BP 146/88, RR
16, O2 100%RA. Initial labs notable for WBC 4.2, HCT 35.9, PLT
243, Na 138, K 3.9, HCO3 25, Cr 1.0, trop neg x1, lactate 1.3.
CXR showed somewhat smaller right pleural effusion but similar
pattern of opacification. NCHCT showed no acute process. Patient
was given 1LNS. VS prior to transfer were HR 99, BP 123/74, RR
17, O2 100%RA.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ presented to her PCP with sinusitis symptoms and was
found to have wheezing on exam. Chest CT showed a 3.8 x 2.5 cm
lobulated soft tissue lesion in the right upper lobe possibly
extending the chest wall with pleural tag mediastinal and right
hilar adenopathy. On PET CT, there was an FDG avid right upper
lobe mass with an FDG avid right hilar and mediastinal
metastasis.
-She underwent bronchoscopy and EBUS. Pathology from the right
upper lobe lesion was moderately differentiated adenocarcinoma,
CK7 positive, TTF-1, ___ 31 and Napsin positive, CK20 negative.
She also had involvement of 4R and level 7, and 11R; 4L was not
diagnostic.
- Negative ___ CT scan with contrast (couldn't tolerate MRI)
- Dx: Lung adenocarcinoma, stage IIIA, with multilevel nodal
involvement. She was recommended to undergo neoadjuvant
chemotherapy/radiation therapy.
-___: 2 cycles cisplatin/etoposide
-___: Radiation therapy
-___: Follow-up chest CT showed multiple new and increase in
some of the pre-existing pulmonary nodules concerning for
widespread metastatic disease.
-___: She underwent right VATS wedge resection x2, both
specimens positive for adenocarcinoma
-___: Started on erlotinib
-___ CT chest: Increase in size of right upper lobe mass
within a region of radiation fibrosis, and increase in right
hilar lymphadenopathy. Increase in number and size of widespread
micronodules, consistent with metastatic disease.
- referred for repeat biopsy with Dr. ___ to assess for T790M
mutation. FNA cytology demonstrated the same EGFR mutation from
before and no ___ mutation.
-___: ___ x 4 cycles
-___ - ___: C1-32 maintenance pemetrexed
-___: CT chest showing disease progression with increased
size of right upper lobe mass and growth of pre-existing
pulmonary nodules, as well as a new layering and nonhemorrhagic
small right pleural effusion.
-___: nivolumab x 3 cycles.
-___: CT torso showing progression, especially substantial
interval increase of right pleural effusion causing left
mediastinal shift. No abdominal disease.
- ___: right TPC placed by IP
- ___: Gemcitabine C1D1
- ___: Hold gemcitabine due to intolerable symptoms
- ___: Restart gemcitabine with 25% dose reduction and
addition of dexamethasone C1D15
- ___: C2D1 gemcitabine, plan for treatment on days 1, 8,
and
___. Per patient request, break during ___ week.
- ___: restaging scans with significant progression
- ___: started osimertinib
- ___: CT chest with response
- ___: CT with ongoing response
- ___ - ___: Admtted with persistent pleural space
infection/pleurX infection. Treated with 14 days of vancomycin
PAST MEDICAL HISTORY:
-Lung cancer, as above
-Hypertension
-Chronic pain, fibromyalgia
-Depression
-Anxiety with panic attacks
-Reflux
-Glaucoma
-Sciatica
-Heart murmur (+ ABX prophylaxis)
-Allergic rhinitis
Social History:
___
Family History:
Father - passed from leukemia
Mother - alive
Aunt and uncle - lung cancer
Physical Exam:
Temp: 98.0 PO BP: 157/91 HR: 104 RR: 18 O2 sat: 98% O2 delivery:
RA
GENERAL: Resting in bed husband at bedside, at times in fetal
position crying, other times sitting up eating
HEENT: OMM
CARDIAC: s1s2 RRR
LUNG: No respiratory distress, TPC capped in R lung, decreased
breath sounds up to ___ of R lung, otherwise clear
ABD: SNT/ND
EXT: WWP No ___
NEURO: Alert and oriented to only self. + intermittent word
finding difficulties. CN III-XII intact. Strength grossly full
throughout. no dysmetria or dysdiadochokinesia.
PSYCH: Anxious, at times tearful discussing plans moving
forward,
but at times very jovial
SKIN: No significant rashes.
Pertinent Results:
3.21 CT Chest w/ Con
IMPRESSION: The persistence of large right hydropneumothorax,
predominantly basal, despite an apparent communicating pleural
drainage tube in the right lower hemithorax, is probably a
function of severe right pleural encasement and right upper lobe
collapse due to pulmonary fibrosis. The tube may have succeeded
in breaking up the adhesions in the pleural space since the
dependent layering of a smaller volume of fluid has replaced
multi previous loculations. Persistent, treated central
adenopathy. Esophagus may be compromised by the residual
subcarinal nodal component. No new adenopathy. Multiple stable
metastases, easiest to recognize in the left lung.
3.21 CT scan of the abdomen and pelvis with contrast
Stable examination.
3.20 MR ___
1. Study is mildly degraded by motion. 2. Numerous intracranial
enhancing lesions as described, some which demonstrate ring
enhancing pattern, and the largest measuring 8 mm in the left
frontal lobe, concerning for intracranial metastatic disease,
with differential considerations of infectious or inflammatory
etiologies less likely. 3. No evidence of acute intracranial
hemorrhage or acute infarct. 4. Paranasal sinus disease , as
described.
3.19 CT ___
No acute intracranial abnormality.
3.19 CXR
FINDINGS: PA and lateral views of the chest provided. Again seen
is a right pleural chest tube as well as a left upper extremity
access PICC line, terminating in the upper SVC. Right pleural
effusion is similar in overall extent. Pattern of right
hemithorax opacification is unchanged. Left lung remains clear.
No additional findings. IMPRESSION: No change from prior.
Brief Hospital Course:
___ w/ EGFR mutated NSCLC metastatic to pleura on osimertinib
s/p
TPC c/b persistent TPC colonization/infection p/w 3 weeks of WFD
and cognitive dysfunction found to have diffuse brain metastases
on MRI, started on steroids and WBRT.
# Diffuse brain metastatic disease
# Encephalopathy:
# Unsteady gait:
She has no focal findings on exam but has subacute subtle
cognitive dysfunction with inattention and word finding
difficulties. MRI confirmed suspicion for diffuse brain
metastatic disease. Received whole brain XRT without
complications with somewhat decline in physical status.
Hospice was raised with patient and family by palliative
care and the plan at this time is to get the patient home
as soon as possible to maximize her time there with 24hr
support. they will continue to have ongoing discussions re
goals of care as outpatient but in meantime, will continue the
remaining fractions of XRT.
- Dexamethasone 4mg qAM + PPI
- Continue WBRT per RadOnc
- ___ at home
- Hold osimertinib while undergoing WBXRT
# Pleural space colonization by CoNS: Continued growing CoNS on
pleural fluid culture on ___ and ___. Pleural fluid has
downtrending PMN count and LDH. Patient is asymptomatic and
afebrile. Discussed with ID and IP. Will keep for now. She was
drained daily with maximum of 150 ml each time
- Drain TPC daily as tolerated (ok to do every other day)
- hold off abx for now
# Sinus tachycardia: Chronic. Prior CTA without PE and TSH wnl.
# Anxiety:
- Lorazepam 0.5mg po q6 hours as needed
# GERD:
- Continue ranitidine prn
# Glaucoma:
- Continue drops
FEN: Regular
CODE: Confirmed DNR/DNI on ___
COMMUNICATION: Patient
DISPOSITION: home w/ 24/hr care
BILLING: >30 min spent coordinating care for discharge
____________________
___, D.O.
Heme/Onc Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY:PRN allergies
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. osimertinib 80 mg oral DAILY
4. Ranitidine 75 mg PO DAILY:PRN GERD
5. Travatan Z (travoprost) 0.004 % ophthalmic (eye) DAILY
6. Benzonatate 100 mg PO TID:PRN cough
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Amoxicillin ___ mg PO PREOP
Discharge Medications:
1. Dexamethasone 4 mg PO QAM
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Amoxicillin ___ mg PO PREOP
4. Benzonatate 100 mg PO TID:PRN cough
5. Cetirizine 10 mg PO DAILY:PRN allergies
6. Docusate Sodium 100 mg PO BID
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Ranitidine 75 mg PO DAILY:PRN GERD
9. Senna 8.6 mg PO BID:PRN constipation
10. Travatan Z (travoprost) 0.004 % ophthalmic (eye) DAILY
11. HELD- osimertinib 80 mg oral DAILY This medication was
held. Do not restart osimertinib until discussed with your
oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Lung Cancer to brain
Discharge Condition:
Mental Status: Confused
Discharge Instructions:
Mrs. ___,
___ was a pleasure caring for you in the hospital. You were
admitted because of difficulty walking and word finding
difficulties. You were found to have cancer spread to your
brain. You were started on steroids and whole brain radiation.
Please follow up with your oncology team. Please continue your
radiation therapy as instructed.
Your ___ Team
Followup Instructions:
___
|
19638958-DS-5
| 19,638,958 | 20,133,632 |
DS
| 5 |
2172-09-14 00:00:00
|
2172-09-14 21:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Shellfish / Motrin / naproxen / Augmentin / yellow dye
/ morphine / lorazepam
Attending: ___.
Chief Complaint:
Brain metastasis with cerebral edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w significant smoking hx, c-spine fusion, referred from PCP
office with vertigo, abnormal MRI concerning for metastatic
cancer with unknown primary. Patient initially started having
vertigo symptoms 10 days ago and episode of right arm nervous.
She had no syncope or seizures or falling although felt unsteady
on her feet. She presented to ___ on ___ where MRI showed
multiple brain mets with cerebral edema, with unknown primary.
Patient declined admission as she wanted to see her PCP ___.
She was given decadron and discharged on steroids (prednisone 30
mg Q4H per patient). Symptoms have improved since but she was
seen by PCP today with normal breast, pelvic exam and given
concern for continued vertigo, left-sided headache, and blurry
vision in left eye, patient was sent in for workup to identify
primary malignancy.
In the ED, initial vitals were: 9 97.6 71 123/107 18 99% RA
- Labs were significant for WBC 12.6, Cr 0.8, BUN 30. She was
given ativan 1mg PO x 1, dilaudid 0.5 mg and 1 mg IV for
headache.
- She was seen by NSGY and neuro who felt no neurosurgical
intervention but recommended admission for oncologic workup.
Vitals prior to transfer were:
In the ED, VS: 97.6 71 123/107 18 99% RA.
Numbness Left V1 distribution; Left pupil w slight myopia
compared to Right. CN II-XII otherwise intact. Normal strength
and sensation in extremities.
Lateral beating nystagmus
CV, Pulm, Abd benign
MRI report from ___:
Multiple enhancing mass lesions, throughout the brain most
likely representing metastatic disease. Focus of sub acute
ischemic injury in the right cerebellar hemisphere
Upon arrival to the floor, VS: 98.0 ___ 18 99% RA. Patient
complained of persistent Left sided headache, feeling anxious.
No visual deficits at this time.
Past Medical History:
Irritible bowel syndrome
cervical spondylosis s/p spinal fusion ___
Chronic pain syndrome on narcotics contract
Depression
Anxiety
Social History:
___
Family History:
Mom died lung ca age ___, dad died glioblastoma age ___, no other
fam hx cancer of any kind including colon, breast, ovarian
cancer.
Three brothers alive at this time, one with heart problems. One
sister died of suicide at age ___, and another brother died of
complications from heroine addiction.
Physical Exam:
ON ADMISSION:
Vitals: 97.6 71 123/107 18 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI without
nystagmus, pupils round reactive to light with very slight
anisocoria with R>L.
Neck: JVP not elevated, +multiple round pea-sized firm mobile
lymph nodes in the anterior cervical chain and in
supraclavicular region, no axillary LN, no thyromegaly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: R basilar crackle, otherwise clear
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: Notable for numbness to light touch over V1, and R>L
slight anisocoria, CN exam otherwise intact, ___ strength
upper/lower extremities, 2+ reflexes bilaterally, normal heel to
shin and FTN, gait not tested.
ON DISCHARGE:
Vitals: 98.3 Tmax 98.7 ___ 100-130s/70s-80s 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL compared
to slight anisocoria seen on admission.
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no crackles, wheezing or rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: motor and sensation grossly intact, CN II-XII intact
Psych: energetic, pressured speech, lack of insight
Pertinent Results:
ON ADMISSION:
___ 07:30PM BLOOD WBC-12.6* RBC-5.18 Hgb-13.5 Hct-41.3
MCV-80* MCH-26.1 MCHC-32.7 RDW-13.8 RDWSD-39.8 Plt ___
___ 07:30PM BLOOD Neuts-47.0 ___ Monos-10.3 Eos-1.4
Baso-0.2 Im ___ AbsNeut-5.90 AbsLymp-5.09* AbsMono-1.29*
AbsEos-0.18 AbsBaso-0.03
___ 07:30PM BLOOD Glucose-95 UreaN-30* Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
___ 07:30PM BLOOD ALT-20 AST-19 AlkPhos-51 TotBili-0.1
ON DISCHARGE:
___ 06:40AM BLOOD WBC-13.5* RBC-4.57 Hgb-11.9 Hct-38.0
MCV-83 MCH-26.0 MCHC-31.3* RDW-14.7 RDWSD-43.9 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-85 UreaN-19 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-28 AnGap-15
___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0
OTHER DIAGNOSTICS:
___ CT CHEST W/ CONTRAST: Right juxta hilar mass encasing the
right lower lobe bronchus, and lower lobe segmental arteries
with soft tissue extension along the bronchovascular bundle.
Smooth interlobular septal thickening in the right lower lobe
can be venolymphatic obstruction. Extensive necrotic
mediastinal, hilar and right supraclavicular metastatic
lymphadenopathy. No satellite pulmonary nodule or
aggressive bony lesions. *Constellation of findings are
suggestive of primary right juxtahilar lung carcinoma with
metastatic disease.*
___ CT A/P W & W/OUT:
1. Enhancing right adrenal lesion and thickening of the left
adrenal gland, concerning for metastatic disease.
2. Multiple subcentimeter liver hypodensities are too small to
characterize although statistically most likely represent simple
cysts versus biliary hamartomas, metastatic disease however
cannot be excluded. 3. Fibroid uterus.
___ CT NECK W/ CONTRAST: Centrally necrotic cervical
lymphadenopathy without a discrete primary malignancy.
Brief Hospital Course:
Ms. ___ is a ___ old woman with history of smoking and
dysphagia since ___, presenting with vertigo, found to have
multiple brain mets from primary lung carcinoma.
Active issues:
# Metastatic lung carcinoma
Patient was referred from PCP office with vertigo and abnormal
MRI concerning for metastatic cancer with cerebral edema,
unknown primary. Exam notable for anisocoria, lateral beating
nystagmus, numbness V1 distribution, and cervical and
supraclavicular LAD. She was started on high dose dexamethasone
at her PCP's office and continued while hospitalized.
CT chest showed primary R juxtahilar lung carcinoma with
metastasis. CT A/P showed R adrenal lesion c/f metastatic
disease. Biopsy of lung mass was performed on ___ by
interventional pulmonology, tissue results pending, though
primary pathology reading did not look suspcicious for small
cell carcinoma and instead was suggestive of adenocarcinoma.
Patient discharged with plan to follow up with radiation
oncology, neuro-oncology, and thoracic oncology.
# Dysphagia
She states she has had dysphagia since cervical fusion done in
___ this year. CT neck showed extensive lymphadenopathy but no
compressive mass. Barium swallow showed only mild aspiration.
#Altered mood
During admission, patient appeared to be manic, with possible
contribution from high dose dexamethasone, which was decreased
to 4mg daily per neuro onc recs. IP performed transbronchial
biopsy, tissue results pending. Patient discharged and will
continue dexamethasone 4 mg daily with last dose on ___.
Chronic Issues
# Smoking: Nicotine patch
# Depression/anxiety: Continued citalopram, valium prn
# Chronic pain syndrome: Continued gabapentin and home oxycodone
# IBS: Continued dicyclomine, metamucil
TRANSITIONAL ISSUES:
- She is to continue daily dexamethasone 4mg until ___ per
neuro-oncology. She will need to follow up with neuro-oncology
as scheduled below.
- Please follow-up on tissue results for transbronchial biopsy.
She will follow up with hematology oncology as below who will
coordinate an appointment with thoracic oncology
- Please evaluate cause of dysphagia. Consider nerve damage s/p
cervical fusion vs. scleroderma, etc.
- Please follow up with radiation oncology as scheduled
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 60 mg PO QHS
2. DiCYCLOmine 10 mg PO TID
3. Gabapentin 600 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Adderall (dextroamphetamine-amphetamine) 20 mg ORAL BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. oxyCODONE-acetaminophen ___ mg oral 4X/DAY:PRN pain
8. flaxseed 1,000 mg oral daily
9. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 0.52 gram oral daily
10. Lorazepam 0.5 mg PO Q4H:PRN anxiety
11. Dexamethasone 4 mg PO Q6H
Discharge Medications:
1. Adderall (dextroamphetamine-amphetamine) 20 mg ORAL BID
2. Citalopram 60 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. Lorazepam 0.5 mg PO Q4H:PRN anxiety
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Gabapentin 600 mg PO TID
7. DiCYCLOmine 10 mg PO TID
8. flaxseed 1,000 mg oral daily
9. oxyCODONE-acetaminophen ___ mg ORAL 4X/DAY:PRN pain
10. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram oral daily
11. Dexamethasone 4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary lung carcinoma with metastasis to brain and adrenals
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because an MRI was concerning for
metastasis to your brain without a known primary source.
Unfortunately, a CT chest found primary lung cancer with
metastasis. A CT of your abdomen also suggested metastasis to
your adrenal gland. A biopsy of your lung mass was performed to
identify the type of cancer, which will guide appropriate future
treatment.
The CT of your neck also showed enlarged lymph nodes but no mass
that would cause your difficulty swallowing. You should
follow-up with your PCP to address other possible causes.
Please do not drive at this time.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19639613-DS-7
| 19,639,613 | 22,073,864 |
DS
| 7 |
2133-12-15 00:00:00
|
2133-12-21 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
Past Medical History:
HTN
Obesity
Sciatica
Tobacco abuse
Parotitis ___ (treated with augmentin)
Sinusitis
Sleep apnea
COPD vs asthma (recent PFTs showing combined mild restictive and
obstructive ventilatory defects)
h/o MRSA ___
Social History:
___
Family History:
No known ___ of CAD
Physical Exam:
ADMISSION
=========
PHYSICAL EXAM:
Vitals: T: 98.3 BP: 125/82 P: 77 R: 16 O2: 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in epigastric and LUQ, discomfort but not
pain during liver palpation, non-distended, bowel sounds quiet
but audible, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: warm and dry
Neuro: grossly intact
DISCHARGE
=========
Vitals: T: 98.4 BP: ___ P: ___ R: ___ O2: 99-100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation in epigastrum, discomfort but
not pain during liver palpation, non-distended, bowel sounds
quiet but audible, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: warm and dry
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 04:45AM URINE UCG-NEG
___ 04:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:21AM GLUCOSE-113* UREA N-10 CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-30 ANION GAP-9
___ 03:21AM ALT(SGPT)-193* AST(SGOT)-203* ALK PHOS-136*
TOT BILI-0.3
___ 03:21AM LIPASE-28
___ 03:21AM CK-MB-2 cTropnT-<0.01
___ 03:21AM ALBUMIN-3.9 CALCIUM-9.8 PHOSPHATE-4.1
MAGNESIUM-1.8
___ 03:21AM ACETMNPHN-NEG
PERTINENT LABS
==============
___ 5:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
DISCHARGE LABS
==============
___ 05:45AM BLOOD WBC-11.2* RBC-4.43 Hgb-12.2 Hct-39.8
MCV-90 MCH-27.5 MCHC-30.7* RDW-13.4 Plt ___
___ 05:45AM BLOOD Neuts-67.6 ___ Monos-4.4 Eos-2.0
Baso-0.6
___ 05:45AM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-141 K-4.0
Cl-106 HCO3-25 AnGap-14
___ 03:21AM BLOOD Glucose-113* UreaN-10 Creat-0.9 Na-137
K-3.8 Cl-102 HCO3-30 AnGap-9
___ 05:45AM BLOOD ALT-106* AST-62* AlkPhos-115* TotBili-0.3
___ 05:45AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.6
IMAGING
=======
___ RUQ Ultrasound
IMPRESSION:
Gallbladder is mildly distended and contains multiple shadowing
stones. No
specific signs of acute cholecystitis although the possibility
is not excluded
by this study.
___ Abdominal CT
IMPRESSION:
No evidence of acute intra-abdominal process.
___ MRCP
IMPRESSION:
1. Cholelithiasis with slight arterial hyperenhancement within
the liver about
the gallbladder fossa and interval development of gallbladder
wall edema.
Findings can be seen with acute cholecystitis, though the
gallbladder is not
particularly distended. Clinical correlation is recommended and
a HIDA scan
can be obtained for further assessment.
2. Gallbladder adenomyomatosis.
3. No choledocholithiasis or evidence of biliary dilatation.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of
presented to the ER with nausea and abdominal pain found to have
a positive ___ sign suspicious for cholecystitis. She had
recently presented to the ER on ___ after a low speed MVC in
which she was a restrained driver and was rear-ended at
approximately 20 miles per hour. No airbag deployment. She had
been taking 1800-2400mg of ibuprofen per day since her car
accident for her back pain. She reported a short history of
polyuria and polydipsia.
ACUTE PROBLEMS
# Abdominal Pain/Nausea: The patient presented with abdominal
pain of two days duration, associated with food intake. This was
thought to be due to possible NSAID-induced gastritis vs.
biliary colic vs. IBS. Of note, the patient had recently been
taking high-dose NSAIDs for back pain. She was evaluated by
surgery, which recommended outpatient follow-up. A CT was not
revealing and a RUQ U/S and MRCP not definitive for
cholecystitis. Her hemoglobin was stable during the admission.
Her abdominal pain resolved with tylenol PRN. She was advised to
avoid NSAIDs and was started on a PPI. H. pylori serology was
negative (resulted after discharge).
# Transaminitis: On admission, labs were remarkable for negative
HCG, ALT 193, AST 203, AP 136, TB 0.3, WBC 15.7.The pattern of
liver function test elevation indicated a mixed picture of
cholestasis (alk phos elevation, but no elevation in bilirubin)
and hepatitis (transaminitis). Her transaminases and alkaline
phosphatase decreased. HIDA scan was suggested, but given the
patient's lack of symptoms, stable vital signs and improving lab
values, it was thought that cholecystitis was not likely. She
was advised to follow up in the ___ clinic for further
evaluation of cholelithiasis.
CHRONIC PROBLEMS
# HTN: Stable; the patient was treated with her outpatient
medications.
# OSA: Stable; the patient was treated with her outpatient
medications.
TRANSITIONAL ISSUES:
[] Please follow-up with ACS for further evaluation
[] Please consider outpatient Heme/onc follow-up for chronic
leukocytosis
[] Please consider GI referral, given symptoms of IBS
[] Please repeat TFTs within several months of discharge, given
borderline low free T4
[] Please consider further evaluation of polyuria (urine
protein, etc). A1c is pending at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Amlodipine 5 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH Q12H:PRN shortness of
breath
4. Gabapentin 600 mg PO TID
5. Losartan Potassium 100 mg PO DAILY
6. metaxalone 800 mg oral TID
7. Vitamin D 400 UNIT PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ibuprofen 600-800 mg PO Q8H:PRN Pain
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Losartan Potassium 100 mg PO DAILY
3. Vitamin D 400 UNIT PO DAILY
4. Gabapentin 600 mg PO TID
5. Amlodipine 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH Q12H:PRN shortness of
breath
7. metaxalone 800 mg oral TID
8. Acetaminophen 325-650 mg PO Q6H:PRN Pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth Every 6 hours
Disp #*60 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
1. Non Steroidal Anti-Inflammatory Drug-induced gastritis
2. Cholelithiasis
SECONDARY DIAGNOSES
1. Hypertension
2. Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were at ___.
You were admitted for abdominal pain which was thought to be due
to stomach inflammation from ibuprofen use versus possibly due
to gallstones passing out of your gallbladder. You had an
ultrasound, CT scan and MRCP scan done to evaluate your
abdominal pain. These scans showed multiple stones within your
gallbladder, but did not show evidence of an acute infection. We
believe that you may benefit from removal of the gallbladder in
the outpatient setting. Please avoid all non-steroidal
anti-inflammatory medications (Aleve, Ibuprofen, Motrin,
Naproxen, etc.). Please follow up with your doctor.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19639613-DS-8
| 19,639,613 | 25,141,904 |
DS
| 8 |
2133-12-26 00:00:00
|
2133-12-26 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ hx HTN, obesity, COPD presents with acute RUQ and epigastric
abdominal pain for 24hrs. Patient reports she's been
experiencing
intermittent epigastric and RUQ pain for about ___ year now. Pain
is cramping pain mostly in epigastrium exacerbated by eating
associated with occasional nausea. This has increasingly become
more frequent to about once a week starting ___ months ago. She
presented to the ___ ED on ___ and was admitted to the
Medicine service with workup revealing for RUQ US that showed
mildly distended gallbladder, multiple stones w/out s/o
cholecystitis. MRCP ___ showed stones, GB wall edema, no
choledocholithiasis, adenomyomatosis. CT abd/pelvis ___ was
WNL.
Patient was discharged home on HD2 with a referral to
___ to discuss outpatient elective cholecystectomy.
Patient was seen by Dr. ___ in clinic yesterday but was
not able to schedule surgery due to timing issues, however upon
arrival to home, started acute RUQ pain after dinner with nausea
with unsually prolonged time this time around. Patient was
advised to come to the ED. Otherwise denies any fevers, chills,
diarrhea, constipation, melena/BRBPR.
Past Medical History:
HTN
Obesity
Sciatica
Tobacco abuse
Parotitis ___ (treated with augmentin)
Sinusitis
Sleep apnea
COPD vs asthma (recent PFTs showing combined mild restictive and
obstructive ventilatory defects)
h/o MRSA ___
Social History:
___
Family History:
No known FH of CAD
Physical Exam:
Physical Exam: Upon admission ___
Vitals: 97.8 93 135/80 18 100%RA
GEN: A&O, NAD, obese
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation in epigastrium and
RUQ, no rebound/guarding
Ext: No ___ edema, ___ warm and well perfused
Physical Exam:Upon discharge ___
Vitals: 98.4, 140/78, 58, 16, 100%RA
GEN: A&O, NAD, obese
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear bilaterally, No W/R/R
ABD: Soft, nondistended, mildly tender to palpation about port
sites, port sites dressed with dry sterile dressings without
drainage and without surrounding erythema, pos BS X 4quadrants
Ext: No ___ edema, ___ warm and well perfused, no calf tenderness
Pertinent Results:
___ 09:13PM URINE HOURS-RANDOM
___ 09:13PM URINE UCG-NEGATIVE
___ 09:12PM URINE HOURS-RANDOM
___ 09:12PM URINE GR HOLD-HOLD
___ 09:12PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:12PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-5
___ 09:12PM URINE MUCOUS-RARE
___ 06:29PM ___ PTT-27.3 ___
___ 05:33PM GLUCOSE-87 UREA N-9 CREAT-0.9 SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-29 ANION GAP-8
___ 05:33PM estGFR-Using this
___ 05:33PM ALT(SGPT)-22 AST(SGOT)-13 ALK PHOS-75 TOT
BILI-0.2
___ 05:33PM LIPASE-27
___ 05:33PM ALBUMIN-4.1
___ 05:33PM WBC-11.1* RBC-4.52 HGB-12.9 HCT-40.5 MCV-90
MCH-28.6 MCHC-31.9 RDW-13.5
___ 05:33PM NEUTS-74.8* LYMPHS-17.5* MONOS-5.3 EOS-1.8
BASOS-0.6
___ 05:33PM PLT COUNT-330
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study
Date of ___
IMPRESSION:
Cholelithiasis without evidence of cholecystitis.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission (abdominal ultra-sound) revealed cholelithiasis
without evidence of cholecystitis. The patient failed
conservative treatment on the floor and then underwent
laparoscopic cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor on IV fluids, and IV pain
medication for pain control. The patient was hemodynamically
stable. She was transferred back to the floor after a brief
uneventful stay in the PACU.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Albuterol prn, amlodipine 5', flovent 110 2'', gabapentin
600''', losartan 100', metaxalone 800''', oxycodone prn, Vit D3,
ibuprofen 600'', pantoprazole 40'
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Gabapentin 600 mg PO Q8H back pain
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID constipation Duration: 2 Weeks
do not take if having loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
6. Amlodipine 5 mg PO DAILY hypertension
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 on ___ 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 to continue
your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19640369-DS-20
| 19,640,369 | 24,170,156 |
DS
| 20 |
2138-08-30 00:00:00
|
2138-08-30 20:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip dislocation
Major Surgical or Invasive Procedure:
___: Revision left total hip arthroplasty
History of Present Illness:
___ female presents with L-hip dislocation. Past medical
history of EtOH and fall on ___ resulting in a L
acetabular
fracture requiring ___, subsequently developed
purulent drainage from incision site with a subluxed femoral
head
requiring a Girdlestone procedure ___ s/p irrigation and
debridement with total hardware explantation and resection
arthroplasty with abx spacer placement (___).
Cultures grew MRSA and CoNS; pt received 6 week course of IV
vanco thru ___. Pt subsequently underwent LT
hemiarthroplasty
revision with conversion to a permanent ceramic head replacement
and liner replacement on ___.
Since, she underwent L-hip arthrotomy with sinus excision and
revision on ___ with Dr. ___. On ___, she had
a
L-total hip dislocation that was reduced at a local emergency
department.
This morning, she attempted to get out of bed when she heard a
pop. At that time, she did not have her knee brace on. She then
presented to ___ where attempts to reduce the hip were
unsuccessful. Pt was transferred here for further evaluation. Pt
also endorses mild serous drainage from her left-hip without any
fevers, chills, erythema or warmth. On arrival, she endorses
L-hip pain without numbness or parasthesias. No other concerns
at
this time. Orthopaedics consulted for evaluation of L-hip
dislocation.
Past Medical History:
PMH/PSH:
___:
1. ORIF left posterior wall acetabular fracture
2. Open reduction of posterior hip dislocation
___:
1. Left hip arthrotomy with drainage.
2. Removal of deep implant, left hip.
3. Resection arthroplasty, left hip.
___:
1. Stage debridement and irrigation of left acetabular fracture
and infected wound with closure.
___:
1. Total hip replacement with a Prostalac system
___:
1. Revision left total hip replacement with conversion of
pre-existing cemented total hip to new with total hip using the
___ you can components: 56 mm multihole shell, 10 degree
liner,
#9 press-fit stem, 36 mm, +5 ceramic head
___:
1. Left hip arthrotomy
2. Sinus excision
3. Irrigation
4. Revision of polyethylene acetabular and femoral head
component
___:
1. Left total hip dislocation status post reduction in local
emergency department
Social History:
___
Family History:
noncontributory
Physical Exam:
General: Well-appearing, breathing comfortably
MSK: SILT ___ distributions
Drain in place
Fires ___
Toes WWP
Dressing clean dry and intact
Pertinent Results:
___ 05:50AM BLOOD WBC-9.9 RBC-2.86* Hgb-7.3* Hct-23.8*
MCV-83 MCH-25.5* MCHC-30.7* RDW-20.5* RDWSD-61.8* Plt ___
___ 04:26AM BLOOD WBC-13.6* RBC-3.03* Hgb-7.9* Hct-24.5*
MCV-81* MCH-26.1 MCHC-32.2 RDW-20.3* RDWSD-59.3* Plt ___
___ 08:44AM BLOOD Glucose-100 UreaN-5* Creat-0.6 Na-136
K-4.3 Cl-101 HCO3-28 AnGap-7*
___ 10:47AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-137
K-4.4 Cl-104 HCO3-27 AnGap-6*
___ 08:44AM BLOOD Calcium-7.8* Phos-4.2 Mg-1.7
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip dislocation and was admitted to the
orthopedic surgery service. Attempted closed reduction under
conscious sedation in the emergency department was unsuccessful.
The patient was taken to the operating room on ___ for
closed reduction under general anesthesia which was
unsuccessful. Patient was subsequently taken back to the
operating room on ___ as a joint case between trauma and
arthroplasty for an open reduction and revision of her left
total hip arthroplasty. Cultures were also taken at this time.
A drain was left in place which was removed on postop day 2
without incident. For full details of the procedure please see
the separately dictated operative report. The patient was taken
from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
Patient was evaluated by infectious disease. Intraoperative
cultures showed no growth of organisms with only presence of
PMNs. Infectious disease recommended transition to chronic oral
suppression with minocycline.
Patient's labs were monitored during her admission and were
notable for a hematocrit of 16.9 on POD1. She was transfused 2u
pRBC and her hematocrit was stable around her baseline of ___
for the rest of her admission.
Patient's incision was covered with a prevena vac and this was
kept in place on discharge.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ infectious disease per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 30 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS:PRN anxiety
3. Doxepin HCl 50 mg PO HS
4. Vitamin D ___ UNIT PO 1X/WEEK (___)
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN Leg swelling
7. Gabapentin 1200 mg PO TID
8. hydrOXYzine pamoate 50 mg oral TID:PRN anxiety
9. Mirtazapine 15 mg PO QHS
10. orphenadrine citrate 200 mg oral QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM DVT PPX
Take for 4 weeks (28 days)
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Nightly Disp
#*28 Syringe Refills:*0
4. Minocycline 100 mg PO Q24H
Take 2 hours before taking any iron.
RX *minocycline 100 mg 1 tablet(s) by mouth Twice daily Disp
#*30 Tablet Refills:*2
5. Multivitamins W/minerals 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every ___ hours Disp
#*35 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
8. Senna 8.6 mg PO BID
9. Citalopram 30 mg PO DAILY
10. ClonazePAM 0.5 mg PO QHS:PRN anxiety
11. Doxepin HCl 50 mg PO HS
12. FoLIC Acid 1 mg PO DAILY
13. Furosemide 20 mg PO DAILY:PRN Leg swelling
14. Gabapentin 1200 mg PO TID
15. hydrOXYzine pamoate 50 mg oral TID:PRN anxiety
16. Mirtazapine 15 mg PO QHS
17. orphenadrine citrate 200 mg oral QPM
18. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left prosthetic hip dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity with posterior
hip precautions
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add narcotic medication as needed for increased pain. Aim
to wean off this medication in 1 week or sooner. This is an
example on how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated left lower extremity
Posterior hip precautions
No flexion, abduction and internal rotation combined
Treatments Frequency:
Incisional Praveena VAC on left posterior hip can be left on,
either recharged as necessary or when battery runs out may
remove VAC and replace with dry sterile dressing as needed.
Absorbable sutures used.
Followup Instructions:
___
|
19640465-DS-5
| 19,640,465 | 24,949,297 |
DS
| 5 |
2133-10-31 00:00:00
|
2133-11-02 12:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LUQ abdominal pain, splenic mass
Major Surgical or Invasive Procedure:
Splenic biopsy (___)
Bone marrow Biopsy (___)
History of Present Illness:
___ smoker with h/o EtOH abuse, remote h/o cocaine use and
otherwise no known PMHx, who presented with LUQ/L flank pain x
___ months, associated with nausea, anorexia, weight loss x 3
weeks. He complained of back pain and L-sided abdominal pain. He
reported intermittently feeling hot and thought he "probably
had fevers". He had intermittent diarrhea and constipation as
well as nausea and vomiting. He endorsed sweats, but "mostly
when I cough". He had lost about 5 lbs in the prior few weeks
that he attributed to not being able to eat. His daughter also
noted that his cough has changed recently. He quit smoking 8
months ago at the encouragement of his daughters.
He also has chronic dyspnea on minimal exertion, is relatively
sedentary at baseline.
He presented to ___ ED at the urging of his
daughters. CT of the abdomen revealed a large, necrotic splenic
mass. He was noted to have UA with small numbers of bacteria and
was given ceftriaxone for possible UTI. He noted that his urine
had been very dark recently but denied dysuria, frequency.
In ER was febrile: (Triage Vitals: 101.9 100 149/77 20 97% RA)
Review of systems notable for dyspnea as above, and intermittent
nonexertional chest pain which the patient has a hard time
characterizing further.
Past Medical History:
tobacco use
h/o EtOH abuse ___ yrs ago)
remote h/o cocaine, acid
Past Surgical History: L chest mass biopsy (reportedly benign)
"years ago"
Social History:
___
Family History:
F- HTN
M- died from multiple sclerosis
No known malignancy
Physical Exam:
T 99.2 P 97 BP 126/80 RR 16 O2Sat 98% RA
GENERAL: alert, pleasant, mentating clearly, somewhat anxious
Eyes: NC/AT, Pupils 1 mm bilaterally, minimally reactive, EOMI
without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, poor dentition, no lesions noted in
OP
Neck: supple, no JVD appreciated
Respiratory: Lungs with decreased BS bilaterally, no R/R/W
Cardiovascular: Reg, S1S2, no M/R/G noted
Gastrointestinal: soft, + bowel sounds, mildly tender in LUQ. +
splenomegaly.
Genitourinary: L flank tenderness
Skin: no rashes or lesions noted- no spider angiomata, no
splinter hemorrhages. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: pleasant and interactive, anxious
ACCESS: [x]PIV
Pertinent Results:
___ 12:18AM WBC-16.5* RBC-4.55* HGB-11.3* HCT-36.0*
MCV-79* MCH-24.9* MCHC-31.4 RDW-13.3
___ 12:18AM NEUTS-84.4* LYMPHS-8.6* MONOS-6.3 EOS-0.4
BASOS-0.3
___ 12:18AM PLT COUNT-312
___ 12:18AM GLUCOSE-98 UREA N-10 CREAT-0.8 SODIUM-132*
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
___ 12:18AM ALT(SGPT)-42* AST(SGOT)-38 ALK PHOS-100 TOT
BILI-0.5
___ 12:18AM LIPASE-293*
___ 12:18AM ALBUMIN-3.3*
___ 05:55AM BLOOD WBC-8.4 RBC-3.49* Hgb-8.9* Hct-28.0*
MCV-80* MCH-25.5* MCHC-31.7 RDW-14.1 Plt ___
___ 05:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
CT Abd ___): 14cm necrotic mass in spleen w/ several
adjacent
necrotic lymph nodes. Probable necrotic pericardial lymph node,
which was not fully assessed. Malignancy is suspected.
CTA ___. No pulmonary embolism or aortic dissection.
Growing 6 mm left lower lobe nodule and accompanying new small
left greater than right pleural effusion are concerning for
infection, alternatively lymphoma. In this patient about to
commence with chemotherapy, it would be prudent to assess for
resolution with a non-contrast Chest CT prior to initiating
therapy.
3. Epicardial lymph node, smaller, may be responsible for
slightly larger
small pericardial effusion.
CT chest/abd here:
1. 13-cm splenic mass with satellite nodules and 3.6 cm
epicardial mass, both enhancing, concerning for malignancy.
2. Possible splenic vein thrombosis or chronic occlusion.
3. Multiple tiny lung nodules. In the setting of possible
malignancy,
follow-up imaging is recommended in 3 months.
4. Paraseptal emphysema.
5. Mediastinal, hilar and splenic calcifications, suggestive of
prior
granulomatous disease.
Spleen biopsy:
BMBx (___): suspect NHL with large B cell lymphoma with
atypical histiocytes and myeloid cells.
Dx:
1. Mildly hypercellular marrow with preserved trilineage
hematopoiesis.
2. No morphologic or flow cytometry evidence of non-Hodgkin
lymphoma.
3. Mild increase in monocytic precursor is seen.
Immunophenotyping BM (___):
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B cell
lymphoma are not seen in specimen. A mild increase in immature
monocytic precursors are seen. Correlation with concurrently
performed bone marrow biopsy is recommended.
Echo (___): No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
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. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
BM Cytogenetics: PND
Micro data:
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Brief Hospital Course:
Mr. ___ is a ___ smoker with h/o EtOH abuse, remote h/o
cocaine use and otherwise no known PMHx, who presented with
fever and LUQ pain and found to have a new splenic and
pericardial mass concerning for malignancy. Mr. ___
underwent spleen biopsy on ___. Pathology was consistent
with high-grade lymphoma. BM biopsy done ___ showing evidence
of DLBCL. Evaluation also showed splenic vein obstruction seen
on CT, most likely tumor burden but cannot rule out clot (not on
AC). He underwent treatment of CHOP for DLBCL and received
Levofloxacin after being noted to spike fevers (given evidence
of COPD). He had atypical CP, and as descibed below, underwent
workup (negative) for ACS/aortic dissection (most likely CP was
due to GERD in the setting of steroid use). Pt was also found to
have lung nodules and possible splenic vein obstruction on CT.
Pt currently reports feeling chronic SOB, cough and abdominal
pain in area of the spleen.
Active Issues
# High grade lymphoma (DLBCL on BMBx): Echo reviewed (normal
baseline). EBV viral load <200, histo negative. ___,
___, and B-glucan are pending.
- CHOP day 1 = ___
# ? splenic vein obstruction seen on CT, most likely tumor
burden but cannot rule out clot. Given lack of data on
anticoagulation for splenic vein thrombosis, decision made to
not anticoagulate.
# COPD- Evidence on chest CT. Has significant DOE at baseline.
Started spiriva, flovent, nebulizers. Pt's breathing improved
after steroids were initiated as part of CHOP regimen. On
discharge, pt received flovent, spiriva, and rescue
bronchodilators (in addition, pt received final dose of CHOP
prednisone to be taken on day following discharge, please see
below). Recommend outpatient PFTs and follow up
#Chest Pain-
Mr. ___ was triggered for CP. Pain was not severe (and had
occurred many times at rest in the past), pressing, associated
with food, not relieved with Maalox or nitroglycerin, relieved
by morphine, radiating to the back. EKG showed non-specific
T-waves in V1-V4 and PR depressions in I and II (no priors
available). Pt had cardiac enzymes negative x 3 and a CTA
negative for PE or dissection. CTA showed enlarging ___ mass. CP
likely GERD ___ hiatal hernia in setting of steroids
- ___ mass on later imaging
- Continue omeprazole for GERD
#Fever
Pt spiked on ___ of ___
- Levofloxacin 500mg po qd for empiric coverage considering COPD
(intended course = ___
# pulmonary nodules- seen on CT scan. Recommend 3 month f/u.
Inactive Issues
# elevated INR- with low albumin. No e/o liver disease on CT
scan; also LFTs and platelet count are normal. Viral hep panel
negative. Likely dietary insufficiency of vit K. Vit K PO
challenge done with 2mg on ___ and 2mg on ___. Subsequent
INR's showed INR of 1.1
# hyponatremia- on admission, sodium mildly low. Pt did not
appear hypovolemic, and had high urine sodium, suggestive of
SIADH. Normalized by day 2 with fluid restriction. On DC, [Na] =
135
# Fevers
Now resolved.
- Likely ___ lymphoma vs. Enterococcus UTI; UCx positive for
enterococcus but pt denies sx and UA is negative. Pt already on
levofloxacin and abx coverage not expanded.
TRANSITIONAL ISSUES
[ ] Please monitor for evidence of UTI given prior UCx + for
enterococcus
[ ] Patient was to have taken last dose of prednisone of day
after discharge; on ___
[ ] Pt was to have taken final dose of Levofloxacin on day after
discharge; on ___
[ ] Please ___ B-glucan
[ ] Please ___
[ ] Please ___ assay
[ ] Please ___ and Flow cytometry
[ ] Enlarging lung masses noted on CTA from ___ - as per
radiology, more concerning for infection than for pulmonary
DLBCL, given rate of change
[ ] Needs 3 month follow up CT for pulmonary nodules
[ ] Started on albuterol and spiriva/flovent, please obtain PFTs
[ ] Pt has no PCP (an appointment was not able to be scheduled
on current discharge)
[ ] Please ___ Sodium, given initial hyponatremia
Medications on Admission:
none
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Avoid taking this medication while
driving or drinking alcohol as it may cause sedation. .
Disp:*10 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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*
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*3*
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation Inhalation once a day.
Disp:*1 inhaler* Refills:*0*
6. fluticasone 110 mcg/actuation Aerosol Sig: ___ Puffs
Inhalation BID (2 times a day) as needed for shortness of
breath.
Disp:*1 inhaler* Refills:*0*
7. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: please take on ___.
Disp:*1 Tablet(s)* Refills:*0*
8. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. prednisone 50 mg Tablet Sig: Two (2) Tablet PO once a day for
1 days: please take on ___.
Disp:*2 Tablet(s)* Refills:*0*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. dextromethorphan-guaifenesin ___ mg/5 mL Liquid Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*1 container* Refills:*0*
12. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
14. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) Injection once
a day: Please use once daily until your follow-up appointmet.
Disp:*10 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diffuse Large B-Cell Lymphoma
COPD Exacerbation
Discharge Condition:
Mental Status: Alert and Oriented
Ambulatory Status: Ambulating
Condition: Improved
Discharge Instructions:
Dear Mr. ___, It was a pleasure taking care of you at ___.
You were admitted due to shortness of breath and fevers. A bone
marrow biopsy demonstrated Diffuse Large B-Cell Lymphoma and you
began chemotherapy (CHOP regimen). Because of your smoking
history, evidence of chronic obstructive pulmonary disease on CT
scan, and fevers, you were started on an antibiotic called
levofloxacin.
Medication Changes:
In treatment of your cancer please take:
Prednisone 50mg 2 tablets (total of 100mg) on ___ (part of
chemo)
Omeprazole 40mg orally daily (to help heartburn from prednisone)
Allopurinol ___ orally daily (to prevent side effects of
chemo)
Bactrim 1 tab daily (to prevent infection)
Acyclovir three times per day (to prevent infection)
Fluconazole daily (to prevent infection)
Neupogen 1 injection daily (to prevent infection)
In treatment of pain:
Oxycodone 5mg every 4 hours IF NEEDED for pain
In treatment of constipation:
Docusate sodium 100mg orally twice daily IF NEEDED for
constipation
Senna 8.6mg tablet two twice daily IF NEEDED for constipation
In treatment of your COPD please use:
Levofloxacin 500mg tablet on ___ (for your fever/possible
infection)
Spiriva inhaler 1 inhalation per day (for your COPD)
Fluticasone inhaler ___ puffs two times per day IF NEEDED for
shortness of breath
Albuterol inhaler ___ puffs every 6 hours IF NEEDED for
shortness of breath
Robitussin every 6 hours IF NEEDED for cough
Again it was a pleasure taking care of you. Please contact with
any additional questions or concerns.
Followup Instructions:
___
|
19640587-DS-7
| 19,640,587 | 29,807,698 |
DS
| 7 |
2166-07-08 00:00:00
|
2166-07-08 15:06:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Codeine / Demerol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
___ year old female, presenting with 24-hr history of RLQ
abdominal pain, constant, slowly progressive up to ___ in
the ED. Denies any nausea/vomiting, but refers some subjective
fevers and chills. Her last bowel movement was last night and
normal. Has been passing flatus/BMs without problems.
Past Medical History:
migraines, HTN, hypercholesterolemia,
depression, osteoporosis, ___ aneurysm, cholelithiasis,
bleeding
ulcer, h/o SBO & distal SB wall thickening, diverticulosis
Past Surgical History: MVR ___ (porcine), BTL
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Temp: 98.7 HR: 74 BP: 122/67 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Comfortable
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, significant tenderness to palpation in the
right lower quadrant, positive Rovsing's, no rebound or
guarding, not rigid
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
On discharge:
Vitals: 97.9 po, HR 106, BP 114/64, RR 18, 96% on room air.
Neuro: AAO x 3. NAD. Pleasant.
Card: S1, S2. No m/r/g. Intermittent irregular beats.
Pulm: Clear bilaterally in full lung fields (anteriorly).
GI: Active BS. Abdomen softly distended, non-tender.
GU: Voiding frequently. Low post-void residuals per RN. UA
clean. No subjective feelings of dysuria, burning.
Extrem: Warm, dry, well-perfused.
Pertinent Results:
___ 01:15PM BLOOD WBC-17.3*# RBC-4.82 Hgb-14.7 Hct-43.9
MCV-91 MCH-30.6 MCHC-33.5 RDW-12.4 Plt ___
___ 06:05AM BLOOD WBC-5.0# RBC-4.11* Hgb-12.5 Hct-37.9
MCV-92 MCH-30.4 MCHC-33.0 RDW-12.6 Plt ___
___ 01:29AM BLOOD WBC-11.0 RBC-3.71* Hgb-11.1* Hct-34.3*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.1 Plt ___
___ 01:15PM BLOOD Neuts-85.2* Lymphs-9.9* Monos-4.5 Eos-0.1
Baso-0.3
___ 03:49AM BLOOD Neuts-81.9* Lymphs-11.9* Monos-4.1
Eos-1.8 Baso-0.3
___ 01:15PM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-136
K-3.7 Cl-99 HCO3-24 AnGap-17
___ 06:05AM BLOOD Glucose-172* UreaN-8 Creat-0.7 Na-137
K-3.7 Cl-106 HCO3-21* AnGap-14
___ 01:29AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-137 K-3.6
Cl-104 HCO3-23 AnGap-14
CT abd/pelv ___: 1. Prior appendectomy for perforated
appendicitis with presence of multiple rim enhancing collections
within the abdomen as above. Right lower quadrant abscess which
is adjacent to the suture line demonstrates internal locules of
gas and is amenable to percutaneous drainage. 2. Imaging
findings consistent with diffuse peritonitis. 3. There is no
pneumoperitoneum. 4. Mildly dilated loops of small bowel
without transition point. There is no pneumatosis or portal
vein gas.
Brief Hospital Course:
Ms. ___ was initially admitted to the floor for management
of her abdominal pain and concern for ileus vs obstruction. She
was then transferred to the ICU when she went into afib w/ RVR
and became unstable on the floor. She had progressive abdominal
pain, guarding, and tachycardia to 140s in afib. She was given
diltiazem and metoprolol on the floor with minimal reponsive.
She was transferred to the SICU. She responded to diltiazem 25
mg total and her heart rate decreased from 140s to ___. However,
her tachycardia persisted and she was placed on neo early
morning ___. She was cardioverted with amiodarone. She did well
and was transitioned to intermittent IV lopressor on ___.
She stayed in sinus rhythm throughout the day on IV lopressor
and was transferred to the floor on the evening of ___.
Overnight, however, she again went into afib with RVR; she was
given additional doses of lopressor without success. On the
morning of ___ she was transferred back to the ICU. She was
cardioverted again and started on an amiodarone drip. This
effectively rate controlled her; she was then transitioned to a
diltiazem drip with PO amiodarone doses. On ___ she began
passing flatus and tolerated sips of liquids with her
medications. On ___ she spontaneously converted to sinus and
was weaned off the diltiazem drip. Her heart rate remained in
sinus rhythm in the 70's-80's on oral amiodarone and oral
diltiazem. She continued to pass flatus and was advanced to
clear liquids, which she tolerated well. She had a CT scan on
___ that showed multiple pelvic collections. ___ placed a drain.
She was advanced to a regular diet and tolerated that well. She
worked with physical therapy.
Medications on Admission:
METOPROLOL TARTRATE 50', NITROGLYCERIN 0.4mg prn, OMEPRAZOLE
20mg'', SIMVASTATIN 20, ASA 325, CALCIUM CARBONATE-VITAMIN D3
600 mg (1,500 mg)-200 unit daily, multivitamin daily, Topamax
25mg two tabs qhs
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Discharge Instructions:
ACTIVITY:
- Do not drive until you have stopped taking narcotic pain
medicine and feel you could respond in an emergency.
- ___ lift more than ___ pounds for 6 weeks.
- 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.
YOUR INCISION:
- Your incision may be slightly red around the stitches or
staples. This is normal.
- You may gently wash away dried material around your incision.
- Do not remove steri-strips for 2 weeks.
- It is normal to feel a firm ridge along the incision. This
will go away.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
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.
- It is important you take your pain medicine as directed. Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- If you are experiencing no pain, it is OK to skip a dose of
pain medicine.
- To reduce pain, remember to exhale with any exertion or when
you change positions.
DRAIN CARE:
You should continue to keep your drain in place until follow-up.
Please record the output of the drain each day. You can flush
the drain with 5cc of normal saline once a day so that the drain
does not get clogged. Bring the output records to your next
clinic appointment.
Followup Instructions:
___
|
19640899-DS-11
| 19,640,899 | 28,161,837 |
DS
| 11 |
2187-05-06 00:00:00
|
2187-05-07 07:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Tunneled line ___
Right radiocephalic arteriovenous fistula: ___
History of Present Illness:
Ms. ___ is a ___ woman with a history of RA, diastolic
CHF (EF ~55%) CKD (recently worsened to stage V, Cr 4's), DM2 on
insulin, recent presumed septic shoulder, ?COPD, and several
recent admissionf for ___ who presents with SOB since this
morning.
Patient admitted from ___ for PNA and dCHF
exacerbation. She was again admitted from ___ with
___ and discharged on a regimen of alternating days of 10mg and
20mg torsemide daily (10 mg today). Patient initially felt
better after going home, but awoke this morning acutely short of
breath. She was wheezing, which did not improve with albuterol
MDI q30 min. A family member noticed she could not speak in full
sentences and called Dr. ___ physician during prior
admission), who advised coming in to the ED. Patient has not had
fevers, chills, n/v/d, or sick contacts. The swelling in her
legs has improved. She has had a dry cough (also present during
prior admission).
She presented to the ___ ED, where initial vitals were 0 99.4
75 139/76 22 97%. CXR showed pulmonary edema and small
effusions, though improved from prior. Labs were notable for BNP
148___ (improved from ~ 20K prior admission), trop 0.15 (improved
from prior), and WBC WNL at 7.3. Patient received nebs with
slight improvement. Prednisone and azithromycin were ordered.
She was admitted to medicine for ___ vs. COPD.
On arrival to the floor, vitals were 98.5 152/72 72 28 98 RA.
Patient is sitting up, saying she can breath better this way. No
PND. No fevers, chills, congestion, sore throat, n/v/d,
abdominal pain, dysuria, hematuria, or increased frequency at
home. She reports adherence to all home meds, including
torsemide (took 10 mg today). She has not been taking increased
fluids and reports adherence to low-salt diet. She feels
swelling of her legs has slowly been improving.
Past Medical History:
Type 2 Diabetes
Rheumatoid arthritis
Hypertension
Hyperlipidemia
Chronic kidney disease, stage 5
Renal tubular acidosis, type 4
Diastolic heart failure, EF>55%
Presumed COPD
Social History:
___
Family History:
Mother had COPD vs. asthma. Father had rheumatic ___ disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- wt 93.1 kg, 98.2 91 140/58 22 96%2___
General- Sitting up in bed, hard of hearing, tachypnic
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP 10 cm, no LAD
CV- RRR, S1 + S2, no murmurs, rubs, gallops
Lungs- Deep breaths provoke paroxysm of cough. Bibasilar
crackles. No wheezes/rhonchi. No retractions or accessory muscle
use
Abdomen- Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley, no CVAT
Ext- Warm, very faint ___ pulses, 1+ pitting edema to knee
Neuro- CN ___ intact
Pertinent Results:
=============================
ADMISSION LABS:
=============================
___ 08:43PM WBC-7.3 RBC-2.95* HGB-7.5* HCT-25.5* MCV-87
MCH-25.5* MCHC-29.5* RDW-15.7*
___ 08:43PM NEUTS-78.2* LYMPHS-13.4* MONOS-4.4 EOS-3.5
BASOS-0.5
___ 08:43PM PLT COUNT-305
___ 08:43PM GLUCOSE-152* UREA N-51* CREAT-3.8* SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18
___ 08:43PM TOT PROT-6.9 ALBUMIN-3.5 GLOBULIN-3.4
CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.9 IRON-26*
___ 08:43PM calTIBC-406 VIT B12-566 FOLATE-8.4
FERRITIN-99 TRF-312
___ 08:43PM ___
.
=============================
DISCHARGE LABS:
=============================
___ 06:59AM BLOOD WBC-7.8 RBC-3.24* Hgb-8.5* Hct-28.1*
MCV-87 MCH-26.4* MCHC-30.4* RDW-14.9 Plt ___
___ 06:59AM BLOOD Glucose-192* UreaN-38* Creat-3.9* Na-143
K-4.2 Cl-104 HCO3-26 AnGap-17
___ 06:59AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8
.
=============================
PERTINENT LABS:
=============================
___ 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:43PM BLOOD PEP-TRACE ABNO IgG-1172 IgA-393 IgM-646*
IFE-MONOCLONAL
___ 11:00PM URINE U-PEP-NON-SELECT IFE-NEGATIVE F
.
=============================
URINE:
=============================
___ 05:32PM URINE Color-Straw Appear-Clear Sp ___
___ 05:32PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:32PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:00PM URINE Hours-RANDOM Creat-77 TotProt-258
Prot/Cr-3.4*
.
=============================
IMAGING:
=============================
[Previous admission]VENOUS DUP UPPER EXT UNILATERA (___)
IMPRESSION: Patent central veins. Patent brachial and radial
arteries. The radial artery is small in diameter. The forearm
veins are too small for access. The left upper arm cephalic is
thrombosed.
.
CXR (___):
FINDINGS: PA and lateral views of the chest are compared to
previous exam from ___. Right PICC is no longer
seen. Increased interstitial markings are seen throughout the
lungs. There is blunting of the posterior costophrenic angles,
which may represent small effusions, although smaller when
compared to prior. Streaky right basilar opacity may be due to
atelectasis. No acute osseous abnormality detected.
IMPRESSION: Mild pulmonary edema and trace effusions, smaller
when compared to ___.
.
CXR (___):
FINDINGS: Persistent cardiomegaly and pulmonary vascular
congestion with
interval decrease in severity of pulmonary edema with residual
mild
interstitial edema remaining. Within the periphery of the right
upper lobe, at the level of the sixth posterior rib level is a
poorly-defined 7-mm diameter nodular opacity which in retrospect
is present on older study of ___. Note is also made of
small bilateral pleural effusions.
IMPRESSION:
1. Improving pulmonary edema.
2. 7 mm peripheral right upper lobe nodular opacity, for which
chest CT is recommended in order to differentiate a benign
nodule from a slowly growing lung adenocarcinoma.
.
BILAT LOWER EXT VEINS (___)
FINDINGS:
Bilateral common femoral veins demonstrate normal symmetric
waveforms with respiratory variability. Bilateral common
femoral, superficial femoral, and popliteal veins demonstrate
normal compressibility, flow, and augmentation. Bilateral
posterior tibial and peroneal veins demonstrate compressibility
and flow with color Doppler.
IMPRESSION:
No sonographic evidence for lower extremity deep vein
thrombosis.
.
VENOUS DUP UPPER EXT UNILATERA; ART DUP EXT UP UNI OR LMTD
(___)
FINDINGS: There is normal phasicity in the right subclavian
vein suggesting central venous patency. There is a tunneled
hemodialysis catheter in the right internal jugular vein (not
imaged).
The cephalic and basilic veins on the right are both patent.
The cephalic vein measures 6.2 mm in the proximal upper arm, 5.5
mm in the mid upper arm and 6.3 mm tapering to 4.7 mm above the
elbow. The cephalic vein measures 4 mm in the antecubital
fossa, 3.9 mm in the proximal forearm and 3.8 mm in the distal
forearm. The proximal basilic vein measures 4.4 mm in the upper
arm, 3.3 mm above the elbow, 2.4 mm in the antecubital fossa.
There is mild calcification in the right radial artery, and no
plaque or
calcification in the right brachial artery. The brachial artery
measures 4 mm and the radial artery measures 2.2 mm. Triphasic
waveforms were seen in the brachial artery and monophasic in the
radial artery.
IMPRESSION:
Vein mapping of the right upper extremity as described above.
There is a
tunneled hemodialysis catheter in the right IJ, which is not
imaged on this exam and both cephalic and basilic veins are
patent.
.
=============================
MICROBIOLOGY:
=============================
___ 10:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:28 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:32 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of DM II, RA,
HTN, and CKD V with two recent admissions for PNA/COPD/dCHF. She
presents again with shortness of breath and volume overload.
.
# Volume overload secondary to Acute-on-Chronic diast CHF: The
patient's initial presentation (as with her prior recent
admissions) was consistent with volume overload secondary to
CHF. She was seen by ___ cardiology who recommended
aggressive diuresis. Despite attempts with metolazone, Lasix
160mg and multiple doses of chlorothiazide, we were unable to
successfully diuresis her. She was initiated on dialysis during
this admission with a tunneled line placed on ___. Venous
mapping showed poor venous access on the left side so the
fistula was placed on her right radiocephalic arteriovenous
fistula on ___. PPD and hepatitis serologies negative. She
will be receiving dialysis T/H/S at ___ Dialysis.
.
# CKD V: Patient has stage V CKD presumably due to HTN/DM. Given
she was unable to be effectively diuresed with aggressive
medication dosing, she was evaluated by Nephrology and
ultimately initiated on dialysis as per above. She will be
receiving dialysis T/H/S at ___ Dialysis.
# MGUS: Per Atrius records, the patient had iron deficiency
anemia treated with PO iron and a diagnosis of MGUS (M spike
seen on SPEP in ___ but has not had follow-up evaluation.
Repeat SPEP during this admission again showed monoclonal IGG
kappa of 1172 which, along with trace light chains, makes her
generally low risk for progression. Given that it will be
difficult to follow based on her clinical exam and basic lab
work because of her other comorbidities, she might benefit from
repeat SPEP/UPEP yearly.
- Hematology follow up is recommended. Discussed with patient
.
# Lung Nodule: Incidentally noted. Follow up CT recommended.
This was discussed with the patient.
.
.
CHRONIC DIAGNOSES:
------------------
# Hypertension: Continued home labetalol. She was started on
Imdur during this admission. ___ need to be titrated as
necessary.
.
# Rheumatoid Arthritis: Continued prednisone and Tylenol with
codeine prn.
.
# T2DM: Last A1C 7.1%: Insulin glargine increased from 5 to
10units QAM. She was placed on gentle insulin sliding scale for
additional coverage but will be discharged on the Lantus 10
units qam. This may need to be titrated as an outpatient
.
# Hypercholesterolemia: Continued home pravastatin.
.
.
TRANSITIONAL ISSUES:
------------------
[ ] She will need a chest CT to follow-up a 7 mm peripheral
right upper lobe nodular opacity seen on CXR. This was
recommended by radiology to differentiate benign from a slowly
growing lung adenocarcinoma.
[ ] Had SPEP/UPEP during her admission. ___ benefit from
repeating yearly, heme follow up
[ ] Medication changes: For blood pressure control, the
amlodipine was held and she was started on Imdur. This should be
titrated as necessary. We also increased her am Lantus to
10units for better glycemic control
[ ] PPD negative on ___. Quant gold pending
[ ] Will have dialysis ___ at ___
___, ___ , Tel: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. cholecalciferol (vitamin D3) 1000 mg Oral daily
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Ferrous Sulfate 325 mg PO DAILY
6. Glargine 5 Units Breakfast
7. Labetalol 200 mg PO BID
8. Nicotine Patch 7 mg TD DAILY
9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
10. Pravastatin 40 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. sevelamer CARBONATE 1200 mg PO TID W/MEALS
13. Sodium Bicarbonate 1300 mg PO BID
14. Torsemide 10 mg PO DAILY
15. Benzonatate 100 mg PO TID:PRN cough
16. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
18. PredniSONE 5 mg PO DAILY:PRN joint pain
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. cholecalciferol (vitamin D3) 1000 mg Oral daily
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Labetalol 200 mg PO BID
7. Nicotine Patch 7 mg TD DAILY
8. Pravastatin 40 mg PO DAILY
9. PredniSONE 5 mg PO DAILY:PRN joint pain
10. Senna 1 TAB PO BID:PRN constipation
11. sevelamer CARBONATE 1200 mg PO TID W/MEALS
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
14. Glargine 10 Units Breakfast
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 10
unit 10 Units before BKFT; Disp #*30 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Acute on chronic heart failure
- End stage renal disease, on dialysis
SECONDARY DIAGNOSES:
- Hypertension
- Diabetes Mellitus
- MGUS
- Rheumatoid Arthritis
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 participating in your care. You were
admitted on ___ for severe shortness of breath. Because of
your heart failure, you were retaining fluid and the fluid in
your lung was making it hard to breath. We tried giving you very
strong medications via your IV but these medications were unable
to remove enough fluid from your lungs and legs. You were
started on dialysis while inpatient and will continue as an
outpatient at ___ on ___,
___, and ___.
You were also found to have a lung nodule in your CXR. Your PCP
has already ordered at CT scan so that we can get more
information about this.
If you have any worsening or concerning symptoms, please let
your doctors ___.
Again, it was our pleasure participating in your care. We wish
you the best of luck
Followup Instructions:
___
|
19640899-DS-13
| 19,640,899 | 28,162,933 |
DS
| 13 |
2187-09-20 00:00:00
|
2187-09-28 19:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending: ___.
Chief Complaint:
HD access malfunction
Major Surgical or Invasive Procedure:
1. Right upper extremity AV fistulagram.
2. Balloon angioplasty of a juxta-anastomotic arterial limb
stenosis with a
3-mm balloon.
3. Balloon angioplasty of an anastomotic stenosis up to 4 mm.
4. Over-the-wire exchange of a left internal jugular tunneled
catheter
History of Present Illness:
___ w/PMHx significant for HLD, DM2, RA, HTN, MGUS, Long QT w/VT
arrest, h/o endocarditis w/bacteremia no longer on antibiotics,
ESRD on HD ___ sent here from her dialysis center today
after they were unable to dialyze her today.
Notably, patient with recent complicated hospitaliazation from
___ initially for presumed COPD exacerbation and suffered
VFib arrest the evening of admission, thought due to long QTc
syndrome and azithromycin use. Hospitalization was further
complicated by MSSA bacteremia/endocarditis requiring removal of
prior tunneled line and replacement on ___. Since discharge,
she completed abx on ___ and was also seen in ___ clinic
___, at which time her fistula was thought to be mature and
ready for use. Apparently, since then her dialysis center has
been using bother her tunnelled line and AV fistula (but never
for a full session). Today, at outpatient dialysis, she was
noted to have her tunneled line displaced about 3 inches, and
was unable to be flushed. Additionally, they were unable to
access her AVF, so she was sent to the ED.
In the ED intial vitals were: T 97.8, HR 72, BP 164/99, RR 16,
O2 100%. Initial exam was notable for clear lungs with no edema.
RUE AV fistula with thrill and L tunneled line c/d/i but
displaced. Initial labs were notable for Cr 3.8 (baseline) and
HCT 35.7. K and HCO3 were unremarkable. Nephrology was consulted
who recommended cleaning tunneled line in sterile fashion,
advancing catheter, and dressing with tegaderm, which was done
in the ED. Patient was then admitted to medicine for furhter
management. VS prior to transfer were T 97.7, HR 76, BP 147/61,
RR 18, O2 97%RA.
On the floor, patient is without complaint. Denies fevers or
chills. No SOB or cough. No purulence or erythema from RIJ
tunneled line. No leg swelling. No frank orthopnea, sleeps with
two pillows and no PND. Walks ___ yards unassisted, limited by
right hip pain.
Past Medical History:
- ESRD with HD started in ___ s/p distal R AVF placed on
___. Current access with tunneled IJ.
- HFprEF, EF>60%
- Type 2 Diabetes on Insulin
- Long QT Syndrome c/b VT arrest ___ after receiving
azithromycin
- Hx MSSA Bacteremia and endocarditis ___
- Presumed COPD
- Rheumatoid arthritis
- Hypertension
- Hyperlipidemia
- Renal tubular acidosis, type IV
Social History:
___
Family History:
Mother had COPD vs. asthma and lung cancer. Father had rheumatic
heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:99.1 BP:166/71 HR:83 RR:20 02 sat:98%RA Weight 179.1
lb
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ SEM
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
VS:98.6 170/75 80 18 100%ra
GENERAL: ___ in no acute distress. Pleasant and conversant.
CHEST: CTAB
CARDIAC: RRR, S1/S2, ___ SEM
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: obese
EXTREMITIES:no peripheral edema or cyanosis
NEURO: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 06:25PM BLOOD WBC-6.3 RBC-3.92* Hgb-10.4* Hct-35.7*
MCV-91 MCH-26.6* MCHC-29.3* RDW-17.7* Plt ___
___ 06:25PM BLOOD ___ PTT-29.6 ___
___ 06:25PM BLOOD Glucose-317* UreaN-39* Creat-3.8* Na-138
K-3.9 Cl-101 HCO3-23 AnGap-18
___ 08:20AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.1
IMAGING:
CXR ___
FINDINGS: Comparison is made to the prior radiographs from
___. The dialysis catheter has been pulled back
almost 20 cm since the prior study and the distal tip is only a
few centimeters from the skin surface. The heart size is within
normal limits. There is mild prominence of the pulmonary
interstitial markings suggestive of mild pulmonary edema. No
definite consolidation is seen.
Brief Hospital Course:
___ w/PMHx significant for HLD, DM2, RA, HTN, MGUS, Long QT w/VT
arrest, h/o endocarditis w/bacteremia no longer on antibiotics,
ESRD on HD ___ sent here from her dialysis center today
after they were unable to dialyze her today.
#ESRD on dialysis with access malfunction: Patient with
displaced tunneled line access and also with difficulty
accessing AVF at outpatient dialysis. Tunneled line has been
sterily cleaned in ED and dressed. She underwent, right upper
extremity AV fistulagram, Balloon angioplasty of a
juxta-anastomotic arterial limb stenosis with a 3-mm balloon,
Balloon angioplasty of an anastomotic stenosis up to 4 mm.
and an over-the-wire exchange of a left internal jugular
tunneled catheter. She subsequently underwent dialysis without
event.
#MSSA Bacteremia and endocarditis: S/p ___nded ___. Notably, per DC summary, tunneled line was to be
removed following abx course, but has remained as use of AVF
seems imminent. No current signs or symptoms of infection.
She underwent over-the-wire exchange of a left internal jugular
tunneled catheter.
#Prior Cardiac arrest: Thought due to torsades due to
azithromycin and long QTc. Low concern for ischemic etiology.
Plan for outpatient stress/ICD placement.
Avoided MACROLIDE ANTIBIOTICS OR QTC PROLONGING DRUGS .
Continued mexilitine and external defibrillator vest.
#HTN: Continued home regimen of Imdur 30 and hydral 25 q8
#Diabetes mellitus, type 2:Continued home lantus 10 with HISS
#HLD: Continued pravastatin
#HFpEF: Not currently decompnesated. Last echo unremarkable.
Continued imdur and hydral and volume management with HD
TRANSITIONAL ISSUES:
# Lung nodule
- 10mm solitary nodule was noted on CT ___ at 7 mm
last year). Recommended for 3 month radiographic follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Nicotine Patch 7 mg TD DAILY
5. Pravastatin 40 mg PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
7. HydrALAzine 25 mg PO Q8H
8. Mexiletine 150 mg PO Q8H
9. sevelamer CARBONATE 1200 mg PO TID W/MEALS
10. Glargine 10 Units Breakfast
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Epoetin Alfa 6000 UNIT IV WITH HD
5. HydrALAzine 25 mg PO Q8H
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Mexiletine 150 mg PO Q8H
8. Nicotine Patch 7 mg TD DAILY
9. Pravastatin 40 mg PO DAILY
10. sevelamer CARBONATE 1200 mg PO TID W/MEALS
11. Glargine 10 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ESRD
Stenotic A-V fistula
Displaced HD tunnel catheter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you here at ___.
You were admitted due to problems with dialysis: your fistula
was blocked and your catheter was displced.Your fistula has been
unblocked and your catheter replaced. You have been restarted on
dialysis and can go home to continue dialysis as an outpatient.
Please keep all your doctor's appointments
Followup Instructions:
___
|
19640899-DS-14
| 19,640,899 | 28,022,945 |
DS
| 14 |
2189-08-21 00:00:00
|
2189-08-21 20:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending: ___
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mrs. ___ ___ yo F with history of ESRD d/t DM on ___
dialysis, HFpEF, long QT Syndrome c/b VT arrest ___
after receiving
azithromycin, PVD, RA, RTA type IV who presents to ED from ___
___ dialysis for an episode of unresponsiveness. Per dialysis
nurse ___ reports that she has not been feeling well for
some time and losing weight unintentionally. Today at dialysis
the tech found her to have her eyes closed and unresponsive.
Nurse went to go evaluate and noted her to be unresponsive to
sternal rub. Vitals check and were normal. After a few minutes
she opened her eyes and nurse thinks she had R facial droop.
Took several minutes for her to be able to follow command of
"squeeze my hand." Nurse repeatedly says that ___ "wasn't
herself." Charge nurse evaluated her and decided to send her to
ED for evaluation. Of note, patient maintained vital signs
throughout dialysis. Pressures ranged 101-124 systolic. Pulse
mostly in the ___. She got 47 minutes of dialysis and net
volume was +100cc.
In the ED, initial vitals were: 97.8 72 108/60 16 100% RA
Exam notable for a patient who is AO x 4.
Labs notable for:
-WBC count 15
-UA showing lg leuks, > 182 wbc, moderate bacteria, neg nitrite
-lactate 2.7
-lipase 107
Imaging notable for
NCCT Head:
1. No acute intracranial process. Periventricular and deep
subcortical white matter hypodensities suggest chronic small
vessel ischemic disease. If there is clinical concern for acute
infarction, MRI is more sensitive.
2. Chronic appearing deformity of the left lamina papyracea
consistent with prior injury.
CXR:
Stable prominence of the pulmonary interstitium likely relates
to volume overload, similar appearance to prior exams. No
definite focal consolidation.
Patient was given ___ 14:24 IV CeftriaXONE 1 gm
___
Patient was seen by Neurology who recommended extended routine
EEG. Can also get MRI Brain with contrast for sz workup but
would need to be timed with dialysis.
Decision was made to admit for abx for UTI + EEG and/or MRI
head.
Vitals upon transfer: 97.9 66 130/68 18 97% RA
On the floor, patient does not recall anything abnormal. From
her perspective she went to dialysis as usual and then they took
her to the ER for reasons she does not understand. Feels
baseline now. Endorses some lower back pain. Denies dysuria,
chest pain, shortness of breath, confusion, strange
smells/taste.
Review of systems:
A complete and thorough review of systems obtained and is
otherwise negative.
Past Medical History:
- ESRD with HD started in ___ s/p distal R AVF placed on
___. Current access with tunneled IJ.
- HFprEF, EF>60%
- Type 2 Diabetes on Insulin
- Long QT Syndrome c/b VT arrest ___ after receiving
azithromycin
- Hx MSSA Bacteremia and endocarditis ___
- Presumed COPD
- Rheumatoid arthritis
- Hypertension
- Hyperlipidemia
- Renal tubular acidosis, type IV
Social History:
___
Family History:
Mother had COPD vs. asthma and lung cancer. Father had rheumatic
heart disease.
Physical Exam:
ADMISSION:
VS: 98.3 130/63 61 20 97RA
Wt 76kg
Gen: well-appearing woman in NAD
HEENT: PERRL, oropharynx without lesions, no ___
___: JVP base of neck at 90 degrees
CV: systolic murmur best appreciated at left upper sternal
border, otherwise RRR
Pulm: CTAB but poor respiratory effort
Abd: obese, soft, NTND, no HSM
Ext: skinny legs without any edema or lesions; R upper forearm
has bandaged fistula without surrounding erythema
Neuro: AO x 4, able to say months of year backwards, normal
gait, normal muscle tone, muscle strength ___ in all
extremities, CN II-XII intact, no facial droop noted, reflexes
not tested
DISCHARGE:
VS: 98.0 175/67 65 96% RA
Wt 78.4kg
Gen: well-appearing woman in NAD
HEENT: PERRL, oropharynx without lesions, no ___
___: JVP base of neck at 90 degrees
CV: systolic murmur best appreciated at left upper sternal
border, otherwise RRR
Pulm: CTAB but poor respiratory effort
Abd: obese, soft, NTND, no HSM
Ext: skinny legs without any edema or lesions; R upper forearm
has bandaged fistula without surrounding erythema
Neuro: AO x 4, able to spell "world" backwards, normal gait,
normal muscle tone, muscle strength ___ in all extremities, CN
II-XII intact, no facial droop noted, reflexes not tested
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-15.1*# RBC-4.48 Hgb-12.5 Hct-40.0
MCV-89 MCH-27.9 MCHC-31.3* RDW-16.2* RDWSD-50.7* Plt ___
___ 12:00PM BLOOD Neuts-81.8* Lymphs-9.6* Monos-5.8
Eos-0.7* Baso-0.4 Im ___ AbsNeut-12.37* AbsLymp-1.46
AbsMono-0.88* AbsEos-0.11 AbsBaso-0.06
___ 12:00PM BLOOD ___ PTT-29.0 ___
___ 12:00PM BLOOD Glucose-222* UreaN-38* Creat-6.9*# Na-137
K-4.1 Cl-91* HCO3-30 AnGap-20
___ 12:00PM BLOOD ALT-16 AST-18 AlkPhos-69 TotBili-0.4
___ 12:00PM BLOOD Lipase-107*
___ 12:00PM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.2 Mg-2.1
___ 12:12PM BLOOD Lactate-2.7*
___ 12:09PM BLOOD %HbA1c-8.4* eAG-194*
DISCHARGE LABS:
___ 07:13AM BLOOD WBC-9.1 RBC-3.99 Hgb-11.1* Hct-35.5
MCV-89 MCH-27.8 MCHC-31.3* RDW-15.8* RDWSD-50.4* Plt ___
___ 07:13AM BLOOD Glucose-174* UreaN-30* Creat-5.0*# Na-136
K-4.8 Cl-99 HCO3-24 AnGap-18
___ 07:13AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
OTHER PERTINENT LABS:
Blood Cx ___: Pending
Urine Cx ___: >100,000 CFU Klebsiella pneumoniae, pan-senitive
IMAGING:
NCCT Head ___:
1. No acute intracranial process. Periventricular and deep
subcortical white matter hypodensities suggest chronic small
vessel ischemic disease. If there is clinical concern for acute
infarction, MRI is more sensitive.
2. Chronic appearing deformity of the left lamina papyracea
consistent with prior injury.
CXR ___:
Stable prominence of the pulmonary interstitium likely relates
to volume overload, similar appearance to prior exams. No
definite focal consolidation.
EEG ___:
No seizures or epileptiform activity.
MRI Brain without contrast ___:
1. Study terminated prior to completion due to patient inability
to tolerate
examination.
2. Study severely degraded by motion.
3. Paranasal sinus disease and nonspecific mastoid fluid as
described.
4. Within limits of study, no definite acute infarct or large
intracranial
mass identified.
5. If clinically indicated, consider repeat examination when
patient can
tolerate exam.
Brief Hospital Course:
Mrs. ___ is a ___ yo F with history of ESRD d/t DM on ___
dialysis, HFpEF, long QT Syndrome c/b VT arrest ___
after receiving azithromycin, PVD, RA, and RTA type IV who
presented from dialysis after 30-minute episode of
unresponsiveness (but pulse maintained) during dialysis. Found
to have UTI in ED. Workup included EEG and MRI, which were
negative for seizure or stroke.
1. Toxic metabolic encephalopathy: Initial differential included
stroke, seizure, TIA, and dialysis disequilibrium. Patient's UTI
could have contributed to AMS. EEG showed no seizures or
epileptiform activity and MRI was negative (although degraded by
motion and inability for patient to complete full study).
2. Complicated UTI: UA infected on admission and patient had low
back pain and leukocytosis. Treated with ceftriaxone initially,
switched to cefpodoxime when UCx grew pan-sensitive Klebsiella.
3. ESRD: ___ schedule. Received HD in-hospital on ___ and
___.
4. Diabetes: Patient reports taking 28U Lantus qAM at home.
Started on ___ on admission and she was given reduced dose of
14U Lantus in-hospital with normal glycemia. She had previously
been on 21U and was only recently increased to 28U, so we have
discharged her on 21U Lantus qAM.
Transitional Issues:
[] Antibiotic with cefpodoxime for 3 more doses (2 tablets after
each of the next 3 HD sessions)
[] Discharged on reduced dose of 21U Lantus qAM (pt reported
dose prior to admission was 28U qAM). Please f/u FSG and adjust
insulin dose accordingly.
# CODE: FULL
# CONTACT: ___ ___, ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. sevelamer CARBONATE 1200 mg PO TID W/MEALS
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. PredniSONE 7.5 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral QAM
9. Pravastatin 80 mg PO QPM
10. Omeprazole 20 mg PO DAILY
11. Glargine 28 Units Breakfast
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 80 mg PO QPM
5. PredniSONE 7.5 mg PO DAILY
6. sevelamer CARBONATE 1200 mg PO TID W/MEALS
7. Cefpodoxime Proxetil 400 mg PO POST HD (___) Duration: 3
Doses
RX *cefpodoxime 200 mg 2 tablets by mouth after dialysis
(___) Disp #*6 Tablet Refills:*0
8. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral QAM
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
12. Glargine 21 Units Breakfast
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Encephalopathy
Dialysis dysequilibrium
Urinary tract infection, complicated
End stage renal disease, on hemodialysis
Secondary:
HFpEF
T2DM
Long QT syndrome
PVD
RA
RTA type IV
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were hospitalized for a period of unresponsiveness at
dialysis. ___ were found to have a urinary tract infection
which may explain this. We performed an EEG and MRI which did
not show evidence of stroke or seizure.
___ were discharged on a lower dose of Lantus insulin (21 units
instead of 28 units) than ___ were previously taking at home
since your sugars were well controlled on a lower dose here. ___
should continue to monitor your blood sugar at home and follow
up with your PCP to discuss your insulin dose.
___ were discharged with an antibiotic called cefpodoxime for
your urinary tract infection. ___ should take 2 tablets after
dialysis for the next 3 dialysis sessions (6 tablets total).
Thank ___ for letting us be involved in your care!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19640899-DS-15
| 19,640,899 | 20,457,378 |
DS
| 15 |
2189-12-18 00:00:00
|
2189-12-20 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
azithromycin
Attending: ___.
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
HD catheter placement ___
History of Present Illness:
___ with ESRD on HD, HLD, HTN, DM, lifetime smoking who
presents with persistent dysarthria. She was in her usual state
of health until yesterday morning. Sometime after waking, her
family noticed that she was slurring her speech (they assume she
woke up that way). This is unusual for her. She seemed more
tired
than normal and her blood glucose was elevated into the ~200s.
They completed their daily activities. When they came back in
the
evening, she was still very dysarthric (no change from the
morning) so they called ___ because she would otherwise not have
allowed them to bring her to the hospital. Other than increased
fatigue, she had no associated vision changes, weakness, sensory
changes, vertigo, changes in gait. She has never been worked up
for stroke. She thinks that she has slurred her speech in the
past but she can't provide any details and her family is unaware
of this. In ___, she had a brief episode of
non-responsiveness during dialysis. EEG showed generalized as
well as bitemporal delta and MRI was very poor secondary to
motion artifact. She tells me today that she is unwilling to
undergo another MRI at this time. Neurology was consulted for
workup and management recommendations.
On neuro ROS, (+) dysarthria, (+) chronic hearing difficulty,
(+)
chronic mild gait instability. The pt denies headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus. Denies focal weakness,
numbness, parasthesiae.
On general review of systems, the pt denies recent illness but
(+) does have a chronic cough from a lifetime of smoking, (+)
chronic hip pain, (+) makes some urine. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits.
Past Medical History:
- ESRD with HD started in ___ s/p distal R AVF placed on
___. Current access with tunneled IJ.
- Type 2 Diabetes on Insulin
- Long QT Syndrome c/b VT arrest ___ after receiving
azithromycin
- Hx MSSA Bacteremia and endocarditis ___
- Presumed COPD
- Rheumatoid arthritis
- Hypertension
- Hyperlipidemia
- Renal tubular acidosis, type IV
- PVD s/p stenting
- Sciatica
- Cataract s/p extraction
- S/p AV anastomosis, s/p Tunneled IJ
- Unspecified Sensorineural hearing loss
Social History:
___
Family History:
5 healthy children. 1 brother with breathing issues. Does not
remember how her mother and father passed. Per OMR: Mother had
COPD vs. asthma and lung cancer. Father had rheumatic heart
disease.
Physical Exam:
Vitals: 99.2 75 120/56 18 96%RA
- General: Awake, cooperative
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: wet cough
- Abdomen: soft, obese
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented to ___, Obama.
Thinks she is at ___&W. Difficult remembering many details of her
history. Attentive, able to name ___ backward only missing
___. Language is fluent with intact repetition and basic
comprehension. Normal prosody but mildly dysarthric per examiner
and granddaughter at bedside. Unable to make the "caca" sound.
There were no paraphasic errors. Able to name high frequency
objects missed clasp and hands. Able to follow both midline and
appendicular commands. Took 6 attempts to register 3 objects and
recalled ___ with prompting at 5 minutes.
- Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation. EOMI without
nystagmus difficulty with upgaze. Facial sensation intact to
light touch. Asymmetric face, sometimes appears to have left BLF
but activates equally bilaterally. Hearing intact to raised
voice
only. Palate elevates symmetrically. Some white exudate over her
tongue (denies pain). Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No pronator drift
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Sensory: length dependent deficit to light touch and pinprick.
N0 extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was mute bilaterally.
- Coordination: No dysmetria on FNF or heel tap. No truncal
ataxia.
- Gait: antalgic with limp from hip pain. Good balance but veers
off to either direction for multiple steps before correcting her
self and veering off to the opposite direction.
##DISCHARGE##
Patient with mild dysarthria - oriented to name, location, date.
Names objects. PERRL, face symmetric. Strength full throughout
and transfers from chair to bed.
Pertinent Results:
___ 06:20AM BLOOD %HbA1c-7.9* eAG-180*
___ 06:20AM BLOOD Triglyc-107 HDL-59 CHOL/HD-2.3 LDLcalc-58
___ 06:20AM BLOOD TSH-1.0
CTA ___
1. Approximately 25% stenosis of the left proximal internal
carotid artery by NASCET criteria.
2. No evidence of right internal carotid artery stenosis by
NASCET criteria.
3. Severe stenosis of the origin of the left vertebral artery
and left
proximal V1 segment. Diffuse regularity and moderate narrowing
of the V2
segment of the left vertebral artery, with short-segment
moderate to severe focal stenoses at C3 and C5. Diffuse
irregularity of the left V3 and V4 segments with mild to
moderately V3 and moderate V4 segment narrowing.
4. Intracranial atherosclerotic disease causing moderate
narrowing of the left petrous internal carotid artery, and
mild-to-moderate narrowing of the bilateral supra clinoid
internal carotid arteries, and mild narrowing of the left distal
M1 segment appears
5. Multinodular goiter with a 4.5 cm dominant nodule extending
from the left lobe and isthmus substernally into the superior
mediastinum.
6. 9 x 4 mm spiculated left upper lobe pulmonary nodule is new
compared to CT chest from ___.
1. Thyroid ultrasound is recommended according to the ACR
guidelines, if not previously performed elsewhere.
2. Chest CT is recommended for comprehensive evaluation of the
lungs.
Head CT ___
1. No evidence of hemorrhage or infarction.
2. Age-related involutional changes and nonspecific white matter
hypodensities suggesting moderate chronic small vessel ischemic
disease.
___ Echo
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>60%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. No masses or
thrombi are seen in the left ventricle. 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
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with normal
biventricular cavity sizes and systolic function. Mild pulmonary
artery systolic hypertension. Mildly dilated ascending aorta.
Findings c/w hypertensive heart disease. No cardiac source of
embolism identified.
Compared with the prior study (images reviewed) of ___,
there is no significant change.
Brief Hospital Course:
Ms. ___ was admitted to the stroke service given mild
dysarthria. This improved during admission. Given defibrillator,
MRI was not obtained for further analysis of a possible infarct,
and CT did not reveal evidence of acute infarct. CTA was notable
for intracranial atherosclerosis affecting in the intracranial
ICA and narrowing of the posterior circulation.
During admission, new HD catheter was placed by ___ as her
fistula was not functioning and she underwent dialysis without
complication on ___ and ___.
Echocardiogram with normal EF and no evidence of intracardiac
thrombus. She was monitored on telemetry without evidence of
arrhythmia.
A1C 7.9 with known DM. LDL 58 on home atorvastatin 80mg. She was
taking ASA 81mg upon admission that was changed to Plavix 75mg
for secondary stroke prevention.
On the CTA, there was a noted goiter and pulmonary lung nodule.
TSH normal, and thyroid US should be conducted as outpatient.
Additionally, dedicated chest CT should be obtained as
outpatient to evaluate new lung nodule.
TRANSITIONAL ISSUES:
1. Stop ASA81mg and start Plavix 75mg daily.
2. Obtain Chest CT to evaluate pulmonary nodule and thyroid US
to evaluate goiter as outpatient.
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 = 58) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
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?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Glargine 23 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. PredniSONE 5 mg PO DAILY
8. sevelamer CARBONATE 1200 mg PO TID W/MEALS
9. TraMADol 50 mg PO Q8H:PRN pain
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 100 mg PO DAILY
3. sevelamer CARBONATE 1200 mg PO TID W/MEALS
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. PredniSONE 5 mg PO DAILY
8. TraMADol 50 mg PO Q8H:PRN pain
9. Glargine 23 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Possible stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficulty speaking
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 blood pressure
- High cholesterol
We are changing your medications as follows:
- Stop taking aspirin and start Plavix 75mg daily.
Please take your other medications as prescribed.
Please followup with Neurology and 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:
___
|
19640899-DS-16
| 19,640,899 | 22,085,008 |
DS
| 16 |
2189-12-28 00:00:00
|
2189-12-28 12:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
azithromycin
Attending: ___.
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ PMHx ESRD on HD, T2DM, HTN, HLD and
recent hospitalization on stroke service ___ for possible
infarct (MRI unable to be done due to PPM) who presents from HD
___ with acute onset slurred speech.
Pt was hospitalized ___ on stroke service after presenting
with dysarthria. Exam was only notable for dysarthria which
improved during hospitalization and was mild on discharge. An
MRI
was not done due to pt's pacemaker. Echo did not show any
intracardiac
thrombus. Pt's aspirin was switched to Plavix for secondary
stroke prevention as it was felt pt may have had an infarct and
failed aspirin.
Since discharge, pt and husband report that pt's speech was
improving. On the day of presentation, pt left home around 9:30a
for HD. Husband reports pt's speech was only mildly slurred at
the point. At HD, around 14:30, pt was noted to have acute
worsening of dysarthria. Vitals are unknown at this time and are
not available with the HD paperwork. There were no abnormal
events concerning for seizure. Pt was then referred to the ED.
In the ED, pt was code stroke due to acute onset dysarthria, ED
also noted R NLFF. Upon my evaluation, subtle L NLFF and
dysarthria was appreciated (NIHSS = 2). CTA H/N showed
atherosclerosis and severe stenosis of L vertebral artery and
was
unchanged from prior. Pt's speech started to improve during
hospital course, although pt and daughter/husband stated it was
still worse compared to earlier in the day. Pt denied any
word-finding difficulty, comprehension difficulty, diplopia,
dysphagia or lateralized weakness or numbness.
On neurologic review of systems, the patient reports chronic
decreased sensation in her bilateral feet. Pt denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, diplopia,
vertigo, tinnitus, hearing difficulty, or dysphagia. Denies
focal
muscle weakness. Denies bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
- ESRD with HD started in ___ s/p distal R AVF placed on
___. Current access with tunneled IJ.
- Type 2 Diabetes on Insulin
- Long QT Syndrome c/b VT arrest ___ after receiving
azithromycin
- Hx MSSA Bacteremia and endocarditis ___
- Presumed COPD
- Rheumatoid arthritis
- Hypertension
- Hyperlipidemia
- Renal tubular acidosis, type IV
- PVD s/p stenting
- Sciatica
- Cataract s/p extraction
- S/p AV anastomosis, s/p Tunneled IJ
- Unspecified Sensorineural hearing loss
Social History:
___
Family History:
5 healthy children. 1 brother with breathing issues. Does not
remember how her mother and father passed. Per OMR: Mother had
COPD vs. asthma and lung cancer. Father had rheumatic heart
disease.
Physical Exam:
Admission Physical Exam:
Vitals: 97.0 74 124/68 16 95% RA
General: NAD, resting comfortably, well-appearing, obese
HEENT: NCAT, no oropharyngeal lesions, MMM, sclerae anicteric
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Inattentive and slow to recall a coherent history. Speech
is fluent with full sentences, intact repetition, and intact
verbal comprehension. Content of speech demonstrates intact
naming (apart from unable to name cactus on stroke card) and no
paraphasias. Normal prosody. No evidence of hemineglect. No
left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. L NLFF, activates well. Hearing decreased to finger
rub bilaterally. Palate elevation symmetric. Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ ___ ___ 4+ 5 4+ 4+ 5
R 5 ___ ___ 5 5 5 5 5
- Sensory - Decreased sensation to temperature and pinprick in a
stocking distribution.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Deferred.
=
=
=
================================================================
DISCHARGE EXAM:
General Exam:
General: Well appearing, NAD
HEENT: normocephalic, atraumatic
___: breathing comfortably on RA
CV: skin warm, well-perfused
Extremities: symmetric, no edema
Skin: no rashes; L anterior chest tunneled HD line site without
drainage, erythema, tenderness.
Neurologic Exam:
- Mental Status - Awake, alert, oriented to person, place and
time. Speech is fluent with full sentences, intact repetition,
and intact comprehension to multistep complex commands. Naming
intact. No paraphrasic errors. Normal prosody. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. EOMI full with saccadic
intrusions, no nystagmus. V1-V3 without deficits to light touch
bilaterally. L NLFF, with decreased activation of L lower face;
brow furrow symmetric. Hearing intact to loud voice. Palate
elevation symmetric. Trapezius strength ___ bilaterally. Tongue
protrudes to left.
- Motor - Normal bulk and tone. Drift and pronation on pronator
drift testing. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5 4+ ___ 5 4+ 5 4+ 5 5
R 5 ___ ___ 5 5 5 5 5
- Sensory - Decreased sensation to temperature and pinprick in a
stocking distribution bilateral lower extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response mute bilaterally.
- Coordination - No dysmetria with FTN testing
bilaterally.
- Gait - Deferred.
Pertinent Results:
Trop-T: 0.08
137 96 10 152 AGap=19
4.6 27 3.1 ___
Ca: 8.9 Mg: 2.0 P: 2.6 ___
ALT: 14 AP: 65 Tbili: 0.2 Alb: 3.5 AST: 44 Lip: 31
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
94
12.6 10.3 216
33.2
N:78.9 L:11.1 M:8.0 E:1.2 Bas:0.3 ___: 0.5 Absneut: 9.94
Abslymp: 1.40 Absmono: 1.01 Abseos: 0.15 Absbaso: 0.04
___: 10.5 PTT: 29.2 INR: 1.0
Lactate:2.1
Brief Hospital Course:
Ms. ___ was admitted to the Neurology floor. She was monitored
on telemetry, initially treated with aspirin 81 mg and
clopidogrel 75 mg daily due to high suspicion for symptomatic
intracranial stenosis vs small vessel disease given risk factors
and timing of event during dialysis. CTA showed extracranial
atherosclerosis without significant stenosis. MRI was
coordinated with Cardiology given ICD, and when obtained, showed
multiple small embolic-appearing infarcts in multiple vascular
distributions (bilateral, anterior and posterior circulation).
TTE showed no valvular disease but did show LVH; no thrombus.
Bubble study showed no evidence of intracardiac shunting.
Given our high suspicion for cardioembolic etiology, she was
started on apixaban, and DAPT were stopped. She was discharged
with cardiac event monitor.
She was evaluated by ___ recommended discharge to
acute rehab and SLP recommended dysphagia diet and nectar thick
liquids.
Transitional issues:
- Needs Biopsy or PET-CT of right upper lobe spiculated lung
nodule seen on CTA head/neck to exclude malignancy. Thyroid
ultrasound for further evaluation of large multinodular goiter
to exclude malignancy.
Please refer to Neurologist either at ___ or ___, at ___'s
discretion. Recommend follow up to be scheduled for ___ months
from now. She needs follow up of her cardiac event monitor
results.
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 = 58) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
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?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 100 mg PO DAILY
3. sevelamer CARBONATE 1200 mg PO TID W/MEALS
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. PredniSONE 5 mg PO DAILY
8. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
9. Glargine 23 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Glargine 12 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
3. Metoprolol Succinate XL 25 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. sevelamer CARBONATE 1200 mg PO TID W/MEALS
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
7. Apixaban 5 mg PO/NG BID
8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
9. Gabapentin 100 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic 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 ___,
You were hospitalized due to symptoms of slurred speech
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 blood pressure
Dialysis
We are changing your medications as follows:
Start a blood thinner called apixaban. Stop Plavix.
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
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19640899-DS-17
| 19,640,899 | 21,473,903 |
DS
| 17 |
2190-01-25 00:00:00
|
2190-01-25 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending: ___.
Chief Complaint:
L hip intertroch fx
Major Surgical or Invasive Procedure:
L hip DHS fixation ___
History of Present Illness:
Ms. ___ is a ___ yo F w/ PMHx of ESRD on HD (___), long QT
syndrome s/p ICD, IDDM, HTN, HLD and recent hospitalizations for
ischemic stroke on apixaban (___) who presents
following a mechanical fall onto the left side after tripping
over shoes. No HS or LOC, full recollection of the entire event.
Immediate onset of pain in the left hip with inability to bear
weight. No new numbness or paresthesias. Denies pain elsewhere.
Last took apixaban on the morning of ___. Community ambulatory
at baseline without assistive aids.
Past Medical History:
- ESRD with HD started in ___ s/p distal R AVF placed on
___. Current access with tunneled IJ.
- Type 2 Diabetes on Insulin
- Long QT Syndrome c/b VT arrest ___ after receiving
azithromycin
- Hx MSSA Bacteremia and endocarditis ___
- Presumed COPD
- Rheumatoid arthritis
- Hypertension
- Hyperlipidemia
- Renal tubular acidosis, type IV
- PVD s/p stenting
- Sciatica
- Cataract s/p extraction
- S/p AV anastomosis, s/p Tunneled IJ
- Unspecified Sensorineural hearing loss
Social History:
___
Family History:
5 healthy children. 1 brother with breathing issues. Does not
remember how her mother and father passed. Per OMR: Mother had
COPD vs. asthma and lung cancer. Father had rheumatic heart
disease.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.2 74 128/59 18 95% RA
General: Well-appearing female in pain
Bilateral upper extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender arm and forearm
- Full, painless ROM at shoulder, elbow, wrist, and digits
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Left lower extremity:
- Skin intact
- No obvious deformity, edema, ecchymosis, erythema, induration
- Tender thigh
- Full, painless ROM at ankle
- Fires ___
- SILT S/S/SP/DP/T distributions, although diminished diffusely
(baseline per patient)
- 1+ ___ pulses, WWP
DISCHARGE EXAM
==============
VITAL SIGNS: T 97.7 | BP 109/50 | HR 80 | RR 18 | SpO2 97% RA
General: Well appearing in no acute distress
Cardiac: RRR, normal S1+S2, ___ holosystolic murmur with
radiation to carotids. No gallops or rubs.
Pulm: CTAB, no wheezes/rhonchi/rales
Ext: warm and well perfused, no edema, no cyanosis
Neuro: Left upper and lower face paresis. Otherwise, CNII-XII
tested and intact. ___ strength throughout upper extremities.
Lower extremity strength testing limited due to pain.
Mild-moderate dysarthria.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 02:40AM URINE HOURS-RANDOM
___ 02:40AM URINE HOURS-RANDOM
___ 02:40AM URINE UHOLD-HOLD
___ 02:40AM URINE GR HOLD-HOLD
___ 02:40AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:40AM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-2 TRANS EPI-<1
___ 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-TR
___ 12:05AM GLUCOSE-120* UREA N-14 CREAT-3.7*# SODIUM-140
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-19
___ 12:05AM WBC-13.0*# RBC-3.99 HGB-11.4 HCT-37.1 MCV-93
MCH-28.6 MCHC-30.7* RDW-17.1* RDWSD-56.1*
=================
PERTINENT IMAGING
=================
L HIP XRAY (___):
There is an acute nondisplaced left intertrochanteric femoral
fracture. The femoral head is well seated within the
acetabulum. No osseous lesion
concerning for malignancy or infection.
L KNEE XRAY (___):
No fracture or dislocation. Degenerative chain in the medial
compartment is mild. No suspicious lytic or sclerotic lesion is
identified. No joint
effusion is seen. Vascular calcifications are extensive. No
radio-opaque
foreign body is detected. The bones appear somewhat
demineralized.
HEAD CT (___):
1. No acute hemorrhage or fracture.
2. Sequelae of chronic small vessel ischemic disease,
unchanged.
3. Cortical atrophy.
4. Left predominant chronic sinusitis with possible active
component.
5. Chronic deformity of left lamina papyracea, unchanged.
C-SPINE CT (___):
1. No cervical spine fracture.
2. Severe multilevel degenerative changes of the cervical
spine, overall
unchanged in appearance in alignment from ___. Narrowing of
the anterior spinal canal indenting the spinal cord at C5-C6 and
C6-C7.
3. Unchanged multinodular thyroid. Prominent 4.5 cm nodule is
noted in the left lobe of the thyroid.
4. Acute on chronic paranasal sinus disease as above.
CHEST (___)
LOWER EXTREMITY FLUOROSCOPY (___):
Fluoroscopic images show steps in a fixation procedure about the
left femoral neck. Further information can be gathered from the
operative report.
==============
DISCHARGE LABS
==============
___ 06:05AM BLOOD WBC-7.0 RBC-3.08* Hgb-8.6* Hct-28.2*
MCV-92 MCH-27.9 MCHC-30.5* RDW-16.2* RDWSD-53.5* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD ___ PTT-32.8 ___
___ 06:05AM BLOOD Glucose-118* UreaN-38* Creat-5.2*# Na-140
K-4.5 Cl-100 HCO3-27 AnGap-18
___ 06:05AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.3
___ 06:05AM BLOOD
Brief Hospital Course:
===================
SUMMARY
===================
___ year old female with history of ESRD on HD, DM2 on insulin,
HFpEF, long QT Syndrome c/b VT arrest ___ after
receiving azithromycin, PVD, RA, and recent ischemic stroke on
apixaban who presented with a left hip intertrochanteric
fracture. She underwent a dynamic hip screw ORIF. After her
procedure she was transferred to the medicine service for
postoperative care. Her postoperative course was unremarkable
and she was discharged to rehab on ___.
=======================
ACUTE ISSUES
=======================
# Left hip fracture s/p DHS ORIF:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for L hip DHS ORIF. Her procedure was
notable for oscillating systolic pressures ranging from 50-170.
After administration of vasopressors, her pressure normalized
and the procedure was completed without further events. The
patient was given ___ antibiotics and anticoagulation
per routine.
# Postoperative course:
- Pain control: Patient was initially given IV fluids and IV
pain medications. Her pain was controlled with PO Dilaudid PRN,
IV dilaudid PRN, and gabapentin. Patient described her pain as a
circumscribed burning pain of the leg. Patient did not require
any IV dilaudid from ___ and she was discharged on PO
dilaudid ___ q3h:prn and gabapentin.
- DVT prophylaxis: Patient was restarted on apixaban 5mg BID,
her home dose, on POD1. She was discharged on her home dose of
apixaban
- Nutrition: Patient progressed to a regular diet and oral
medications by POD#1.
# ESRD/HD: Patient has a history of ESRD on HD. Patient
continued to receive dialysis according to her normal TuThSat
schedule throughout admission. Nephrology dialysis followed her.
She was continued on sevelamer TID, nephrocaps, low Na/K/phos
diet
# SVT: Patient intermittently had episodes of short runs of SVT
during dialysis. On ___ patient had a run of sustained SVT
during dialysis that required IV metoprolol. As a result she was
kept on telemetry until ___. Tele overnight showed a runs of SVT
(around 7, which lasted seconds - to 1 minute) and questionable
irregular rhythm with no known hx of atrial fibrillation.
Patient asymptomatic. Patient normally in NSR and in NSR on
discharge. On metoprolol 25 daily and apixaban (was on it
initially after recent stroke). Atrius cardiology recommended
changing dose to: metoprolol 25 mg BID.
# s/p ischemic stroke: Patient has sustained two recent strokes.
Her neurologic function remained at baseline throughout
admission. Her apixaban 5mg BID was held for her surgery but
restarted on POD#1.
=================
CHRONIC ISSUES
=================
# T2DM: Continued insulin sliding scale.
# Rheumatoid arthritis: Continued home prednisone 5mg
# HLD: Continued home atorvastatin 80mg.
# Long QT syndrome: Continued home metoprolol XL 25mg and
increased to 25 mg BID by time of discharge.
=====================
TRANSITIONAL ISSUES
=====================
- Patient was started on dilaudid ___ PO q3h:PRN for pain
control postoperatively. Please wean as tolerated to avoid
opioids with deliriogenic effects
- Patient needs followup for thyroid nodule. Per CT scan read:
Further evaluation of multinodular thyroid with dominant 4.5 cm
nodule in the left lobe of the thyroid is suggested by current
ACR recommendations for incidentally noted thyroid nodules.
- Patient will follow-up with Dr. ___ in ___ clinic 14
days postoperatively
- Patient should follow up in ___ clinic for interrogation
- Patient should follow up with her Atrius cardiologist on
discharge. Her metoprolol was changed from 25 mg to 25 mg BID.
# CODE: Full, confirmed
# CONTACT: ___ ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Glargine 12 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
3. Metoprolol Succinate XL 25 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. sevelamer CARBONATE 1200 mg PO TID W/MEALS
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Apixaban 5 mg PO BID
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Gabapentin 100 mg PO DAILY
10. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
11. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Glargine 12 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
7. Metoprolol Succinate XL 25 mg PO BID
8. Apixaban 5 mg PO BID
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Gabapentin 100 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. PredniSONE 5 mg PO DAILY
14. sevelamer CARBONATE 1200 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L hip intertrochanteric fracture
Supraventicular tachycardia
SECONDARY DIAGNOSIS:
End stage renal disease
Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
- ___ were in the hospital for orthopedic surgery of the hip. It
is normal to feel tired or "washed out" after surgery, and this
feeling should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take apixaban as ___ normally would
WOUND CARE:
- ___ 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.
We would also like ___ to follow up with your cardiologist as an
outpatient: Dr. ___ ___.
It was a pleasure taking care of ___! We wish ___ all the best.
- Your ___ care team
Followup Instructions:
___
|
19641005-DS-18
| 19,641,005 | 29,167,179 |
DS
| 18 |
2138-04-16 00:00:00
|
2138-04-16 11:51:00
|
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, anorexia, fever, emesis X1.
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ with 3 day history of abdominal pain in lower quadrants.
Associated with anorexia, fever, emesis x1. Denies sick
contacts. Has been accompanied by headache and chills.
Past Medical History:
None
Social History:
___
Family History:
No history of bleeding disorders, coagulopathy
Physical Exam:
Vitals: Temp 98.7 ; BP: 100/64 ; Pulse: 102 ; RR: 18 ; O2 94%RA
General: Alert, oriented X3, in no acute distress
HEENT: Oral mucosa moist, absent lymphadenopathy
Resp: Clear breath sounds bilaterally
CV: RRR, absent murmurs, rubs, or gallops
Abd: Soft, non-distended, mild generalized tenderness, incisions
C/D/I
Extr: atraumatic
Pertinent Results:
___ 12:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:51PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:05AM GLUCOSE-128* UREA N-17 CREAT-1.0 SODIUM-131*
POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-20* ANION GAP-21*
___ 11:05AM ALT(SGPT)-26 AST(SGOT)-33 ALK PHOS-54 TOT
BILI-0.8
___ 11:05AM WBC-10.4* RBC-5.17 HGB-15.7 HCT-44.1 MCV-85
MCH-30.4 MCHC-35.6 RDW-12.6 RDWSD-38.6
___ 11:05AM NEUTS-89.7* LYMPHS-3.0* MONOS-6.9 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-9.37* AbsLymp-0.31* AbsMono-0.72
AbsEos-0.00* AbsBaso-0.01
___ 11:05AM PLT COUNT-150
CT ABD & PELVIS WITH CONTRAST
___
IMPRESSION:
1. Dilated, fluid-filled, hyperemic presacral appendix
compatible with acute
appendicitis. Small amount of fluid within the pelvis and
tracking into the
paracolic gutters without drainable fluid collection.
2. Borderline splenomegaly.
3. Incompletely characterized 1 cm hyperenhancing lesion in the
right lobe of
the liver. This could potentially represent a flash filling
hemangioma
although given proximity to the vasculature, portohepatic venous
malformation
is also possible.
Brief Hospital Course:
The patient presented to ___ on ___. Pt was
evaluated by the surgical staff and anaesthesia and taken to the
operating room for laparoscopic appendectomy. 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 managed with PO oxycodone and IV
Dilaudid.
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: On POD0, the patient was put on a regular diet, which
was well tolerated. Patient's intake and output were closely
monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
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 to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ 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.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple 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 could have a poor appetite for a couple days. 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.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. 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:
___
|
19641231-DS-16
| 19,641,231 | 21,599,982 |
DS
| 16 |
2123-02-13 00:00:00
|
2123-02-13 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Aspirin / Ampicillin / Cipro
Cystitis / Shellfish Derived / Wheat / Chicken Derived / Soy /
Ciprofloxacin / Latex / oil based chemicals / clindamycin /
cholecalciferol / cephalexin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMH of DM, kyphosis/scoliosis, chronic
pain/fatigue, hypothyroidism, anxiety, and COPD who presents
with
increasing SOB. Patient is a difficult historian.
Patient states that over the past few weeks she has been
increasingly short of breath w/ exertion and when lying flat.
She
reports needing to use 3 pillows when sleeping. She has not
noticed significant ___ swelling.
She denies fever/chills, cough, chest pain, n/v/d. She does
report intermittent night sweats. Of note, she was recently
hospitalized at ___ and had ?CTA chest to evaluate for PE
(reportedly negative) and TTE, treated with IV Lasix. She left
AMA from that hospitalization. Records not available from this
hospitalization
In the ED, initial VS were: 97 106 120/72 18 97% RA
Exam notable for: 2+ pitting edema bilaterally to mid shins, w/
psoriatic plaques on lower shins. +bibasilar crackles
Labs showed:
138 97 26 AGap=10
-------------< 151
5.5 31 0.7
- 6.8 > 12.2/41.6 < 153
- Trop < 0.01 @ 1650
- proBNP: 8913
- INR 1.3
- UA benign
Imaging showed:
- CXR: Limited evaluation of the right upper lobe and medial
left
apex as these regions are obscured by the patient's head.
Otherwise, no acute cardiopulmonary process.
Patient received:
- Duoneb
- Furosemide 20 mg IV
Transfer VS were: 98.7 106 ___ 95% 2L NC
On arrival to the floor, patient reports dyspnea improved
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Cholelithiasis- s/p cholecystectomy
Chronic fatigue syndrome
Fibromyalgia
Diabetes
Hypothyroidism- on pork thyroid
Scoliosis
___
Torticollis
Social History:
___
Family History:
Patient adopted. Believes her mother passed away secondary to
lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.9 PO 116 / 62 L Sitting 96 20 87 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, JVD 12 cm at 90 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Bibasilar crackles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: trace-1+ pitting edema to mid shin
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: anterior shins with psoriatic plaques
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 749)
Temp: 99.2 (Tm 99.3), BP: 114/73 (___), HR: 105
(97-120), RR: 18, O2 sat: 100% (82-100), O2 delivery: 2L, Wt:
196.2 lb/89 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, JVD 12 cm at 90 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: crackles at the R base
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: trace-1+ pitting edema to mid shin
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: anterior shins with psoriatic plaques, 3 groups of
erythematous papules on left flank with 1 on superior back
Pertinent Results:
ADMISSION LABS:
___ 04:50PM BLOOD WBC-6.8 RBC-4.77 Hgb-12.2 Hct-41.6 MCV-87
MCH-25.6* MCHC-29.3* RDW-16.7* RDWSD-52.4* Plt ___
___ 04:50PM BLOOD Neuts-73.7* Lymphs-16.6* Monos-7.2
Eos-1.6 Baso-0.3 Im ___ AbsNeut-4.98 AbsLymp-1.12*
AbsMono-0.49 AbsEos-0.11 AbsBaso-0.02
___ 04:50PM BLOOD ___ PTT-25.7 ___
___ 04:50PM BLOOD Plt ___
___ 04:50PM BLOOD Glucose-151* UreaN-26* Creat-0.7 Na-138
K-5.5* Cl-97 HCO3-31 AnGap-10
___ 04:50PM BLOOD proBNP-8913*
___ 04:50PM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD Calcium-8.2* Phos-5.9* Mg-2.4
PERTINENT LABS:
___ 04:50PM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:10PM BLOOD cTropnT-<0.01
___ 04:50PM BLOOD proBNP-8913*
___ 03:20PM BLOOD D-Dimer-472
___ 04:45AM BLOOD TSH-0.90
DISCHARGE LABS:
___ 04:52AM BLOOD WBC-6.1 RBC-4.84 Hgb-12.6 Hct-44.0 MCV-91
MCH-26.0 MCHC-28.6* RDW-16.6* RDWSD-54.4* Plt ___
___ 03:20PM BLOOD PTT-93.0*
___ 03:20PM BLOOD Glucose-170* UreaN-14 Creat-0.5 Na-138
K-4.4 Cl-94* HCO3-38* AnGap-6*
___ 03:20PM BLOOD Calcium-8.1* Phos-3.4 Mg-2.4
___ 03:20PM BLOOD D-Dimer-472
MICRO:
Time Taken Not Noted Log-In Date/Time: ___ 8:36 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
TTE ___:
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Moderate pulmonary artery systolic hypertension.
Normal left ventricular cavity size with preserved regional and
global systolic function.
Compared with the report of the prior study (images unavailable
for review) of ___, the findings are new and suggestive of
an acute pulmonary process (e.g., pulmonary embolism,
bronchospasm, etc.).
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
LENIS ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CTA ___:
1. Equivocal filling defect in a segmental pulmonary artery in
the right upper
lobe, which is in a location with significant motion artifact.
2. Multiple pulmonary nodules, the majority of which appear
stable. The
largest pulmonary nodule has slightly increased in size as
compared to ___,
now measuring 5 mm in mean diameter.
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 ___ months is
recommended
in a high-risk patient.
See the ___ ___ Guidelines for the Management
of
Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
3. Right adrenal mass previously characterized as an adenoma has
increased in
size slightly as compared to ___.
RECOMMENDATION(S): Multiple pulmonary nodules, the majority of
which appear
stable. The largest has slightly increased in size as compared
to
___, now
measuring 5 mm in mean diameter.
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.
Brief Hospital Course:
Ms. ___ is a ___ with PMH of DM, kyphosis/scoliosis, chronic
pain/fatigue, hypothyroidism, anxiety, and COPD who presented
with
increasing SOB.
#DYSPNEA: Patient presented with worsening dyspnea, orthopnea,
volume overloaded on exam w/ BNP elevated to 8.9K. EKG unchanged
from prior and initial trop negative. CXR w/o acute abnormality
although limited by patient positioning given kyphosis/
scoliosis. The patient denied cough/fever so pneumonia less
likely. The patient was given Lasix 20mg IV. She continued to
have hypoxia as well as an elevated bicarb on her BMP and
elevated CO2 on her VBG. Per outside records, V/Q negative for
clot and TTE with RV dilation/hypokinesis. Therefore, given
prior cancer history, obtained CT-A which showed motion artifact
and was equivocal for PE. Lower extremity ultrasound negative
for deep vein thromboses. Given high concern for PE, plan was to
obtain D dimer and repeat CTA if D dimer elevated. However, D
dimer 472 so lower likelihood of clot. Patient's heparin drip
discontinued on discharge and not started on any
anticoagulation. Patient with significant anxiety and wanted to
leave and have her workup as an outpatient. We explained to the
patient that if she were to leave, would be AGAINST MEDICAL
ADVICE. She understood the risks of leaving including worsening
medical condition, worsening shortness of breath, and
potentially death. However, she has capacity to leave.
Therefore, in order to make her discharge as safe as possible,
we discharged her with home oxygen.
#metabolic alkalosis:
Patient with increasing bicarbonate of unclear etiology. Did not
appear dry on exam but could have had contraction alkalosis.
Therefore we gave 500cc NS bolus ___. Patient left AMA prior
to proper workup. Patient with increased CO2 on VBG so likely
had mixed picture of respiratory acidosis from retention.
#Lung nodules: CTA showed multiple pulmonary nodules with the
largest 5mm in diameter. Most were stable from prior and per
radiology, recommended optional repeat follow up scan in ___ year.
#Night sweats: pt endorses night sweats. Recommend
age-appropriate cancer screening.
#Adrenal adenoma: On CTA preformed ___, adrenal adenoma found
that was seen previously on CT but increased in size.
#COPD: She had no significant wheezing on exam, no new cough or
change
in sputum production. Therefore, we have duonebs PRN.
#Anxiety: continued home alprazolam 1 mg qAM, 1.25 mg 3x/d
(confirmed on ___
# Chronic pain:
We gave the patient Acetaminophen PRN.
# Hypothyroidism:
We continued home thyroid pork tablets
# DM:
Diet controlled. Patient on insulin sliding scale while in the
hospital.
TRANSITIONAL ISSUES:
====================
[ ] Please continue to assess hypoxia and need for O2
[ ] Consider CT-Chest noncontrast to evaluate lung parenchyma,
although no clear etiology for suspected pulmonary hypertension
on CTA.
[ ] Patient endorsed night sweats, so consider further workup
for malignancy given history of endometrial cancer
[ ] Consider optional repeat follow up scan in ___ year for
pulmonary nodule
[ ] F/u adrenal adenoma
[ ] Continue workup for hypoxia-- consider sleep apnea
[ ] please consider further workup for metabolic alkalosis
including repeat VBG/BMP
#CODE: Full (confirmed)
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
2. ALPRAZolam 1 mg PO QID:PRN anxiety
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
4. thyroid (pork) 60 mg oral DAILY
5. ALPRAZolam 0.25 mg PO TID:PRN anxiety
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
2. ALPRAZolam 1 mg PO QID:PRN anxiety
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
5. thyroid (pork) 60 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypoxia
Shortness of breath of unclear etiology
Secondary Diagnosis:
Chronic Obstructive Pulmonary Disorder
Anxiety
Chronic Pain
Hypothyroidism
Diabetes Mellitus
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 WAS I ADMITTED?
-You were admitted because you were short of breath.
WHAT WAS DONE WHILE I WAS HERE?
-We gave you a water pill to help you get rid of fluids from
your lungs.
-We looked at your heart with an ultrasound and it showed that
your heart was working harder than it should perhaps due to a
blood clot in your lungs
-We did a CT scan of your lungs and it showed that you may have
a blood clot
-You had a blood test that suggested you might not have a blood
clot.
-We recommended further workup in the hospital to figure out why
your oxygen is low, however you elected to go home.
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
-We were concerned about the possible blood clot in your lungs
and suggested you stay in the hospital, however, you wanted to
go home. Therefore, if you are feeling unwell, you should come
back to the emergency department or call your doctor.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19641231-DS-18
| 19,641,231 | 24,910,123 |
DS
| 18 |
2123-04-15 00:00:00
|
2123-04-15 18:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Aspirin / Ampicillin / Cipro
Cystitis / Shellfish Derived / Wheat / Chicken Derived / Soy /
Ciprofloxacin / Latex / oil based chemicals / clindamycin /
cholecalciferol / cephalexin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a PMH of COPD,
kyphosis/scoliosis, pulmonary hypertension, HFpEF, anxiety,
T2DM,
hypothyroidism presenting with worsening shortness of breath for
___ days.
Patient has a history of multiple admissions for hypercarbic,
hypoxemic respiratory failure (___). On those hospitalizations, she was treated for COPD
exacerbation, and diuresed. ECHO in ___ was notable for
right ventricular distension and global hypokinesis, suggestive
of acute pulmonary process, but normal EF and no evidence left
ventricular dysfunction. Notably, her d-dimer was low (~200)
last
admission. Previous CTA was negative. Following her last
discharge, she went for her sleep study as planned, which was
suboptimal in quality. She was unable to get the rest of her
scheduled outpatient work up.
Of note, she was recently found to have a new compression
fracture of her lumbar spine on MRI on ___, for which she
was
prescribed Vicodin by her PCP's office.
She states that she has felt "air hunger" for the past ___ days.
she cannot identify any acute trigger for her dyspnea. She
denies
recent URI symptoms or worsening sputum production. She denies
chest pain, palpitations, orthopnea, diarrhea, constipation,
fever, weight loss. Per previous OMR discharge summaries, she
has
a history of intermittent night sweats over the past few months.
However, she does not endorse night sweats over the past week.
Upon arrival to the floor, patient reports that she feels back
to
her recent baseline. However, this is a significant decrease in
respiratory status back in ___, before she was started on
home O2. She used to be able to walk around and complete her
ADLs
without difficulty, but now she is unable to do much of
anything.
She does have several PCAs who are with her around the clock
except from 6pm-11pm. They know her well and help her with
cooking/cleaning/personal care.
Past Medical History:
Cholelithiasis- s/p cholecystectomy
Chronic fatigue syndrome
Fibromyalgia
Diabetes
Hypothyroidism- on pork thyroid
Scoliosis
Rosacea
Torticollis
Social History:
___
Family History:
Patient adopted. Believes her mother passed away secondary to
lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS: T 98.8 BP 119/78 HR 115 RR 18 POx 99% of 3L O2.
GENERAL: elderly obese woman lying in bed with head turned to
right, in no acute distress, pleasant, oriented
HEENT: NCAT, PERRL
NECK: supple, no LAD, JVP flat
CARDIAC: RRR, no murmurs/rubs/gallops, 2+ pulses
LUNGS: Faint wheezes in the upper air fields bilaterally.
Scattered bibasilar crackles. Fine red rash under breasts
bilaterally, pruritic.
ABDOMEN: + BS, obese, soft, nontender
EXTREMITIES: No clubbing or cyanosis. 1+ pitting edema of the
LLE. LLE larger in size than RLE
NEUROLOGIC: AAOx3, moving all extremieies
SKIN: scattered psoriatic plaques on bilateral shins. Two large
ecchymoses on the popliteal fossa of the left leg, indurated.
DISCHARGE PHYSICAL EXAM
Vitals: ___ ___ Temp: 97.9 AdultAxillary BP: 105/66 HR:
107 RR: 20 O2 sat: 94% O2 delivery: 2Lcpap
GENERAL: elderly obese woman lying in bed with head turned to
right, NAD. Disheveled. Daughter at bedside.
HEENT: NCAT, PERRL
NECK: supple, no LAD, JVP flat
CARDIAC: RRR, no murmurs/rubs/gallops, 2+ pulses
LUNGS: Faint wheezes in the upper air fields bilaterally.
Scattered bibasilar crackles. Red patches under breasts
bilaterally.
ABDOMEN: + BS, obese, soft, nontender
EXTREMITIES: No clubbing or cyanosis. 1+ pitting edema of the
LLE. LLE larger in size than RLE
NEUROLOGIC: AAOx3, moving all extremieies
SKIN: scattered psoriatic plaques on bilateral shins. Two large
ecchymoses on the popliteal fossa of the left leg, indurated.
Pertinent Results:
ADMISSION LABS
------------------
___ 02:15AM BLOOD WBC-8.2 RBC-3.36* Hgb-8.3* Hct-28.8*
MCV-86 MCH-24.7* MCHC-28.8* RDW-18.0* RDWSD-54.4* Plt ___
___ 02:15AM BLOOD Neuts-82.6* Lymphs-10.1* Monos-5.7
Eos-0.2* Baso-0.1 NRBC-0.4* Im ___ AbsNeut-6.77*
AbsLymp-0.83* AbsMono-0.47 AbsEos-0.02* AbsBaso-0.01
___ 02:15AM BLOOD ___ PTT-24.4* ___
___ 02:15AM BLOOD Ret Aut-6.8* Abs Ret-0.23*
___ 02:15AM BLOOD Glucose-168* UreaN-26* Creat-0.5 Na-128*
K-5.7* Cl-87* HCO3-30 AnGap-11
___ 10:56AM BLOOD K-4.6
___ 02:15AM BLOOD LD(LDH)-432* DirBili-<0.2
___ 02:15AM BLOOD ___
___ 02:15AM BLOOD cTropnT-<0.01
___ 02:15AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.4 Iron-27*
___ 02:15AM BLOOD calTIBC-369 Hapto-229* Ferritn-297*
TRF-284
___ 02:48AM BLOOD ___ pO2-81* pCO2-57* pH-7.38
calTCO2-35* Base XS-6
___ 02:48AM BLOOD Lactate-1.4
DISCHARGE LABS
-------------------
___ 06:46AM BLOOD WBC-6.1 RBC-3.19* Hgb-7.8* Hct-27.6*
MCV-87 MCH-24.5* MCHC-28.3* RDW-18.4* RDWSD-57.1* Plt ___
___ 06:46AM BLOOD Glucose-150* UreaN-24* Creat-0.5 Na-132*
K-PND Cl-90* HCO3-33* AnGap-9*
___ 06:46AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.5
IMAGING
-----------
+ ___ CXR
1. Cephalization of the pulmonary vessel suggest mild pulmonary
edema.
2. No focal consolidation.
+ ___ CTA CHEST
1. No evidence of major pulmonary embolism, however study is
limited by
motion artifact.
2. No significant change in multiple bilateral pulmonary
nodules. The
largest measures 5 mm and is within the right upper lobe.
3. Severe compression deformity of T11, which is unchanged from
prior
imaging.
+ ___ ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. 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+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Moderately dilated, moderately hypokinetic right
ventricle with pressure/volume overload on a hyperdynamic
underfilled left ventricle. Severe pulmonary hypertension. Study
performed on a weekend so no bubble study performed (if still
needed please or order a limited aggitated saline contrast at
rest only study to be done ___.
Compared with the prior study (images reviewed) of ___ the
right ventricle is moderately dilated. Pulmonary pressures are
slightly higher. Other findings are similar.
MICRO
--------
___ 6:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 11:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
PATIENT SUMMARY
==================
This is a ___ year old woman with a PMH of COPD (started 2L home
O2 in ___, OSA (on home BiPAP), moderate pulmonary
hypertension, anxiety, kyphoscoliosis with restrictive pattern
on PFTs, and recent spinal compression fracture, who presents
with worsening dyspnea likely from multifactorial hypoxemic
respiratory failure, CTA negative for PE, but found to have new
anemia, now back to recent baseline respiratory status.
ACUTE ISSUES:
=============
# MIXED HYPOXEMIC, HYPERCARBIC RESPIRATORY FAILURE
# SLEEP DISORDERED BREATHING
# COPD
# PULMONARY HYPERTENSION (Suspected Class III ___ OSA)
Patient presented with significant dyspnea described as "air
hunger". Multiple recent admissions for dyspnea,
hypoxemia/hypercarbia. Trop was neg, D Dimer was elevated to
>1000 this admission (negative on previous admissions). CTA
limited by motion artifact but within limits of study was
negative for PE. No increased sputum production or recent URI
symptoms, not concerning for COPD exacerbation. VBG on admission
not concerning for hypercarbic respiratory failure. Last
admission in ___, pulmonary consult team recommended
evaluation for sleep disordered breathing (likely that pHTN,
hypercarbia, and hypoxia may be primarily from kyphosis and
abnormal breathing at night). Patient underwent sleep study of
suboptimal quality as outpatient. She has been wearing her BiPAP
every night for about 6 hours. Anemia (as described below) may
also be contributing.
# ELEVATED D-DIMER
# LLE UNILATERAL SWELLING
Left lower extremity increased in size compared to right, with
1+
pitting edema. Two large ecchymoses on the popliteal fossa of
the left leg, indurated. Patient reports these are from heparin
last admission. ___ negative for DVT.
# ANEMIA:
Hg 8.3 on admission, baseline appears to be 12. Patient reports
recent nosebleeds with new O2 that dries out her nares, up 3
times per week. She also reports 2 recent bowel movements with
stool covered with blood. Told in the past that she may have an
anal fissure. She has never had a colonoscopy, and refuses
future ones. Her family
history is uncertain, as patient is adopted.
# HYPONATREMIA: Likely secondary to poor PO intake, stable.
# BACK PAIN
# COMPRESSION FRACTURES
Patient was found to have compression fracture of T11 in ___.
In early ___, she again developed back pain, and was found
to have a new compression fracture of the superior endplate of
L1 with bone edema. ___ checked, has narcotics contract at
___. Takes Vicodin at home, was given Tylenol and oxycodone PRN
inpatient.
# ADRENAL ADENOMA
CT scan ___ showed right adrenal mass previously
characterized as an adenoma has increased in size slightly as
compared to ___. AM cortisol normal.
TRANSITIONAL ISSUES (INCLUDING FROM PREVIOUS ADMISSIONS)
=============================================
[ ] Pulmonary Hypertension / COPD:
- Pulmonology (General) follow up
- Full PFTs
- FYI: Patient is on 2L NC, but no other COPD medicines other
than Albuterol inhaler.
- Repeat TTE with bubble if desired (not able to be completed
over weekend of admission from ___ to rule out
shunting (though low suspicion given normal A-a gradient); of
note: TTE done this admission was without bubble but did show
moderately dilated RV.
[ ] ___:
- Patient is on waitlist for ___ pulmonary rehab
(___).
[ ] OSA:
- Consider repeat sleep study (given suboptimal quality of
___ study). Patient on CPAP at home.
[ ] Iron deficiency vs Blood loss Anemia:
- Recommend Colonoscopy to evaluate for bloody stool (patient
has refused in the past, guaiac on ___ negative)
[ ] Pulmonary nodule
- Consider optional repeat follow up CT scan in ___ year (___)
[ ] Adrenal adenoma
- Stable on imaging.
# CODE: full (confirmed)
# CONTACT: HCP is Case manager, ___ ___.
Alternate contact (not HCP): ___ ___ ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO QID:PRN anxiety
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
4. thyroid (pork) 60 mg oral DAILY
5. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
2. ALPRAZolam 1 mg PO QID:PRN anxiety
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
5. thyroid (pork) 60 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute on chronic hypoxemic respiratory failure
SECONDARY DIAGNOSES
COPD
Pulmonary Hypertension
Obstructive sleep apnea
Anxiety
Kyphoscoliosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___.
Why was I admitted?
- You were admitted for shortness of breath.
What happened to me in the hospital?
- You had a CT scan of your lungs to make sure you did not have
a pulmonary embolism.
- You were monitored on BiPAP in the ED.
- You had an ultrasound of your left leg to make sure you did
not have a deep vein thrombosis (clot).
- You had a repeat ultrasound of her heart (echocardiogram),
which was similar to the last one. You have pulmonary
hypertension and this is making the right side of your heart a
little bigger than normal.
- You did not have a COPD exacerbation, you do not have an
infection, and you do not have a pulmonary embolism.
What should I do when I leave the hospital?
- Please take all of your medicines as prescribed.
- Please attend all followup appointments.
- Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19641231-DS-20
| 19,641,231 | 26,224,604 |
DS
| 20 |
2123-05-15 00:00:00
|
2123-05-16 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Aspirin / Ampicillin / Cipro
Cystitis / Shellfish Derived / Wheat / Chicken Derived / Soy /
Ciprofloxacin / Latex / oil based chemicals / clindamycin /
cholecalciferol / cephalexin
Attending: ___.
Chief Complaint:
Regurgitation/Inability to tolerate PO intake
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
___ with recent complicated hospitalization (dyspnea,
hypercarbia ___ COPD, kyposcoliosis, and sleep related
hypoventilation requiring MICU stay for cpap/bipap, altered
mental status, aspiration pneumonia (req vanc-> ___, was
discharged from hospitalist service on ___ who presents
with emesis.
Reports that emesis x 2 days and had emesis prior to discharge
but attributed to food allergy or reflux (had eaten eggs over
last few days before discovering it was food allergy). She also
had aspiration during the prior hospital stay (known
oropharyngeal dysphagia). Speech/swallow had recommended thick
liquids / meds with pureed due to known aspiration risk on prior
evaluations, but liberalized diet on ___ at patient request.
Now she reports that she cannot keep any food down since
discharge including medications at rehab. Has had emesis of all
food intake, also some foamy spit-up.
Emesis is immediate and consist of intact food. It is resolved
if she maintains NPO. She previously declined video swallow
study due to goals of care but now would like to do so and is
also amenable to tube feeding as last resort. Denies associated
nausea or abdominal pain. No fever, chills, headache, diarrhea,
blood in stool, hematemesis.
In the ED, initial VS were:
Today 16:33 99.0 106 119/37 18 97% 3L NC
Exam notable for:
Dry mucous membranes, nontender abd, clear lungs.
ECG: SR, rate 79, no acute ischemic changes
Labs showed:
BMP wnl
Lactate 1.3
ALT: 17 AP: 115 Tbili: 0.4 Alb: 2.4
AST: 31 Lip: 7
WBC 6.7 Hgb 8.9
UA mod leuks, many bac, 6 RBCs
KUB IMPRESSION:
Nonobstructive bowel gas pattern. Increased, large rectal stool
ball and moderate colonic fecal loading. Increased, moderate
right pleural effusion with adjacent relaxation atelectasis.
Difficult to exclude infection in the
appropriate clinical setting.
Patient received:
1L NS
IV zofran
On arrival to the floor, patient reports no further emesis since
7am. She reports she does not feel nauseated but rather only
vomits immediately after eating and she has not eaten since the
morning. She denies cough, CP, dyspnea, orthopnea. She is on her
home 2L NC O2.
Past Medical History:
1. Cholelithiasis - s/p cholecystectomy
2. Chronic fatigue syndrome
3. Fibromyalgia
4. Diabetes
5. Hypothyroidism - on pork thyroid
6. Scoliosis
7. Rosacea
8. Torticollis
9. COPD
10. Pulmonary hypertension
11. Paroxysmal atrial fibrillation
12. Anxiety
Social History:
___
Family History:
Patient adopted. Believes her mother passed away secondary to
lung cancer.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Temp 98.0 BP 117/69 HR 82 RR 18 ___
General: lying on right side in bed, NAD
Eyes: Sclera anicteric.
HEENT: MMM, clear OP
Neck: supple, no LAD, torticollis with neck to right side
Resp: mildly decreased bibasilar breath sounds, no crackles,
wheezes, rhonchi
CV: RRR, nl S1/S2, no m/g/r
GI: soft, NTND,+BS, no rebound tenderness or guarding
MSK: WWP with no cyanosis, pneumo boots in place, 1+ pitting
edema to knees b/l
Skin: no ulcers appreciated
Neuro: AxO x3. CNs grossly intact. Moving all extremities
equally
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 07:37AM BLOOD WBC-7.8 RBC-3.14* Hgb-8.7* Hct-31.1*
MCV-99* MCH-27.7 MCHC-28.0* RDW-22.5* RDWSD-79.6* Plt ___
___ 06:17PM BLOOD Neuts-81.8* Lymphs-7.7* Monos-8.9
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.51 AbsLymp-0.52*
AbsMono-0.60 AbsEos-0.01* AbsBaso-0.02
___ 06:17PM BLOOD Glucose-122* UreaN-16 Creat-0.3* Na-145
K-4.3 Cl-100 HCO3-28 AnGap-17
___ 06:17PM BLOOD ALT-17 AST-31 AlkPhos-115* TotBili-0.4
___ 06:17PM BLOOD Lipase-7
___ 06:17PM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.5 Mg-2.1
___ 06:30PM BLOOD Lactate-1.3
======
MICRO:
======
___ Urine culture - mixed bacterial flora, likely
contamination
================
IMAGING/REPORTS:
================
___ ABDOMINAL X-RAY
Nonobstructive bowel gas pattern. Increased, large rectal stool
ball and
moderate colonic fecal loading. Increased, moderate right
pleural effusion with adjacent relaxation atelectasis. Difficult
to exclude infection in the appropriate clinical setting.
___ CXR
Moderate to large right pleural effusion has increased
substantially over 10 days. Absence of leftward mediastinal
shift reflects right lower lobe
collapse. Left lung shows only mild vascular engorgement.
Borderline
cardiomegaly stable. No pneumothorax or appreciable left pleural
effusion.
New left PIC line ends in the mid to low SVC.
___ EGD
Upon entrance into the esophagus there was food up at the upper
esophageal sphincter. The procedure was aborted and the paient
was intubated. The scope was then reinserted. The scope easily
passed into the stomach with only slight narrowing at the lower
esophageal sphincter but no clear stricture. The food was then
pushed and washed into the sstomach. There was a hiatal hernia
and liquid kept regurgitating up into the esophagus. This was
easily suctioned. Otherwise normal EGD to third part of the
duodenum.
___ BARIUM SWALLOW WITH TABLET
Esophageal dyskinesia with retention of barium and the barium
tablet within
the mid to distal esophagus. Limited evaluation of small bowel
dilatation.
___ ABDOMINAL X-RAY
There are no abnormally dilated loops of large or small bowel.
There is a
nonspecific bowel gas pattern. Contrast is seen within several
small bowel loops in the right lower quadrant. Osseous
structures are unremarkable. A copious amount of stool is
re-demonstrated in the rectum. Clips are seen in the right
upper quadrant. There is a small right effusion.
=====================
OTHER PERTINENT LABS:
=====================
___ 08:10AM BLOOD CK-MB-3 cTropnT-0.03*
===============
DISHCARGE LABS:
===============
Brief Hospital Course:
___ with a background history of hypothyroidism, anxiety,
chronic hypercarbic respiratory failure due to kyphoscoliosis
with restrictive lung disease on PFTs, torticollis, COPD (on
home O2), pulmonary hypertension, and recent prolonged
hospitalization with hypercarbia requiring MICU stay for
CPAP/BiPAP, altered mental status and aspiration pneumonia,
discharged on ___, who now presents from rehab with ongoing
emesis and inability to keep any PO intake down.
====================
ACUTE/ACTIVE ISSUES:
====================
# Regurgitation of food / Inability to tolerate PO / Unspecified
Malnutrition
Patient presented with several days of regurgitation with
eating. Reported associated reflux symptoms, but no nausea,
abdominal pain or diarrhea. Unable to tolerate PO intake. GI was
consulted and was concerned for mechanical obstruction vs.
esophageal dysmotility. EGD demonstrated food at the upper
esophageal sphincter, but no obvious obstruction, however
regurgitation was noted from stomach to esophagus. Barium
swallow with tablet demonstrated dyskinesis of the esophagus.
Diet was gradually increased to soft dysphagia solids following
discussion with GI, with no further recurrence of regurgitation.
Diet should not be advanced any further than this. GI will
follow the patient post discharge, with a plan to perform
further motility studies as an outpatient on ___. It is
important patient is NPO the morning of this procedure. She will
subsequently follow with GI on ___.
# Recurrent aspiration
# Right sided pleural effusion
Patient with aspiration event last admission, with CT on ___
showing new right lower lobe consolidation and pleural effusion
concerning for aspiration pneumonia. Previously, she received
course of vancomycin and meropenem. In ED, KUB showed increased
pleural effusion on right side and patchy opacification,
concerning for ongoing aspiration. However, as patient remained
afebrile and asymptomatic, this was felt unlikely to represent
aspiration pneumonia, and patient was not treated with
antibiotics. Speech and swallow were consulted once the patient
had been cleared by GI and cleared patient for soft, moist
solids with thin liquids via single cup
sips with close supervision for meals and UPRIGHT IN CHAIR when
taking PO.
# Constipation
Patient with known issues with chronic constipation. KUB on
admission demonstrated rectal stool ball and moderate colonic
constipation. Patient asymptomatic. Given aggressive PO and PR
bowel regimen with good results and increased frequency of bowel
movements. However, repeat KUB on ___ demonstrated persistent
rectal stool bowel. Given this was a potential nidus for future
stercocolitis, patient underwent aggressive treatment with
enemas with continued good bowel movement frequency.
======================
CHRONIC/STABLE ISSUES:
======================
# Chronic hypercarbic respiratory failure
Multifactorial secondary to kyphoscoliosis with restrictive lung
disease, pulmonary hypertension, COPD and sleep related
hypoventilation. On 2L supplemental oxygen at home. Continued
tiotropium one capsule daily and albuterol neb PRN.
# Anxiety
Continued alprazolam 1mg QID, with PRN dose. Important to note,
patient has a history of altered mental status when attempting
to de-escalate benzodiazepine dose.
# Paroxysmal atrial fibrillation
Continued metoprolol succinate 50mg daily for rate control.
Apixaban was held in the setting of interventions, but restarted
when it was no clear no further interventions would be required.
# Hypothyroidism
Continued pork thyroid 60mg daily. TSH was within normal limits
during last admission. T4 was noted to be low, but important to
note pork thyroid is predominantly T3.
# Failure to thrive
# Multiple vitamin/mineral deficiencies
Continued zinc sulfate 220mg daily, thiamine 100mg daily,
multivitamin with minerals daily and folic acid 1mg daily.
# Anemia
Remained stable at baseline throughout admission.
# Back pain
# Previous L1 compression fracture
Continued vicodin 5mg-325mg Q6H:PRN.
====================
TRANSITIONAL ISSUES:
====================
- discharge WBC 7.3
- discharge Hgb 8.7
- discharge Plt 106
- discharge Creatinine 0.2
[] GI follow-up for outpatient esophageal motility studies
[] Diet: S&S recommended soft, moist solids with thin liquids
via single cup
sips with close supervision for meals and UPRIGHT IN CHAIR for
PO.
[] Rectal stool ball demonstrated on KUB despite aggressive
bowel regimen; if constipation refractory to medication, would
favor manual disimpaction, and take seriously given future risk
of stercocolitis
[] Right lower lobe collapse and large right pleural effusion;
most likely the result of severe kyphoscoliosis, however
malignancy is possible. Could consider CT chest to further
evaluate.
From previous admission:
[] Patient will need outpatient pulmonary follow-up which was
arranged for her
[] Patient should be initiated on metformin for diabetes
mellitus diagnosed this hospitalization
[] Patient should be considered for IV zoledronic acid in the
outpatient setting given her multiple compression fractures
[] Patient was found to have multiple vitamin deficiencies and
was started on supplementation for these during her
hospitalization
[] Patient suffered from benzodiazepine w/d from holding her
home Xanax. This should be continued in the short term, and she
should be considered for prolonged taper per psychiatry
recommendation
[] Pt's code status was changed to DNR/DNI this admission, and
MOLST form was completed with patient to document these wishes
[] Patient was discharged on apixaban and metoprolol for her
atrial fibrillation
=========================================================
# CODE STATUS: DNR/DNI
# CONTACT: HCP is Case manager, ___, ___
Home health ___, ___
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, cough
2. ALPRAZolam 1 mg PO QID anxiety
3. thyroid (pork) 60 mg oral DAILY
4. Acetaminophen 500 mg PO Q8H
5. Apixaban 5 mg PO BID atrial fibrillation
6. Atorvastatin 80 mg PO QPM
7. Calcium Carbonate 500 mg PO TID W/MEALS osteoporosis
8. Docusate Sodium 100 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
11. Lidocaine 5% Patch 1 PTCH TD QAM lower back pain
12. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN reflux
13. Metoprolol Succinate XL 50 mg PO DAILY atrial fibrillation
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Omeprazole 20 mg PO BID reflux
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. Polyethylene Glycol 17 g PO DAILY
18. Ramelteon 8 mg PO DAILY
19. Senna 8.6 mg PO BID constipation
20. Simethicone 40-80 mg PO QID:PRN gas
21. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
22. Thiamine 100 mg PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
24. Vitamin D ___ UNIT PO 1X/WEEK (___) Vitamin D deficiency,
?malabsorption
25. Zinc Sulfate 220 mg PO DAILY zinc deficiency
26. ALPRAZolam 0.25 mg PO TID:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES:
==================
Regurgitation of food secondary to esophageal dysmotility
Acute on chronic constipation
Chronic recurrent aspiration
====================
SECONDARY DIAGNOSES:
====================
Chronic respiratory failure
Anxiety
Paroxysmal atrial fibrillation
Hypothyroidism
Failure to thrive
Chronic anemia
Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
WHY YOU CAME TO THE HOSPITAL
You were admitted to ___ as you were vomiting/regurgitating
food
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL
- You had an endoscopy which did not show an obstruction in your
esophagus
- You also had a barium swallow, which showed the movement of
your esophagus was sluggish and uncoordinated
- We gradually advanced your diet to soft solid food, which you
should not advance any further
- You were also constipated, for which we gave you
laxatives/enemas with good results
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL
- You need to follow-up with your PCP when you are discharged
from rehab
- You will have a motility study on ___ it is important
you do not eat breakfast on the morning of this procedure
- You will also follow-up with GI with the results of this study
on ___
- You should continue to eat soft food only
- It is important to continue to take all your medications as
prescribed, including your laxatives
It was a pleasure taking care of you!
Your ___ Healthcare Team
Followup Instructions:
___
|
19641331-DS-21
| 19,641,331 | 23,649,829 |
DS
| 21 |
2173-11-30 00:00:00
|
2173-12-01 07:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
s/p seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with no significant PMHx who presents
with first time seizure. History per ED staff and second-hand
reports of description from friend, ___, who was no longer
available at the time of Neurology evaluation (with no known
phone number).
Ms. ___ lives in ___ and is currently visiting ___. She
was with a friend, ___ in a taxi and then stated she felt
nauseated and hungry (she had not eaten yet today). She then had
a generalized convulsion, which was described as lasting 5
minutes.
On arrival to the ED she was sleepy and amnestic to events of
today. She woke up over several hours and returned to baseline
mental status and remembered events of the day leading up to the
seizure, which she did not recall.
Family (son ___ reports that she has been neurologically and
medically well lately.
In the ED, she then had a second seizure. RN became aware of
seizure when they heard loud/heavy breathing. Neurology came to
bedside within ___ seconds and witnessed the end of the
seizure. Seizure consisted of facial flushing, snoring, gaze
midline, flaccid extremities and nonreactive pupils. She
received
2mg IV lorazepam rapidly. After approx. 1 min she began to have
spontaneous roving eye movements, facial flushing decreased (but
did not resolve). Over the next ___ minutes she began to have
spontaneous movements of all four extremities, but was still
very
sleepy and not following commands.
Unable to complete ROS due to mental status.
Past Medical History:
s/p cataract surgery.
Recent PCP visit in the past few months, was told she was
healthy
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 98.2 HR: 80-116 BP: 126-164/82-106 RR: ___ SaO2:
97% RA after second seizure.
General: sleepy. Facial flushing.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Bloody
spittle present, Unable to visualize mouth well to evaluate for
location of injury.
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Asleep. No EO, no commands. Spontaneous
nonpurposeful movements x4.
-Cranial Nerves: PERRL 4->3. No BTT bilaterally. VOR intact.
Roving eye movements. Face symmetric.
- SensoriMotor: brisk withdrawal from noxious x4.
- DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 2 2 3 2 2 +
R 2 2 3 2 2 +
Plantar response was extensor bilaterally.
- Coordination: UTA
- Gait: UTA
DISCHARGE PHYSICAL EXAM
___ 0437 Temp: 98.1 PO BP: 109/67 R Lying HR: 64 RR: 16 O2
sat: 95% O2 delivery: Ra
General: awake, alert, NAD
HEENT: no scleral icterus, MMM, small lesion on tongue
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema. left arm in sling
Neurologic Examination:
- Mental status: awake, alert, oriented to ___, ___,
date, year. No evidence of apraxia
or neglect. Recall ___ at 5 mins
-Cranial Nerves: PERRL 3->2 bilaterally, EOMI, face symmetric,
sensation intact V1-V3, tongue midline, palate elevates
symmetrically
- DTRs: deferred
- ___: deferred
- Gait: deferred
Pertinent Results:
ADMISSION LABS
---------------
___ 10:48AM BLOOD WBC: 11.4* RBC: 5.17 Hgb: 14.7 Hct: 46.1*
MCV: 89 MCH: 28.4 MCHC: 31.9* RDW: 13.6 RDWSD: 44.___
___ 10:48AM BLOOD Neuts: 63.8 Lymphs: ___ Monos: 6.2 Eos:
1.5 Baso: 0.7 Im ___: 3.8* AbsNeut: 7.26* AbsLymp: 2.73
AbsMono:
0.71 AbsEos: 0.17 AbsBaso: 0.08
___ 12:07PM BLOOD ___: 11.8 PTT: 27.5 ___: 1.1
___ 10:48AM BLOOD Glucose: 142* UreaN: 12 Creat: 0.9 Na:
139
K: 4.3 Cl: 103 HCO3: 16* AnGap: 20*
___ 10:48AM BLOOD ALT: 17 AST: 20 CK(CPK): 60 AlkPhos: 67
TotBili: 0.5
___ 10:48AM BLOOD cTropnT: <0.01
___ 10:48AM BLOOD Albumin: 4.6 Calcium: 10.3 Phos: 3.2 Mg:
2.3
___ 10:48AM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
___ 01:22PM URINE Blood: NEG Nitrite: NEG Protein: TR*
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5
Leuks:
TR*
___ 01:22PM URINE RBC: 1 WBC: 6* Bacteri: FEW* Yeast: NONE
Epi: 6
___ 01:22PM URINE bnzodzp: NEG barbitr: NEG opiates: NEG
cocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG
Lactate 10.3->2.9
___ BONE SCAN
___ MAMMOGRAM
Tissue density: B- The breast tissues are fatty with some
scattered
fibroglandular and fibronodular tissue which does somewhat lower
the
sensitivity of mammography. Scattered coarse dystrophic
appearing
calcifications are seen in both breasts, a few of which are
associated with small masses on tomosynthesis and therefore
favor involuting fibroadenomas. No area of architectural
distortion or cluster of suspicious microcalcification is seen.
Several more focal areas of nodularity in the outer posterior
and upper right breast wrist seen on the initial CC and MLO
views, although only one appeared slightly persist on the
additional imaging. This was further evaluated with ultrasound.
Ultrasound of the right breast from ___ o'clock 5-15 cm from
the nipple in the area of concern on mammography was performed.
At 10 o'clock 10-11 cm from the nipple is identified a 0.5 x 0.3
x 0.4 cm benign-appearing intramammary lymph node. This likely
accounts for the mammographic finding. No solid suspicious mass
or cystic lesion is seen.
IMPRESSION:
No specific mammographic evidence of malignancy.
RECOMMENDATION: Routine mammography would be recommended based
on age and
risk assessment.
BI-RADS: 2 Benign.
CT Chest ___
IMPRESSION:
1. No definite evidence of intrathoracic malignancy.
2. Bilateral pulmonary nodules and subpleural densities
measuring up to 8 mm.
See below for recommendations.
CT Abd/Pelvis ___
IMPRESSION:
1. No evidence of malignancy in the abdomen or pelvis.
2. Mild loss of vertebral body height at T10.
MRI/MPRAGE ___
1. No acute intracranial abnormality on contrast enhanced MRI
brain. No acute infarct or intracranial hemorrhage. No
suspicious parenchymal FLAIR signal abnormality. No
intracranial
mass or abnormal enhancement.
2. The dural venous sinuses are patent.
3. Unremarkable MRA of the head.
CT head ___
No acute intracranial process.
DISCHARGE LABS
--------------
___ 05:05AM BLOOD WBC-8.7 RBC-4.61 Hgb-13.4 Hct-40.2 MCV-87
MCH-29.1 MCHC-33.3 RDW-14.0 RDWSD-43.4 Plt ___
___ 05:05AM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-142
K-4.3 Cl-107 HCO3-23 AnGap-12
___ 05:05AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ woman with no significant PMHx who presents
with first time seizure x2.
#Seizures:
Patient was admitted to the neurology service for workup of ___
onset seizures. She had an MRI with and MP rage that was
negative for any structural cause of seizures including bleed,
ischemic stroke, mass, venous sinus thrombosis. She was
monitored on EEG without any recurrence of seizures. she had an
LP that was overall bland and negative for any bacterial
infection. CSF Gram stain showed no PMNs and no microorganisms
HSV was sent but she was empirically started on acyclovir which
was stopped after the HSV PCR from CNS was negative. In her
workup she was found to have an elevated CRP to 64.4. CT torso
is negative for any evidence of solid malignancy. Other workup
included rheumatoid factor that was negative, anti-thyroglobulin
and anti-TPO that were normal, and an negative ANCA. Of note her
___ was positive with a titer of 1:80.
Whipple PCR was negative. In addition to HSV other infectious
etiologies were considered including EBV that was negative.
Pending at the time of discharge CSF Powassan virus,
paraneoplastic antibodies.
#Left humerus fracture: On admission patient was complaining of
left shoulder pain that was severe and restricted her range of
motion. An x-ray of the shoulder showed a fracture surgical neck
of the left humerus with extension
to the lesser tuberosity. There was question of if there was
some evidence of posterior dislocation so a CT of the shoulder
was done. This did not show any posterior dislocation.
Orthopedic surgery was consulted. They felt that there was no
need for operative intervention and her fracture could be
managed conservatively with a sling and non weight bearing. She
will follow-up with an orthopedist as an outpatient in 2 weeks.
Given the humerus fracture and concern for pathologic fracture,
she underwent mammogram and bone scan which were reassuring. She
plans to move to ___ on the morning after hospital
discharge, and so she was advised to call a local primary care
doctor, ___, and orthopedics doctor for follow up.
#Cataract surgery: She was continued on her home eyedrops after
her cataract surgery.
#Vitamin D deficiency
She was started on vitamin D supplements
Transitional Issues
======================
[] paraneoplastic, vitamin b1 and CSF viral studies pending at
time of discharge
[] patient will need follow up with orthopedics in 2 weeks for
shoulder fracture
[] follow up with neurology and primary care
[] discharged on keppra 750mg BID and atorvastatin 20mg qd
[] vitamin D level should be rechecked in several weeks as
patient was deficient
[] Patient cannot drive for at least 6 months following a
seizure
#L humerus fracture
She can use the left upper extremity for light activities of
daily living. Encourage pendulums to maintain shoulder ROM. She
can use the sling for comfort but encourage getting out of sling
regularly for ROM therapy.
[] Follow up with orthopedics in 2 weeks with left shoulder
xrays.
Medications on Admission:
1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
2. Prolensa (bromfenac) 0.07 % ophthalmic (eye) DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
2. LevETIRAcetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*40 Tablet Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
5. Prolensa (bromfenac) 0.07 % ophthalmic (eye) DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Generalized seizure
Right shoulder fracture
vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why were you admitted?
You were admitted to the hospital because you had a seizure.
What happened while you were here?
You had an EEG that showed that you were no longer having
seizures. You had a lumbar puncture that showed that you did
not have any infections in your brain. You had an MRI that
ruled out any structural causes for your seizures. You were
started on a medicine to help prevent seizures from happening
again.
You were also found to have fractured your right arm from the
seizure. You were seen by orthopedic surgery who felt that your
arm can be managed conservatively without any surgical
intervention.
You received a mammogram which was reassuring.
What should you do when you get home?
-Continue to take your medications as prescribed
-Please do not drive for at least the next 6 months
Please follow-up with neurology, primary care, and orthopedic
surgery as an outpatient.
All the best,
Your neurology care team
Followup Instructions:
___
|
19641848-DS-17
| 19,641,848 | 22,737,346 |
DS
| 17 |
2160-07-15 00:00:00
|
2160-07-15 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
seasonal
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with a history of advanced PD ___ years) c/b
dysautonomia including postural hypotension followed by Dr.
___ at ___, cognitive decline, hallucinations and REM sleep
behavior disorder, lumbar spinal stenosis s/p fusion complicated
by chronic back pain presenting with auditory and visual
hallucinations and confusion from his nursing home facility.
His baseline mental status appears oriented to place but
occasionally will be disoriented to situation and date. Per
wife, he was having hallucinations for ___ days prior to
admission. He was complaining that people were trying to attack
him and was quite paranoid.
Previously, he was admitted to the hospital on ___ in the
setting of hypotension and UTI and discharged to rehab, where he
has been having issues with episodic hypotension and SBPs in the
___. After being discharged, he was seen in the ED on ___ for
an episode of unresponsiveness in the setting of SBP in the ___
at rehab.
Social History:
___
Family History:
Reviewed. None pertinent to this hospitalization
Physical Exam:
Day of Admission:
Mild distress in pain
Tremor, choreiform movements in all extremities
sensation and motor intact in all 4 extremities
Rectal tone intact
Day of Discharge:
=============
- General: NAD, elderly man, awake, cooperative. Sleeping in
chair at side of bed
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, non-distended
- Extremities: no edema
- Skin: no rashes or lesions noted
Neuro (varies with time of Sinemet dosage):
MS: Alert, oriented to person, and month, not day of week,
orient
to hospital but not the name of the hospital. Speech is
stuttering with palilalia. Perseverates on ideas. Can understand
50% of what he is saying. Follows simple commands.
CN: Pupils are 3->2 bilateral, does not fully bury sclera on L,
limited upgaze. Hypomimia with decreased blink rate,
mild left nasolabial fold flattening with symmetric activation,
voice is hypophonic and dysarthric, tongue midline.
Motor:
Increased tone throughout L>R, distal>proximal. Increased tone
in
neck. There is a low amplitude high frequency tremor at rest b/l
lower and upper extremities R>L. Intermittent pill-rolling
tremor
b/l L>R. There is moderate bradykinesia w/ irregularity
with hand open close and finger tap R>L. Antigravity all
extremities, moves spontaneously in all extremities.
Sensation: Denies diminished to LT
Coordination: Action tremor with finger nose finger bilaterally
L>R
Reflexes: 2+ throughout except 1+ at Achilles. +glabellar,
snout,
grasp and palmomental reflexes.
Gait: Deferred
Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-7.0 RBC-3.31* Hgb-10.2* Hct-31.7*
MCV-96 MCH-30.8 MCHC-32.2 RDW-12.9 RDWSD-45.3 Plt ___
___ 11:20AM BLOOD Neuts-53.7 ___ Monos-7.7 Eos-4.7
Baso-0.6 Im ___ AbsNeut-3.75 AbsLymp-2.32 AbsMono-0.54
AbsEos-0.33 AbsBaso-0.04
___ 11:20AM BLOOD Glucose-90 UreaN-28* Creat-1.3* Na-143
K-4.8 Cl-107 HCO3-21* AnGap-15
___ 11:20AM BLOOD ALT-<5 AlkPhos-90 TotBili-0.5
___ 11:20AM BLOOD cTropnT-0.18*
___ 04:30PM BLOOD cTropnT-0.17*
___ 06:10AM BLOOD CK-MB-3 cTropnT-0.08*
___ 11:20AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.7 Mg-2.3
Imaging:
========
___ CTH
IMPRESSION: No acute intracranial process.
___ CXR
IMPRESSION: No acute findings.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with a history of advanced PD ___
years) complicated by
dysautonomia including postural hypotension (followed by Dr.
___ at ___) cognitive decline, hallucinations and REM
sleep
behavior disorder, lumbar spinal stenosis s/p fusion
complicated
by chronic back pain who presents with auditory and visual
hallucinations and confusion from his nursing home facility.
His
recent change in his mental status was attributed to changes in
his recent ___ medications. He was original admitted for
NSTEMI in setting of prerenal ___ resolved with fluid
repletion and troponin
downtrended. Subsequently transferred to neurology for
optimization of ___ disease.
ACUTE ISSUES:
=========
___ disease
Clinical presentation of altered mental status and
hallucinations can be explained by his ___ disease. Of
note, the patient recently had an increase in his
Carbidopa-Levodopa noon dose. Upon admission, his baclofen and
oxycodone were held. He was his given his scheduled
Carbidopa-Levodopa, but his noon dose was reduced from 1 tablet
to 0.75 tablet. He was also given his entacapone and
ropinirole.
Fludricort and Midodrine were originally held out of concern
for supine
hypertension, but fludricort was restarted in hospital due to
downtrending sodium (stabilized when fludricort restarted).
Midodrine can be restarted upon discharge. Due to previous
behavioral issues, pt's Ropinirole was
spread out from 2mg BID to 0.5mg 7x/day at same time as Sinemet
dosing. Patient and wife also give information about Duopa, as
could benefit from fine titrations of medication. Wife reports
his cognition has been steadily improving over the past week.
#Agitation
Continued quetiapine 25mg TID. Additional queitiaine PRN can be
considered
#Type II NSTEMI
Patient had no chest pain and no changes on ECG. Unclear
etiology but thought to be due to supply/demand mismatch in the
setting of dehydration. Trop downtrended 0.18 --> 0.17 -->
0.08.
___
Cr 1.3 on presentation. Likely in the setting of poor PO
intake.
Given IVF and subsequently decreased to 1.1.
================================================================
TRANSITIONAL ISSUES:
[ ] Follow up with primary neurologist in ___ weeks from
hospital discahrge
[ ] Received information about Duopa, as could benefit from
fine
titrations of medication
[ ] Follow up with PCP ___ ___ weeks for monitoring of
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. QUEtiapine Fumarate 25 mg PO TID
3. Senna 17.2 mg PO HS
4. Vitamin D 1000 UNIT PO DAILY
5. Zonisamide 25 mg PO BID
6. Cyanocobalamin 100 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Requip XL (rOPINIRole) 4 mg oral QAM
10. Carbidopa-Levodopa (___) 0.75 TAB PO 6X/DAY
11. Tizanidine 4 mg PO TID
12. ENTAcapone 200 mg PO 5X/DAY
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
14. Carbidopa-Levodopa (___) 1 TAB PO DAILY
15. Carbidopa-Levodopa CR (___) 1 TAB PO DAILY
16. Hydrocortisone Acetate Suppository ___AILY
17. Lactulose 15 mL PO DAILY:PRN constipation
18. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
2. Ramelteon 8 mg PO QHS:PRN insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
3. rOPINIRole 0.5 mg PO 7X/DAY
Cinemet: 6a,8a,10a,12p,2p,6p,8p
RX *ropinirole [Requip] 0.5 mg 1 tablet(s) by mouth 7 times a
day Disp #*210 Tablet Refills:*3
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
5. Carbidopa-Levodopa (___) 1 TAB PO DAILY
6. Carbidopa-Levodopa (___) 0.75 TAB PO 6X/DAY
7. Carbidopa-Levodopa CR (___) 1 TAB PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. ENTAcapone 200 mg PO 5X/DAY
(with each carbidopa/levodopa dose)
11. Fludrocortisone Acetate 0.05 mg PO DAILY
12. Hydrocortisone Acetate Suppository ___AILY as
needed
13. Lactulose 15 mL PO DAILY:PRN constipation
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Midodrine 2.5 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. QUEtiapine Fumarate 25 mg PO TID
19. Senna 17.2 mg PO HS
20. Vitamin D 1000 UNIT PO DAILY
21. Zonisamide 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ disease, polypharmacy
Discharge Condition:
Stable
Discharge Instructions:
Dear Dr. ___,
___ were admitted to ___ for concerns of confusion thought to
be caused by recent medication changes. Further workup did not
reveal infectious source of confusion, but did show that ___ had
cardiac injury and acute kidney damage, both of which improved
with IV fluids. Your confusion was noted to improve with fluid
repletion and adjustment of your medications. Your reported
nightmares are thought to be part of the progression of
Parkinsons.
The following changes in your medication are:
- Stop taking baclofen
- Stop taking oxycodone
- Continue Carbidopa-Levodopa as scheduled EXCEPT reduce noon
dose from 1 tablet to 0.75 tablet
- Ropinirole was spread out from 2mg BID to 0.5mg 7x/day at same
time as Carbidopa-Levodopa
- Lidocaine patch as needed for back pain
- Ramelteon as needed at night for insomnia
Take your other medications as prescribed prior to
hospitalization.
___ will be discharged to a rehabilitation facility to further
therapy.
It was a pleasure taking care of ___.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19641962-DS-18
| 19,641,962 | 20,934,205 |
DS
| 18 |
2182-12-08 00:00:00
|
2182-12-08 20:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of atrial fibrillation on Apixaban presents
evaluation of epistaxis. Patient states that approximately 45
minutes prior to presentation he began having severe epistaxis
from the left nostril which has been resistant to pressure.
History is somewhat limited at this time given the patient
continues to bleed. After hemostasis was achieved, patient
states that he just began to bleed earlier today without any
evident trauma. He denies chest pain, shortness of breath,
lightheadedness.
In the ED, vitals intially 97.4 90 150/82 16 97%RA. Labs in ED
significant for bicarb 33, BUN 23, proBNP of 2386, Hct 36.3 and
INR of 1.9. CXR showed patchy opacity in R hilar region which
may represent atelectasis but cannot exclude aspiration or RLL
infection. Also there is a loculated effusion vs left pleural
thickening. Evidence of R ___ & 7th rib fractures. Hemostasis of
the left nostril was achieved with afrin spray as well as Afrin
soaked gauze. No formal packing or cautery. Episodes of
desaturation into the mid ___ and subsequently required nasal
cannula for support. Had episodes of desaturation into the mid
___ and subsequently required nasal cannula for support. Likely
due to partial aspiration from his severe epistaxis earlier
today rather than pneumonia or primary cardiac etiology.
On the floor, pt reports resolution of his epistaxis. Vitals
stable. Overall, he feels well but does report some mild ___
edema and abdominal swelling. Denies fever, chills, CP, SOB,
cough, abd pain, N/V/D, constipation, hematemesis, melena,
hematochezia, BRBPR.
Review of Systems:
(+) as in HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
CHF: EF unknown (pt has cardiologist outside ___ ?LVH -->pt
states his ventricular wall is "too thick"
Murmur
A fib - on coumadin
HTN
BPH
GERD
Depression
h/o Pneumonias
s/p pacemaker --> pt states that this was placed for his CHF
no h/o CAD
Social History:
___
Family History:
Sister - CHF
Physical ___:
ADMISSION EXAM:
Vitals- 97.3, 154/84, 68, 20, 98%RA
General- Alert, oriented x3, no acute distress, lying
comfortably in bed
HEENT- Atraumatic, Sclera anicteric, PERRL, EOMI, MMM,
oropharynx clear, dried blood in left nare with some dried blood
on face
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, no fluid wave
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals- 98.0, 143/73, 74, 18, 100%SM
General- Alert, oriented x3, no acute distress, sitting up at
edge of bed confortably
HEENT- Atraumatic, Sclera anicteric, PERRL, EOMI, MMM,
oropharynx clear, minimal dried blood in left nare with some
dried blood under his nose
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, no fluid wave
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-5.8 RBC-4.52* Hgb-11.7* Hct-36.3*
MCV-80*# MCH-25.8*# MCHC-32.1 RDW-17.9* Plt ___
___ 12:45PM BLOOD Neuts-67.5 ___ Monos-9.5 Eos-0.8
Baso-0.8
___ 12:45PM BLOOD ___ PTT-37.1* ___
___ 12:45PM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-141
K-4.4 Cl-102 HCO3-33* AnGap-10
___ 12:45PM BLOOD proBNP-___*
PERTINENT LABS: None
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-6.3 RBC-4.10* Hgb-10.4* Hct-33.0*
MCV-81* MCH-25.3* MCHC-31.4 RDW-18.0* Plt ___
___ 06:55AM BLOOD ___ PTT-33.7 ___
___ 06:55AM BLOOD Glucose-96 UreaN-25* Creat-1.2 Na-142
K-3.8 Cl-105 HCO3-31 AnGap-10
___ 06:55AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.2*
MICRO: None
PERTINENT IMAGING:
___ CHEST (PA & LAT)
IMPRESSION: Area of patchy opacity in the region of the right
hila, more prominent than on prior exam, which may represent
atelectasis, but aspiration or infection in the right lower lobe
cannot be excluded. Area of loculated pleural effusion vs.
pleural thickening along the lateral left lung. Right ___ and
___ lateral rib fractures, age indeterminate.
Brief Hospital Course:
___ M with PMH significant for Afib on apixaban, ___ and HTN,
presenting to the ED for epistaxis refractory to direct
pressure.
ACTIVE ISSUES:
#Epistaxis: Spontaneous, no known trauma to the nose. Pt
starTed apixaban ___ months ago, was taking warfarin before.
Bleed began 45 minutes before presenting to the ED while reading
the newspaper. Pt attempted to stop bleeding by applying
pressure but was unsuccessful. Denies experiencing
lightheadedness, palpitations, N/V, CP or SOB. BP remained
stable in the ED and overnight. Hct did drop from 36.3 to 33.0.
Seen by ENT at ___ in ___ ___ yr ago for a soft tissue
mass in the nasopharynx on CT sinus. Mass not vascular on MRI.
Bleeding resolved in ED after administration of Afrin. Apixaban
and BP meds were held on the floor in the setting of acute brisk
bleed. No further episodes of bleeding overnight and throughout
the day, pt remained asymptomatic. All of his home medications
were restarted on the day of discharge. The pt and his
daughters (one is a ___ and one ___ ___) prefer that
the pt remain on the Apixaban. He was instructed to restart his
apixaban the day after discharge. Encouraged pt to come to the
nearest emergency room if this should recur. Pt from
___. Encouraged pt to make a post-discharge follow
up appointment with his PCP when he returns home.
CHRONIC ISSUES:
#Afib: Patient remained clinically stable on the floor. He is
paced. Home Apixiban was held during admission in case of
rebleed.
#___: Patient remained clinically stable on the floor. Home BP
meds were held in the setting of acute bleed and ?volume loss.
Has cardiologist in ___. Gave pt a CD with a copy
of his CXR from this admission so that he can give it to his
PCP.
#HTN: Patient remained clinically stable on the floor.
Initially held home BP meds but restarted on the morning of
discharge.
TRANSITIONAL ISSUES
Encouraged pt to make a post-discharge appointment with his home
PCP.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Verapamil SR 180 mg PO Q24H
2. Apixaban 5 mg PO BID
3. Furosemide 80 mg PO QAM
4. Furosemide 40 mg PO QPM
5. NexIUM (esomeprazole magnesium) 20 mg Oral daily
6. Simvastatin 20 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Avodart (dutasteride) 0.5 mg Oral daily
9. Potassium Chloride Dose is Unknown PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Cyanocobalamin Dose is Unknown PO DAILY
12. Calcium Carbonate Dose is Unknown PO DAILY
13. Magnesium Oxide Dose is Unknown PO ONCE
Discharge Medications:
1. Furosemide 80 mg PO QAM
2. Furosemide 40 mg PO QPM
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Verapamil SR 180 mg PO Q24H
6. Apixaban 5 mg PO BID
Please restart this medication on ___.
7. Avodart (dutasteride) 0.5 mg Oral daily
8. Calcium Carbonate 600 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Magnesium Oxide 140 mg PO ONCE Duration: 1 Dose
continue home dose
11. NexIUM (esomeprazole magnesium) 20 mg Oral daily
12. Potassium Chloride 20 mEq PO DAILY
continue home dose
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Epistaxis
SECONDARY DIAGNOSIS:
Congestive heart failure, diastolic dysfunction
Hypertension
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for a nose bleed.
We watched you overnight and you had no futher episodes of
bleeding. We recommend that you restart your home Apixaban
tomorrow morning. If the nose bleed recurs, please go to the
nearest emergency room. Be sure to say that you take Apixaban.
Once you go home, you should make an appointment with your
primary care doctor and inform him that you were at the
hospital.
Please take all your medications as prescribed.
Thank you for allowing us to participate in your care.
Your chest XR showed a slight abnormality so we have given you a
copy of the image on a CD for review with your primary care
physician.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19642223-DS-16
| 19,642,223 | 21,652,416 |
DS
| 16 |
2160-07-15 00:00:00
|
2160-07-15 18:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache and left sided weakness
Major Surgical or Invasive Procedure:
Stereotactic abscess drainage ___
History of Present Illness:
The pt is a ___ y/o RHM with a history of IVDA ___ the past
(___) presented to an OSH with HA and left sided weakness.
He states that last week he started to develop on and off
headaches. Lasting hours, not positional, pressure ___ nature
(bi-frontal). Then over the last 3 days had been more
consistent.
2 days ago he noticed that he had trouble with his left side,
like getting up out of a chair and using his left hand for
things
like the remote. This has been getting progressively worse and
today was unable to walk (fell, no LOC). He states that he does
not usually suffer from headaches. He has a history of a staph.
infection ___ the right thumb ___ ___. Denies any recent IVDA but
still occasionally uses heroin and cocaine. He denies any teeth
pain. He did feel warm but no recorded fever at home. No chills
but GF says he was complaining of being cold yesterday.
Last HIV test 6 months ago, states it was (-)
Past Medical History:
BPH
Heroin/Cocaine use
Depression/anxiety
Hep C (not treated)
Some sort of arrythmia "years ago"
Social History:
___
Family History:
Dad had stroke at ___
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. NO oral lesions
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
(-) brud___
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Pt. was able
to name ___ card items and read ___ card sentences. 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, slight L NL fold flattening.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength ___ trapezii and SCM bilaterally.
XII: Tongue protrudes ___ midline.
-Motor: Normal bulk, tone throughout.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4- ___ ___ 4- 5 4 4- 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 2+ 2
R ___ 2 1
Plantar response was flexor right, mute left.
-Coordination: No dysmetria/ ataxia on FNF or HKS on the right.
Did not test the left.
-Gait: Can stand but wide based, needs lots of support (on the
left) to walk
===============
DISCHARGE EXAM:
AF VSS
NEURO: anisocoria with R>L but both briskly reactive.
Significant for flaccid weakness on the left side throughout,
able to move his left thumb and wiggle his toes.
Pertinent Results:
Initial labs:
___ 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:55PM ___ PTT-32.6 ___
___ 01:55PM PLT COUNT-294
___ 01:55PM NEUTS-69.0 ___ MONOS-2.3 EOS-0.9
BASOS-0.6
___ 01:55PM WBC-11.1* RBC-4.79 HGB-14.4 HCT-41.3 MCV-86
MCH-30.1 MCHC-34.9 RDW-13.3
___ 01:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:55PM URINE HOURS-RANDOM
___ 01:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:55PM ALBUMIN-4.4
___ 01:55PM ALT(SGPT)-52* AST(SGOT)-45* LD(LDH)-185 ALK
PHOS-76 TOT BILI-0.4
___ 01:55PM estGFR-Using this
___ 01:55PM GLUCOSE-99 UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 02:03PM LACTATE-1.6
___ 03:00PM HIV Ab-NEGATIVE
Discharge Labs:
___ 09:05AM BLOOD WBC-19.8*# RBC-5.02 Hgb-14.8 Hct-42.7
MCV-85 MCH-29.5 MCHC-34.7 RDW-13.5 Plt ___
___ 09:05AM BLOOD Glucose-157* UreaN-12 Creat-0.6 Na-141
K-4.5 Cl-107 HCO3-23 AnGap-16
___ 09:05AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.2
STUDIES:
TTE ___
The left atrium and right atrium are normal ___ cavity size. A
patent foramen ovale is present with premature appearance of
agitated saline ___ the left atrium. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Patent foramen ovale. No valvular pathology or
pathologic flow identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CT Head ___
IMPRESSION: 1.7-cm round lesion ___ the superior aspect of the
right frontal lobe with marked surrounding vasogenic edema and
mass effect that includes minimal leftward shift of normally
midline structures. The differential for this lesion includes
both neoplasm, primary versus metastatic, and infection
(abscess). Further evaluation with a contrast-enhanced MRI is
recommended, unless contraindicated.
MRI Head w/ constrast ___
FINDINGS:
There is a 3.8 x 3.2 x 4.0 cm (AP x transverse x craniocaudad)
rim-enhancing lesion ___ the white matter of the right frontal
lobe. Compared to the MRI performed 3.5 hours earlier, there is
increased thickness of peripheral enhancement within the lesion.
However, a nonenhancing center remains present. There is a rim
of low signal ___ the periphery of this lesion on gradient echo
images, indicating hemosiderin from blood products. There is
slow diffusion throughout the ___ this lesion, highly
suggestive of an abscess. The lesion has a small point of
contact with the anterior body of the right lateral ventricle,
but there is no subependymal contrast enhancement to suggest
ventriculitis. The frontal horn and anterior body of the right
lateral ventricle are effaced. There is extensive vasogenic
edema surrounding the lesion, and mild leftward shift of the
anterior falx, as seen previously. No additional lesions are
identified. The major arterial flow voids are grossly
preserved.
IMPRESSION:
Rim-enhancing right frontal lesion with central slow diffusion,
highly
suggestive of an abscess. Malignancy is less likely.
CT Head ___, post-op
IMPRESSION:
1. No postoperative intracranial hemorrhage.
2. Decrease ___ size of right frontal abscess with stable
surrounding edema and mild mass effect.
3. Expected postoperative pneumocephalus ___ the region of the
right frontal burr hole.
CT Head ___
IMPRESSION:
No evidence of interval change ___ the right frontal lesion or
surrounding
vasogenic edema. No new hemorrhage. MRI would be more sensitive
for
evaluation of third nerve palsy, if clinically warranted.
CT Head ___
IMPRESSION: No interval change ___ right frontal lobe lesion
with stable
degree of surrounding vasogenic edema and minimal mass effect on
the anterior falx. No interval hemorrhagic conversion.
====================
MICROBIOLOGY:
Time Taken Not Noted ___ Date/Time: ___ 6:38 pm
ABSCESS Site: BRAIN RIGHT ABSCESS.
___ AND ___ ADDED ON PER ___. ___ ___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
Reported to and read back by ___. ___ #
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
SENSI PER ___ ___ (___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 11:27 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Brief Hospital Course:
TRANSITIONAL ISSUES:
[] Monitor WBC/fever curve, if further questions regarding
antibiotics, can contact ___ clinic at ___ or to the
on-call ID fellow when the clinic is closed.
[] Staple removal on ___ or ___, to be done at rehab.
[] Monitor neurologic status
====================
___ year old right handed man who prested with headache and left
sided weakness, found to have right frontal lobe strep anginosus
abscess, operatively drained on ___. Patient had worsening
weakness after his drainage despite antibiotics, repeat head CT
showed worsening edema, so he was started on dexamethasone with
a plan for taper.
# Brain Abscess: The patient presented with an intermittent
headache that had developed the week prior to admission and
progressed to a constant headache ___ the 3 days prior to
admission. Additionally, he reported left sided weakness over
the three days prior to admission. His exam was significant for
left sided weakness ___ the upper and lower extremities ___ an
upper motor neuron pattern. A non-contrast CT head showed a
1.7cm ring-enchanicng lesion ___ the right frontal lobe that was
confirmed on MRI, consistent with abscess. A transthoracic
echocardiogram was performed that revealed evidence of a PFO.
The patient was also started on keppra 500mg BID for seizure
prophylaxis, and will need Keppra until ___. He did not
seize during his hospital stay. The abscess was stereotactically
drained on ___.
Postoperatively, the patient developed left sided hemiplegia and
anisocoria, with his right pupil larger than left. A repeat CT
head showed decrease ___ the abscess size but no interval change
___ surrounding vasogenic edema. The patient was started
empirically on vancomycin, flagyl, and ceftriaxone on admission,
and vancomycin and flagyl were stopped when the abscess culture
grew Strep anginosus.
The patient's paralysis was thought to be due to vasogenic edema
and he was started on a dexamethasone taper on ___ (4 mg QID x2
days, 2 mg QID x2 days, 2 mg BID x2, 2 mg daily x2 and then
stop). At discharge, the patient's exam was notable for left
sided hemiplegia with some movements ___ his thumb and toes. His
antibiotic regimen was narrowed to ceftriaxone 2g IV q12h until
___. He will be seen by ID as an outpatient. He did have
increased WBC on ___, thought to be secondary to
dexamethasone, but this should be monitored at the rehab to make
sure that it trends down.
# IV drug use: The patient has a history of IV drug use. His
serum tox screen at admission was negative. He was palced on a
CIWA scale at admission but did not score highly enough to
require treatment. He did not exhibit any symptoms of withdrawal
during his hospitalization and was not given his home suboxone
as he was not complaining of pain and did not complain of
withdrawal symptoms. If needed, suboxone can be restarted as
outpatient. His suboxone is prescribed by his psychiatrist Dr.
___ at ___.
# Depression: The patient has a history of depression and was
continued on his home fluoxetine 20mg PO daily.
# Agitation: patient became agitated after being started on high
dose steroids, and started on ativan prn, trazodone and
clonidine for sleep. (patient had been on clonidine prn for
sleep as outpatient). These can be continued while patient is on
steroids, but should be tapered off afterwards.
# BPH: The patient was continued on doxazosin and had no
symptoms of urinary retention during his hospitalization.
# Hepatitis C: The patient has a history of hepatitis C,
untreated. His LFTs showed slightly elevated transaminases on
admission that trended down.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. Doxazosin 4 mg PO HS
3. CloniDINE 0.1 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. Ranitidine 150 mg PO BID
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Ranitidine 150 mg PO BID
3. LeVETiracetam 500 mg PO BID Duration: 3 Days
For post-operative seizure prophylaxis. Last day ___.
4. Heparin 5000 UNIT SC TID
5. Outpatient Lab Work
CBC with Diff, Chem 7, AST/ALT: ___,
___.
Send results to infectious disease RN by fax to ___
ICD-9: 324.0
6. Doxazosin 2 mg PO HS
7. CeftriaXONE 2 gm IV Q 12H
day 1 = ___
last day = ___ (unless directed by ID physician)
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
10. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety
11. Milk of Magnesia 30 mL PO Q12H:PRN constipation
12. Senna 1 TAB PO BID:PRN constipation
13. traZODONE 50 mg PO HS:PRN insomnia
14. Dexamethasone 4 mg PO Q6H Duration: 7 Days
Day 1 = ___
Adjust according to the taper given.
15. Acetaminophen 325-650 mg PO Q6H:PRN pain or temp >100.4
16. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
17. CloniDINE 0.1 mg PO QHS
For sleep while patient is on dexamethasone.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: streptococcus anginosus abscess with left
sided motor neglect/hemiplegia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic Status: Alert, oriented to ___ and date.
Pupils 3>2, R 3.5>2. Flaccid ___ L UE, occasionally able to move
L thumb and fingers. Flaccid ___ L ___, able to move his big toe.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital with left
sided weakness and found to have a brain abscess. You were
started on antibiotics and also had surgery to drain the
abscess.
You were monitored on the neurology floor and physical
therapy/occupational therapy recommended that you go to
rehabilitation facility to regain strength on your left side.
We gave you two new medications that you will need to take after
you leave ___. You will be on ceftriaxone, an
antibiotic, for ___ weeks for treatment of your infection. You
will see infectious disease doctors to monitor your antibiotics.
They will set up 2 appointments for you over the next month and
will contact you with the details. If you have any questions,
you can call their clinic at ___.
You will also be on dexamethasone for several more days to help
with the swelling of your brain. Instructions about dosing have
been given to your rehab facility.
Followup Instructions:
___
|
19642232-DS-13
| 19,642,232 | 26,255,099 |
DS
| 13 |
2187-03-27 00:00:00
|
2187-03-30 13:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of bipolar HTN,
fatty liver who presents with dyspnea, who was referred to the
ED
from his PCP for leg swelling and elevated D-Dimer, and was
found
to have DVT and PE.
The patient initially presented to his PCP in ___ with
fatigue and shortness of breath for several weeks. Symptoms were
initially attributed to his sleep apnea.
He had a D-dimer sent as an outpatient on ___ which was
elevated. He was instructed to present to the ED for workup,
however patient declined.
The patient noted having new onset leg swelling 3 days ago.
He presented to the ED and was found to have extensive clot
burden in his right lower extremity as well as extensive
bilateral pulmonary emboli with pulmonary infarct.
The patient has never had a clot in the past. He has no family
history of blood clots. He has no known malignancy or family
history of malignancy. OF note he had a cross country road trip
2 months ago.
Past Medical History:
Bipolar Disorder
Celiac Disease
HTN
Gout
Sleep Apnea
Basal Cell Carcinoma
Fatty Liver
OSA
Angioedema/hives
Social History:
___
Family History:
No family history of VTE
Father CHARCOT ___ TOOTH
CORONARY ARTERY
DISEASE
DIABETES MELLITUS
Brother CHARCOT ___ TOOTH
Mother Living NON-HODGKIN'S
LYMPHOMA
SARCOIDOSIS
RAYNAUDS
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Per OMR
GENERAL: Well appearing, NAD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs
RESP: Clear to auscultation bilaterally.
ABDOMEN: Soft, non distended, non-tender
SKIN: Warm. normal sensation in feet bilaterally, both feet
warm.
Right leg >left leg. Ne edema in right or left ___
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 0809 Temp: 97.8 PO BP: 152/97 HR: 108 RR: 18 O2
sat: 95% O2 delivery: RA
GENERAL: Lying comfortably in bed in no acute distress.
HEENT: No scleral icterus.
CARDIAC: Normal rate and rhythm. No murmurs, rubs, gallops.
RESP: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi. No increased work of breathing.
ABDOMEN: Soft, non distended, non-tender.
NEURO: AOx3. CN II-XII grossly intact.
SKIN: Warm, well perfused. Right leg circumference larger than
left leg. No pitting edema. Non-tender to palpation. No erythema
or excess warmth.
Pertinent Results:
ADMISSION LABS
___ 02:00PM BLOOD Neuts-79.5* Lymphs-10.2* Monos-6.8
Eos-2.3 Baso-0.5 Im ___ AbsNeut-10.95* AbsLymp-1.40
AbsMono-0.94* AbsEos-0.31 AbsBaso-0.07
___ 02:00PM BLOOD WBC-13.8* RBC-4.49* Hgb-13.8 Hct-42.6
MCV-95 MCH-30.7 MCHC-32.4 RDW-12.2 RDWSD-42.4 Plt ___
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-189* UreaN-17 Creat-1.3* Na-138
K-4.6 Cl-103 HCO3-23 AnGap-12
___ 09:41PM BLOOD proBNP-70
DISCHARGE LABS
___ 05:45AM BLOOD WBC-7.9 RBC-4.34* Hgb-13.1* Hct-41.3
MCV-95 MCH-30.2 MCHC-31.7* RDW-12.4 RDWSD-43.4 Plt ___
___ 06:25AM BLOOD Neuts-69.6 Lymphs-15.2* Monos-10.8
Eos-2.8 Baso-0.7 Im ___ AbsNeut-7.21* AbsLymp-1.57
AbsMono-1.12* AbsEos-0.29 AbsBaso-0.07
___ 05:45AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-34.6 ___
___ 06:25AM BLOOD Lupus-PRESENT* dRVVT-S-1.86*
dRVVT-C-1.27* dRVVTNR-1.47*
___ 05:45AM BLOOD Glucose-104* UreaN-12 Creat-1.1 Na-144
K-4.5 Cl-108 HCO3-23 AnGap-13
___ 06:25AM BLOOD ALT-67* AST-33 AlkPhos-127 TotBili-0.2
___ 06:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3
STUDIES
___ CTA CHEST
IMPRESSION:
Bilateral pulmonary emboli extending from the left main
pulmonary artery into
the lobar and distal branches of the upper and lower lobes.
Subsegmental
pulmonary emboli in the right upper and right lower lobes.
Left-sided upper
lobe and lower lobe infarcts. No evidence of right heart
strain.
RLE ___
IMPRESSION:
1. Extensive, occlusive deep venous thrombosis in the right
lower extremity
extending from the right calf veins to the common femoral vein.
Normal color
flow is seen in the most proximal portion of the common femoral
vein.
2. No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
PATIENT SUMMARY
================
___ male with a history of bipolar HTN, fatty liver who
presents with dyspnea, who was referred to the ED from his PCP
for leg swelling and elevated D-Dimer, and was found to have DVT
and PE. He remained hemodynamically stable throughout his
hospitalization. He was started on apixaban and discharged home.
TRANSITIONAL ISSUES
===================
[] Consider getting transthoracic echocardiogram to evaluate for
evidence of pulmonary hypertension, as patient is at risk for
CTEPH
[] Found incidentally to have LFT elevation. ___ be due to
poorly controlled Celiac disease as he doesn't adhere to gluten
free diet. Given the new PE, would recommend repeat LFTs and if
persistently elevated would recommend further workup (eg
imaging) to ensure no hepatic malignancy. Discharge LFTs: ALT
67, AST 33, ALP 127 Tbili 0.2.
[] Please ensure patient up to date with age appropriate cancer
screening.
[] Recommend repeat BMP in one week. ___ that resolved,
thought to be prerenal in etiology (discharge Bun/Cr: ___
[] Patient noted to have hypertension during inpatient stay with
SBP>150. Recommend increasing antihypertensive regimen in the
outpatient setting.
[] Patient will need ongoing anticoagulation for at least 3
months for provoked DVT. Consider hematology consultation to
consider if patient should be instead classified as unprovoked
and/or need longer treatment.
[] Hypercoagulability workup pending on discharge. Please follow
up as outpatient.
ACUTE ISSUES
=============
#Subacute low-risk pulmonary embolism, provoked
Patient presented with dyspnea and right lower extremity
swelling. Had cross-country car travel in ___. Was seen by
PCP in ___ with fatigue and dyspnea, noted to have
elevated D-dimer and was referred to ED but patient declined.
Patient presented on ___ with worsening symptoms. CT evidence
of bilateral PE, ultrasound with evidence of DVT in right leg.
Most likely provoked by recent cross-country car drive given
this long period of stasis and timing that fits with this. No
personal or family history of clots. No evidence of heart strain
on CT imaging or ECG, troponin negative and BNP normal. sPESI
score of 0, low risk 1.1% of mortality. Patient was initially
started on LMWH but transitioned to apixaban prior to discharge.
Patient was hemodynamically stable throughout admission and did
not require any supplemental oxygen. APLS labs were sent during
hospitalization and still pending at time of discharge.
___
Per our records, baseline Cr of ~1.0. Cr elevated to 1.3 here.
Patient does not endorse poor PO intake and does not appear
hypovolemic. No new medications to suggest AIN. No RBCs in UA to
suggest acute GN. Received contrast with CTA, but too early to
represent contrast nephropathy. No risk factors for obstructive
uropathy. Most likely prerenal, as improved with empiric fluid
resuscitation. Possibly some element of preload dependence from
PE, which may result in hypoperfusion to kidneys. Cr improved to
1.1 on discharge.
CHRONIC ISSUES:
===============
#Bipolar Depression
Continued home bupropion, duloxetine, oxcarbazepine
#Hives/Angioedema
Continued home cetirizine. Started on prednisone taper for
ocular symptoms: ___ pred 40, ___ pred 20, ___ pred
10.
#Insomnia
Continued home lorazepam
>30 minutes spent on patient care and coordination on day of
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. DULoxetine ___ 40 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. OXcarbazepine 600 mg PO BID
6. LORazepam ___ mg PO QHS
7. Propranolol LA 80 mg PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 7 Days
2. Apixaban 5 mg PO BID
To be started after finishing 1 week of 10mg dose
3. PredniSONE 40 mg PO DAILY Duration: 1 Dose
This is dose # 1 of 3 tapered doses
RX *prednisone 10 mg 4 (Four) tablet(s) by mouth once a day Disp
#*9 Tablet Refills:*0
4. PredniSONE 20 mg PO DAILY Duration: 2 Doses
This is dose # 2 of 3 tapered doses
Tapered dose - DOWN
5. PredniSONE 10 mg PO DAILY Duration: 1 Dose
This is dose # 3 of 3 tapered doses
Tapered dose - DOWN
6. amLODIPine 5 mg PO DAILY
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. DULoxetine ___ 40 mg PO DAILY
10. LORazepam ___ mg PO QHS
11. OXcarbazepine 600 mg PO BID
12. Propranolol LA 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute symptomatic low-risk pulmonary embolism
RLE Deep Vein Thrombosis
SECONDARY DIAGNOSIS
====================
Angioedema
Bipolar Disorder
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for shortness of breath
What was done for me while I was in the hospital?
- You had a CT scan of your chest that showed blood clots in
your lungs
- You had an ultrasound of your leg that showed a blood clot in
your leg
- You were started on a blood thinner to treat the clot
What should I do when I leave the hospital?
- You should take all of your medication as prescribed
- You should keep your follow up appointments
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19642235-DS-12
| 19,642,235 | 26,183,087 |
DS
| 12 |
2173-09-23 00:00:00
|
2173-09-25 22:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Hydralazine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Bronchoscopy
___: Brochoscopy, trach change
History of Present Illness:
___ w CAD sp CABG ___, CKD, DMII, tracheal stenosis s/p
tracheostomy ___, s/p discharge on ___ after rigid bronch
___ with stoma revision, now transferred from OSH w SOB and
chest pressure found to have purulent secretions with rebronch
___ (bx, cauterzation, dilation, t-tube placement) and possible
ANCA+ vasculitis.
On discharge ___ his tube was capped and he was feeling well.
Prior to presentation he developed SOB, chest pressure, and
clear-white sputum with secretions that he couldn't clear. At
the OSH he received deep suctioning, his trach was uncapped and
put on a trach mask with humidified air, and his SOB improved
although the chest tightness remained. Pt has a history of CAD w
CABG in past, so was worked up for MI but EKG and one set of
troponins were negative per OSH ED attending. After transfer
here, he underwent rigid bronch on ___ and was found to have
thick, foul smelling secretions. Prelim gram stain shows 4+
GPCs, 1+ GNRs. He was started on Vanc, Zosyn. He has been
afebrile, HD stable.
His procedure ___ had no complications. A large amount of
abnormal appearing granulation tissue at the stoma was removed,
dilated, and sent for biopsies. A T-tube was placed. He was
given dexamethasone 5mg in OR as well as racemic epi. Of note,
he has a P-ANCA from ___ of 1:1280, as well as ___ >1:1280.
Given pulmonary disease and CKD, thoracics concerned for
Wegner's. Thoracic's, IP following. Going for repeat bronch
today
Currently, he is feeling well and breathing better without pain
at trach site, which is uncapped. He does have a sore throat and
is coughing up phlegm.
ROS: per HPI, denies night sweats, headache, vision changes,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
HLD
DM 2 w/ neuropathy, retinopathy, dx'd ___
CRF stage III since ___
Anxiety
CAD (cardiologist Dr ___ stress ___ yr ago)
laryngeal/pharyngeal mass (biopsy neg) turned out to be soft
tissue swelling s/p tracheostomy in ___
pneumonia
thrush
left arm phlebitis
dysphagia (resolved)
CABG x ___ (___)
orif fx mandible ___
trach, fiberoptic intubation, DL and biopsy ___
GERD (resolved)
Social History:
___
Family History:
Mother with COPD
Physical Exam:
ADMISSION EXAM ___:
VS - Temp 98.1 (Tm 99.5), 99/53 (90s-130s systolic), 70, 20,
97RA. FSBG 109
GENERAL - NAD, comfortable, appropriate, barely audible voice
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, trach site with pink granulation tissue
HEART - RR, nl S1-S2, no MRG appreciated but trach background
noise may obscure this
LUNGS - resp unlabored, Coarse breathsounds diffusely throughout
anterior and posterior fields without rales or wheezes
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
GENERAL - NAD, comfortable, appropriate, clear voice
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, trach site with pink granulation tissue. 1-2cm
ulcer present at lower border of trach site, aquacel in place,
minimal drainage
HEART - RR, nl S1-S2, no MRG appreciated but trach background
noise may obscure
LUNGS - resp unlabored, Coarse breathsounds diffusely throughout
anterior and posterior fields without rales or wheezes
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 04:30AM LACTATE-0.8
___ 04:25AM GLUCOSE-63* UREA N-44* CREAT-2.2* SODIUM-133
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
___ 04:25AM WBC-3.6* RBC-3.81* HGB-10.4* HCT-32.3* MCV-85
MCH-27.3 MCHC-32.1 RDW-15.6*
___ 04:25AM NEUTS-72.9* ___ MONOS-3.1 EOS-0.8
BASOS-0.7
___ 04:25AM PLT COUNT-308
Cr trend:
___ 2.2
___ 1.9
___ 2.3
___ 2.7
___ 2.6
___ 2.4
___ 2.1
___ 2.5
RHEUMATOLOGIC LABS:
___ 06:25AM BLOOD ESR-76*
___ 06:25AM BLOOD CRP-105.4*
___ 06:25AM BLOOD C3-62* C4-7*
___ 02:35PM BLOOD TYPE II COLLAGEN ANTIBODY-PND
___ 06:25AM BLOOD SM ANTIBODY- negative
___ 06:25AM BLOOD ANTI-HISTONE ANTIBODY-9.9H
___ 06:25AM BLOOD dsDNA- positive (1:80)
URINE:
___ 05:52PM URINE Hours-RANDOM Creat-92 Na-29 K-41 Cl-13
TotProt-64 Phos-70.0 Prot/Cr-0.7*
___ 05:52PM URINE Osmolal-330
___ 05:52PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:52PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:52PM URINE RBC-6* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 05:52PM URINE CaOxalX-FEW
MICRO
Blood cx ___: NG
___ 12:35 pm TISSUE TRACHEAL MEMBRANE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 4 I
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING
CT SINUS ___:
IMPRESSION: Very minimal right greater than left ethmoid and
right maxillary sinus mucosal thickening.
CXR ___:
IMPRESSION: Status post tracheostomy tube placement. Low lung
volumes with left base atelectasis.
CXR ___:
IMPRESSION: Subtle retrocardiac opacity, which could reflect
either
atelectasis or developing pneumonia. Followup radiographs may
be helpful in this regard.
LABS PENDING ON DISCHARGE:
TypeII Collagen Antibody
Brief Hospital Course:
REASON FOR ADMISSION: ___ w CAD sp CABG ___, CKD, DMII,
tracheal stenosis s/p tracheostomy ___, transferred ___ from
OSH w SOB and chest pressure found to have purulent secretions,
now s/p rebronch ___ and ___ with trach tube placement,
debridement, dilation and suspicion for ?hydralazine-induced
ANCA positive vasculitis and both upper and lower airway
infection with cultures growing MRSA and pseudamonas.
ACTIVE PROBLEMS BY ISSUE:
# Tracheal stenosis s/p tracheostomy ___. Patient is now s/p
rigid bronch ___ and rebronch ___ with cauterization of
granulation tissue, balloon dilation, and fenestrated T-tube
with visualization notable for gross airway edema. He has a
non-cuffed fenestrated tube which was capped ___. He continued
to maintain good O2 saturation on RA, both at rest and with
activity, and was tolerating 24hr capped trach at time of
discharge. His home budesonide and guaifenasin were continued.
He will continue his home nebulizer regimen with ipratropium and
albuterol. He has IP follow up on ___.
# Pressure ulcer under cap: Difficult care due to movement
around trach site. Wound care recommended saline cleaning with
aquacel ag and allevyn tracheostomy foam sponges.
# MRSA and pseudamonal PNA/tracheitis: Patient was febrile with
purulent sputum and secretions visible on bronch, growing MRSA
and pseudomonas. CXR concerning for retrocardiac pna. He was
treated with vancomycin and zosyn, which were renally dosed at
Vanc 750g q24h and zosyn 2.25 q8h to finish on ___ for which he
will get visiting infusion specialist to administer the last 3
doses.
# ANCA positive vasculitis. Patient's with airway was concerning
for a granulomatous process, and he was found to have positive
anti-MPO and antiPR3 ab, high P-ANCA ANTIBODY TITER = 1:1280,
and C-ANCA ANTIBODY TITER = 1:80 with ___ is GREATER THAN
1:1280. dsDNA positive (1:80), antiSm negative, anti-histone
stronly positive (>9.9). This is felt to be consisten with a
hydralazine induced vasulitis process, given hydralazine use at
least as far back as ___. He endorses chronic rhinnorhea, but
denies nasal crusting, otitis media, oral ulcers, sinusitis. He
also has CKD, previously diagnosed as DM, but could have GN
component. His Protein/Cr is 0.7. His C3 and C4 are low. He has
elevated ESR, CRP. He will continue on prednisone 30mg, and has
rheumatology follow up on ___. His hydralazine was d/c'd.
The only lab test pending at time of discharge was anti type II
collagen.
# Acute on Chronic kidney disease. Patient reports baseline
creatine in low 2's, which were elevated to 2.7 here. His CKD
has been diagnosed as DM, but it was thought that there could be
a glomerulonephritic component in setting of +ANCA. He has
reports of known proteinuria, and a protein/Cr ratio here was
0.7. ASA and hydralazine were stopped. A renal biopsy was
initially considered but Cr improved on prednisone, so was
deferred at the time of this hospitalization. ASA was restarted
on discharge.
# HTN. Patient's home BP meds were altered as needed during
inpatient stay. Hydralazine was discontinued as above.
# DM type II. His HbA1c ___ was 5.8, indicating good glucose
control. He was on ISS as an inpatient with restart of home
glipizide on discharge.
# CAD s/p CABG with CP on admission to OSH: He remained CP free
during this hospitalization. His initial pain was attributed to
SOB/respiratory infection, given negative EKG and trops at OSH,
nml EKG here. He had nl stress test in ___. He was continued on
home medications, however, aspirin and hydralazine were dc'd for
reasons discussed above. Aspirin was restarted on discharge.
# Leukopenia. Patient reports widely variable WBC as outpatient,
and was as low as 1.4 here. We would expect higher WBC in
setting of infection and steroids. He could also have BMS in
setting of a lupus/vasculitis process, meds (vanc), or
infection. Myelodysplastic syndrome or malignancy should remain
on differential. This should be followed up with PCP.
# HLD. Patient was found to have hyperTG and low HDL on
cholesterol panel (Total cholesterol 154, ___ 296, HDL 17, LDL
78). He should be followed for this in the outpatient setting.
# GERD. Patient was continued on home omeprazole.
TRANSITIONAL ISSUES:
-___ care - wound care
-Infusion specialist - complete course of Abx (vanc, zosyn) on
___, then d/c PICC
-f/u tracheal biopsy from ___ and ___ re-read of
tracheal biopsy with thoracic surgery
-f/u with rheumatology for possible cyclophosphamide
-f/u leukopenia with rheum and/or PCP
-___ dyslipidemia
-f/u BP given stopped hydralazine
-repeat Cr as outpatient
-f/u anti type II collagen
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluoxetine 10 mg PO DAILY
2. GlipiZIDE 5 mg PO BID
3. HydrALAzine 100 mg PO Q8H
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. NIFEdipine CR 30 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Guaifenesin ER 1200 mg PO Q12H
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation BID
12. budesonide *NF* 0.5mg/2mls Inhalation BID
13. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Medical devices
519.02 Mechanical complication of tracheostomy
Suction machine with yankauer
2. Medical devices
519.02 Mechanical complication of tracheostomy
Nebulizer machine and supplies
3. budesonide *NF* 0.5mg/2mls Inhalation BID
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Fluoxetine 10 mg PO DAILY
6. Guaifenesin ER 1200 mg PO Q12H
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Aspirin 325 mg PO DAILY
11. GlipiZIDE 5 mg PO BID
12. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation BID
13. Omeprazole 40 mg PO DAILY
14. Piperacillin-Tazobactam 2.25 g IV Q8H
RX *piperacillin-tazobactam 2.25 gram q8hours Disp #*4 Bag
Refills:*0
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY pcp ppx
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
16. NIFEdipine CR 60 mg PO DAILY
Hold for SBP < 110, HR < 60
17. Vancomycin 750 mg IV Q 24H
RX *vancomycin 750 mg daily Disp #*1 Bag Refills:*0
18. PredniSONE 30 mg PO BID
RX *prednisone 10 mg 3 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Tracheal stenosis
pneumonia
ANCA positive vasculitis
Acute on chronic kidney 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 to be involved in your care at ___. You were
transferred here with shortness of breath and found to have an
infection in your airway, which we treated with antibiotics.
Your tracheal tube was replaced, and you will need a followup
visit for monitoring (see below). You will also need to complete
your IV antibiotic course until ___, through your PICC line.
You have developed a wound surrounding your tracheal stoma site
and will require a visiting nurse for wound care and antibiotic
administration.
During your time in the hospital, your bloodwork demonstrated
that your kidney function was worse than your baseline.
Additionally, some markers of inflammation in your blood
demonstrated that you have an inflammatory condition called
ANCA+ vasculitis, which may have been a side effect of your
hydralazine which was stopped.
In terms of your medications:
Please STOP taking:
Hydralazine
Please CONTINUE:
Vancomycin (750mg IV every 24hr) and Zosyn (2.25g IV every 8hr)
until ___. At that time your visiting nurse should remove your
PICC line.
Please CONTINUE taking all your other home medications as you
had been doing prior to being hospitalized.
Instructions for ___ can be found on Page 1 of discharge
summary.
Followup Instructions:
___
|
19642235-DS-15
| 19,642,235 | 21,918,363 |
DS
| 15 |
2173-12-18 00:00:00
|
2173-12-20 12:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Hydralazine
Attending: ___.
Chief Complaint:
Lower extremity pain
Major Surgical or Invasive Procedure:
Skin biopsy of right calf
Skin biopsy of right digit
History of Present Illness:
Mr. ___ is a ___ yo M with history of HTN, CKD, hydralazine
induced vasculitis on prednisone several recent hospitalizations
for pseudomonas bacteremia, C difficile colitis and non-healing
lower extremity leg ulcers
.
The patient was recently admitted from ___ with sepsis
secondary to P. putida and C. difficile protocolitis complicated
by ATN (renal biopsy negative for vasculitis). He was treated
with a 2 week course of cefepime in addition to po vancomycin.
During that admission he was found to have several macular
petechiae on his R>L extremities with bullous lesions, biopsy
was performed which grew P. putida. Pathology from the biopsy
was notable for leukocytoclastic vasculitis with thrombosis.
Overlying bulla formation was consistent with ischemia. He was
discharged to ___ on ___.
.
IN the interim pt was transferred to an OSH for sepsis and
returned to ___ again on ___. On ___ he was evaluated by
an ID physician at his rehab facility who was concerned for
cellulitis of his ___ ulceration and tigecycline was started. He
was transferred back to ___ for evaluation on ___ in the
setting of ?expanding erythema and increasing discharge.
.
In the ED, initial VS were: 98.1 53 140/79 18 100% ra. WBC found
to be 24, lactate 2.2. Patient received Cefepime, and
intravenous and oral vancomycin. Overnight his antibiotics were
transitioned from cefepime to imipenem after review of culture
data and concern over cefepime indetermine pseudomonas.
This morning patient is feeling up beat. Over he reports that
his wounds have significantly improved over the last 8 weeks
though notes that his rehab was concerned for increasing
erythema and malodorous discharge. However he continued to
endorse significant pain in bilateral lower extremities,
especially with ambulation.
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:
# HTN
# HLD
# DM 2 w/ neuropathy, retinopathy, dx'd ___
# CRF stage III since ___
# Anxiety
# CAD (cardiologist Dr ___
# Laryngeal/pharyngeal mass (biopsy neg) turned out to be soft
tissue swelling s/p tracheostomy in ___
# CABG x ___ (___)
# orif fx mandible ___
# trach, fiberoptic intubation, DL and biopsy ___
# Hydralazine induced autoimmune syndrome
Social History:
___
Family History:
Mother with COPD
Physical Exam:
Vitals: T: 97.5, BP: 160/81, P: 84, R: 17, O2: 100% RA
General: Alert, oriented, non-toxic appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, patient has stoma that appears to be without
ulceration or erythema
CV: S1, S2, no murmurs auscultation
Lungs: CTA
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, ___ pitting edema of lower
extremities, Neuro: Strength and sensation grossly normal.
LLE: full thickness ulcer with tendon exposed; wound bed
covered by thin brown eschar. Small amount surrounding erythema,
Left heel: dry fissured ulcer 3 x 1 cm
RLE: lateral foot with full thickness ulcer, necrotic eschar
Right medial ___: full thickness 8 x 9 cm ulcer with minimal
amount necrotic tissue,
Right lateral ___ full thickness ulcer approx 3.5 x 4.5 cm, soft
black/yellow eschar
Drainage from the RLE ulcers is moderate and has a foul odor.
Pertinent Results:
Plain films of bilateral lower extremities:
MULTIPLE STUDIES OF THE LOWER EXTREMITIES
HISTORY: ___ man with non-healing ulcers. Looking for
evidence of osteomyelitis.
Following views are submitted. Five views of the right lower
leg, three views of the right foot, five views of the left lower
leg, and three views of the left foot. There is extensive soft
tissue ulceration, but no evidence of fasciitis, osteomyelitis,
or purulent arthritis.
CXR:
FINDINGS: AP upright and lateral views of the chest were
provided. Midline sternotomy wires and mediastinal clips are
again noted. There is a new right arm PICC line with tip
located in the mid SVC. There is no pneumothorax. No focal
consolidation, effusion, or signs of CHF. The heart and
mediastinal contour is stable. Bony structures appear intact.
IMPRESSION: Right arm PICC line with tip positioned
appropriately.
SPEP:
___ 05:20 NO SPECIFI1 ___ TRACE MONO2
Source: Line-PICC
NO SPECIFIC ABNORMALITIES SEEN
BASED ON IFE (SEE SEPARATE REPORT),
TRACE MONOCLONAL FREE (___) LAMBDA DETECTED
BUT BELOW THE DETECTION LIMIT OF PEP
SUGGEST REPEATING PEP IN ___ MONTHS
REPORTED BY ___, PHD;FINAL INTERPRETATION BY ___.
___, MD
TRACE MONOCLONAL FREE (___) LAMBDA DETECTED
INCREASE IN IGM IS POLYCLONAL
REPORTED BY ___, PHD;FINAL INTERPRETATION BY ___.
___, MD
Micro:
___ 3:52 pm TISSUE RIGHT LATERAL CALF BIOPSY.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) ___
@1705.
TISSUE (Final ___:
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 32 I
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): pending
Blood culture: NGTD
___ 03:25PM BLOOD WBC-24.2*# RBC-4.24*# Hgb-11.7*#
Hct-36.3*# MCV-86 MCH-27.5 MCHC-32.1 RDW-18.9* Plt ___
___ 04:35AM BLOOD WBC-25.2* RBC-3.96* Hgb-11.0* Hct-34.6*
MCV-87 MCH-27.9 MCHC-31.9 RDW-19.0* Plt ___
___ 03:59AM BLOOD WBC-18.0* RBC-3.84* Hgb-10.7* Hct-33.9*
MCV-88 MCH-28.0 MCHC-31.7 RDW-19.1* Plt ___
___ 05:20AM BLOOD WBC-15.7* RBC-3.85* Hgb-10.4* Hct-34.0*
MCV-88 MCH-27.1 MCHC-30.6* RDW-19.3* Plt ___
___ 05:54AM BLOOD WBC-14.9* RBC-3.76* Hgb-10.6* Hct-33.4*
MCV-89 MCH-28.2 MCHC-31.8 RDW-19.0* Plt ___
___ 06:00AM BLOOD WBC-12.7* RBC-3.69* Hgb-10.5* Hct-32.6*
MCV-88 MCH-28.6 MCHC-32.3 RDW-18.9* Plt ___
___ 05:01AM BLOOD WBC-12.7* RBC-3.52* Hgb-9.8* Hct-31.0*
MCV-88 MCH-27.8 MCHC-31.6 RDW-19.1* Plt ___
___ 06:45AM BLOOD WBC-11.7* RBC-3.63* Hgb-10.0* Hct-31.8*
MCV-88 MCH-27.6 MCHC-31.5 RDW-18.9* Plt ___
___ 05:31AM BLOOD WBC-11.7* RBC-3.54* Hgb-9.9* Hct-31.4*
MCV-89 MCH-28.1 MCHC-31.7 RDW-19.0* Plt ___
___ 09:48AM BLOOD WBC-14.9* RBC-3.54* Hgb-10.1* Hct-32.0*
MCV-90 MCH-28.4 MCHC-31.5 RDW-18.9* Plt ___
___ 04:35AM BLOOD ___ PTT-31.3 ___
___ 03:25PM BLOOD ESR-36*
___ 05:31AM BLOOD Ret Aut-4.5*
___ 05:31AM BLOOD Ret Aut-3.1
___ 05:31AM BLOOD QG6PD-PND
___ 03:25PM BLOOD Glucose-134* UreaN-128* Creat-3.2* Na-138
K-5.8* Cl-93* HCO3-31 AnGap-20
___ 09:48AM BLOOD Glucose-165* UreaN-56* Creat-2.2* Na-138
K-5.3* Cl-105 HCO3-25 AnGap-13
___ 03:59AM BLOOD ALT-21 AST-23 LD(LDH)-328* AlkPhos-102
TotBili-0.2
___ 06:45AM BLOOD ALT-16 AST-25 AlkPhos-73 TotBili-0.3
___ 03:25PM BLOOD Calcium-8.5 Phos-6.4*# Mg-2.3
___ 09:48AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.9 Cholest-PND
___ 05:20AM BLOOD ___ * Titer-GREATER TH
___ 03:25PM BLOOD CRP-37.5*
___ 09:48AM BLOOD Triglyc-PND HDL-PND
___ 09:48AM BLOOD %HbA1c-PND
___ 05:20AM BLOOD PEP-NO SPECIFI IgG-1058 IgA-295 IgM-271*
IFE-TRACE MONO
___ 03:53PM BLOOD Lactate-2.2*
___ 11:58PM BLOOD Lactate-1.4
Brief Hospital Course:
Mr ___ is a ___ year old gentleman with a history of DMII,
benign tracheal mass/stenosis, ESRD, hydralazine induced
vasculitis, recent hospitalization with pseudomonal bacteremia
and lower extremity ulcer infection presenting with worsening
extremity pain.
#. Non-healing leg ulcers/Lower extremity pain. On admission
patient with complaint of lower extremity pain and rehab concern
for persistent/recurrent infection. On admission, patient with
elevated WBC and malodorous/purulent discharge appreciated on
exam. Infectious disease, Vascular surgery, rheumatology and
dermatology. Patient empirically covered with IV vancomycin,
imipenem. Antibiotics were narrowed when cultures returned with
rare group B strep and pseudomonas sensitive to ceftaz. Plain
films were negative for osteomyelitis therefore decision made to
treat for two week course; end date of antibiotics: ___.
Prior to discharge, erythema of left lower extremity recurred
with WBC uptrending to 14 therefore decision made to restart
vancomycin 1000mg IV QD. First dose will need to be given at
rehab on evening of ___.
Additionally right digit biopsy consistent with neutrophilic
infiltration with concern for Pyoderma gangrenosum. Dermatology
recommended started minocycline 100mg PO BID as well as dapsone
25mg daily. G6Pd was pending at time of discharge therefore
dapsone was discontinued with plan to start with dermatology as
an outpatient
OUTPATIENT ISSUES:
[] Continue ceftazadime 1gm Q12hrs; end date: ___
[] Continue vanc 1000mg QD; end date ___
[] Check vancomycin trough on ___ (prior to 4th dose) and
redose if needed
[] Continue minocycline 100mg PO BID
[] Follow-up pending G6Pd; if negative dermatology will restart
dapsone as an outpatient
[] Continue enzymatic wound care (avoid further full surgerical
debridements)
[] Continue pain control with oxycontin 10mg BID; bowel regimen
as needed
# Pyoderma gangrenosum. Biopsy of right digit consistent with
neutrophilic infiltrate favoring PG. Dermatology recommended
started minocycline 100mg PO BID as well as dapsone 25mg daily.
G6Pd was pending at time of discharge therefore dapsone was
discontinued with plan to start with dermatology as an
outpatient
OUTPATIENT:
[] Follow-up with dermatology on ___
[] Continue minocycline 100mg PO BID
[] Follow-up pending G6Pd; if negative dermatology will resume
dapsone
# C. difficile infection, Per report patient with + C.diff at
rehab on ___ and started on PO vanc. In setting of IV
antibiotics decision made to complete extended course of PO
vanc; will plan to continue for additional 10days after
completion of ceftazidime. Throughout hospitalization patient
remained without abdominal complaint or loose stool.
OUTPATIENT ISSUES
[] Continue PO vanc 125mg Q6hrs; end date: ___
# CKD. Previous stage 3 however creatinine elevation since last
admission. Renal biopsy with e/o ESRD without notable
vasculitis. In house, renal supplementation was continued,
creatinine ranged from 2.2-2.9. K: 5.0-5.4.
On day of discharge, creatinine: 2.2, K 5.3
OUTPATIENT ISSUES:
[] Monitor electrolytes and renal function (chem 10) weekly
creatinine (start ___
# Hydralazine induced autoimmune disorder. Rheumatology was
consulted regarding continued treatment and mgmt. Patient was
continued on prednisone 30mg daily with plan to taper to 25mg
daily on ___. Plan to continue 25mg daily x1week. At that time
will downtitrate to 20mg daily. In house patient was continued
on pcp ppx, GI ppx, as well as calcium/vitamin.
OUTPATIENT ISSUES
[] Continue prednisone 25mg daily ___ downtitrate to
20mg daily thereafter
[] Follow-up with rheumatology on ___
# DM II. Patient continued lantus and ISS. Decision made to
discontinue oral medications as patient stable on insulin
regimen.
OUTPATIENT ISSUES:
[] Continue glargine daily; titrate insulin sliding scale as
needed
# CAD/HTN. Patient continued on outpatient cardiac regimen
(metoprolol, imdur, ASA); SBPs in house 120s-150s/70-80s.
Patient remained without cardiovascular complaint.
# PPX: hep sq
# Dispo: rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 7 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. GlipiZIDE 5 mg PO DAILY
3. PredniSONE 30 mg PO DAILY
until ___
Tapered dose - DOWN
4. Acidophilus *NF* (L.acidoph &
___ acidophilus) 175 mg Oral
daily
5. Aspirin 325 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO HS
7. Isosorbide Mononitrate 180 mg PO DAILY
8. Heparin 5000 UNIT SC BID
9. Magnesium Oxide 400 mg PO DAILY
10. Tigecycline 50 mg IV Q12H
last dose o n ___. Vitamin D ___ UNIT PO DAILY
12. Doxazosin 4 mg PO DAILY
13. Calcium Acetate 1334 mg PO HS
14. Atovaquone Suspension 1500 mg PO DAILY
15. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or RR < 10
16. Multivitamins 1 TAB PO DAILY
17. Calcium Acetate 667 mg PO TID W/MEALS
18. Epoetin Alfa 40,000 units SC ___ Start: HS
19. Fluoxetine 10 mg PO DAILY
20. Rhinocort Nasal Inhaler *NF* 1 spray Other BID
21. Calcitriol 0.25 mcg PO DAILY
22. Metoprolol Succinate XL 200 mg PO DAILY
hold for sbp < 100 and hr < 60
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atovaquone Suspension 1500 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Acetate 1334 mg PO HS
5. Calcium Acetate 667 mg PO TID W/MEALS
6. Doxazosin 4 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO HS
8. Fluoxetine 10 mg PO DAILY
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
10. Isosorbide Mononitrate 180 mg PO DAILY
11. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
hold for sedation or RR < 10
12. Vitamin D ___ UNIT PO DAILY
13. Minocycline 100 mg PO BID
14. Metoprolol Tartrate 100 mg PO BID
hold for sbp<100, hr<50
15. Famotidine 20 mg PO Q24H
16. Acidophilus *NF* (L.acidoph &
___ acidophilus) 175 mg Oral
daily
17. Epoetin Alfa 40,000 units SC ___
18. Magnesium Oxide 400 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Rhinocort Nasal Inhaler *NF* 1 spray Other BID
21. Glargine 7 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
22. CefTAZidime 1 g IV Q12H
23. Vancomycin Oral Liquid ___ mg PO Q6H
24. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
25. Outpatient Lab Work
Please check weekly CBC, chemistry panel (chem 10); start date
___. Silver Sulfadiazine 1% Cream 1 Appl TP BID ulcers
27. Outpatient Lab Work
Please check vancomycin trough prior to the 4th dose of
vancomycin 750mg QD. (first dose should be administered at rehab
on ___ therefore trough should be checking on ___
28. Heparin 5000 UNIT SC TID
29. Vancomycin 1000 mg IV Q 24H
please check vanc trough on ___ (prior to 4th dose)
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Pseudomonal/Group B Strep infection of lower extremity ulcers
Pyoderma gangrenosum
Hydralazine induced autoimmune disorder
Chronic Renal Insuffiency
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.
You were admitted to ___ in the setting of lower extremity
ulcers and pain. Due to concern for infection, biopsies were
performed and you were placed on broad spectrum antibiotics.
Prior to discharge, antibiotics were narrowed to
ceftazadine/vanc which you will continue for the next two weeks.
Additionally, which on IV antibiotics it will be necessary for
you to take PO vancomycin to treat/prevent recurrent C.difficile
infection.
In addition to infection, the biopsies revealed an inflammatory
process that maybe contributing to your ulcers. You were started
on two medications, minocycline and dapsone for treatment of the
inflammation. You received these medications prior to discharge
without appreciable side effect. Dermatology would like to see
you before resuming dapsone.
It will be important to follow-up with your outpatient providers
(dermatology, rheumatology) after discharge to ensure ulcers are
healing well.
Please see a list of your medications, which are attached below.
Followup Instructions:
___
|
19642259-DS-13
| 19,642,259 | 25,123,510 |
DS
| 13 |
2120-04-16 00:00:00
|
2120-04-16 08:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Haldol / Levaquin / bacitracin / Neomycin / Aminoglycosides
Attending: ___.
Chief Complaint:
Nausea, vomiting, decreased ostomy output
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of a right colectomy ___ for colonic polyps
and completion colectomy and end ileostomy for rectal cancer in
___ presented to ___ earlier today with a ___
hour history with increasing abdominal distention, lower
abdominal pain, nausea, vomiting, and decreased ostomy output.
He has not had any fevers, chills, shortness of breath, chest
pain, dysuria. At ___, a CT scan demonstrated a
small bowel obstruction and was transferred to ___ for further
management. An NGT was placed in the ED with 1200 cc of bilious
output.
Past Medical History:
PMH: polyposis (gastric, duodenal, colonic) s/p duodenal/colonic
resections, HTN, AAA s/p repair
PSH: Segmental Duodenotomy ___ ___ R hemicolectomy
ileosigmoid anastomosis (OSH remote); completion colectomy with
end ileostomy ___ CCY
Social History:
___
Family History:
non contributory
Physical Exam:
On day of discharge:
Tempt 98.3 HR 68 BP 103/60 RR 18 98% RA
Gen: alert and oriented x 3, NAD
___: RRR
Pulm: CTA b/l
Abd: s/nt/nd, ostomy functioning
Brief Hospital Course:
The patient was admitted to the surgical service for close
observation and serial abdominal exams. Initially, he was NPO,
on IVF with an NGT in place. The NGT initially put out over 1L
and he had no ostomy function. On HD 2, his NGT output
declined, he began having ostomy function and his NGT was
removed. He was advanced to a clear liquid diet. On HD 3 he
had continued ostomy output, tolerating clears without nausea or
vomiting. He was advanced to a full liquid diet and instructed
to remain on this diet until ___.
Medications on Admission:
1. omeprazole 20 mg capsule,delayed ___ Sig: One (1)
capsule,delayed ___ PO DAILY (Daily).
Discharge Medications:
1. omeprazole 20 mg capsule,delayed ___ Sig: One (1)
capsule,delayed ___ PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within ___ hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
___
|
19642259-DS-14
| 19,642,259 | 26,231,035 |
DS
| 14 |
2120-06-22 00:00:00
|
2120-06-22 14:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Haldol / Levaquin / bacitracin / Neomycin / Aminoglycosides
Attending: ___.
Chief Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right handed man with a history of
hypertension, duodenal adenoma, polyposis syndrome s/p colectomy
with ileostomy, and paroxysmal atrial fibrillation ___ years ago
not on Coumadin, who presents after an episode of losing
consciousness, with shaking of all limbs, urinary incontinence
and post-ictal confusion. This is in the context of a 6 week
history of intermittent light headedness.
He began having symptoms of "dizziness" 6 weeks ago. He
describes multiple incidences of light headedness and loss of
balance, but denies vertigo, sensations the room was spinning,
or LOC. Some times these episodes occur when he stands up
quickly, but other times they come on when he is already
standing and walking. He reports that his gait has been
unsteady, and that he cannot walk in a straight line well. He
stumbles normally to the left when he walks. He had some general
malaise and felt as if something was "wrong". He denies
presyncopal events, headache, focal weakness, tinnitus, ear pain
or fullness, or hearing loss during this time. He saw his PCP
who prescribed him meclizine, and discontinued his
anti-hypertensives, because of concern that they were
contributing to his symptoms and because he was normotensive.
In the last two weeks he describes additional symptoms. Twice in
the past 2 weeks he has experienced rapid onset numbness of his
left forearm and hand, followed several seconds later by
numbness on the left side of his tongue. Each of these episodes
lasted approximately 20 minutes. Concerning these episodes, he
denies headache, vision changes, LOC, tongue biting,
incontinence, shaking, or post-ictal confusion. He visited his
PCP again who ordered an MRI at this time that by report showed
an ischemic infarct in the right temporal-occipital region.
Yesterday, he was watching the ___ game with his sister and
niece and was socializing well when he went to the bathroom to
empty his ostomy bag. He was taking a long time in the bathroom
(approximately 15 minutes) so his family knocked on the bathroom
door to check on him, but he did not respond. They broke down
the door and found him standing in the bathroom, conscious but
disoriented and confused. He then raised his hands in the air
and screamed and then loss consciousness and fell. His sister
caught him and he only hit his right shoulder. His aunt and
niece report seeing him violently shake all of his limbs and he
had urinary incontinence. He reportedly did not bite his tongue.
EMS was called. When Mr. ___ awoke minutes later he was able
to recognize the people around him but he was confused. His
confusion persisted during the ambulance ride, approximately 20
minutes. The last thing Mr. ___ remembers is watching the
___ game, and he does not remember getting up and going to
the bathroom. The next thing he remembers is being in the
hospital.
He was taken to ___ where they got a non-contrast
head CT that showed no acute intracranial process or hemorrhage.
There is report that he had MRI brain and MRA head/neck but the
images are not available and neither the patient nor his son
believe this was done; however, someone told his son that Mr.
___ had narrowed vessels in his neck.
There is a report that the patient has a history of pAfib from
___ years ago, but I spoke to his cardiologist and he does not
note any history of atrial fibrillation. His children remember
that he fell ___ years ago and they were told he had afib at that
time, but they have not heard about it since. He has never been
on anti-coagulation. He denies recent illness, infections, or
sick contacts. He has been eating and drinking well.
On ROS (+)
HEENT: He endorses intermittent blurry vision in both eyes that
lasts 20 minutes and then disappears. On questioning he says it
is like double vision, and that the double vision resolves when
he covers one eye, but the blurriness does not. He reports pain
in the ___ the eye. This is a new symptom over the past 2
months and it occurs independently of the other symptoms.
He reports bad hearing in both ears.
PULM: He reports shortness of breath when he bends over
forwards, and mild SOB on exertion.
ABD: He had a SBO for which he was hospitalized in ___.
EXT: He reports parasthesiae and pain in his toes bilaterally.
He reports weakness in his thighs bilaterally with walking that
his limited his amount of physical activity. He also reports
cramps in his calves bilaterally after walking that recurs every
time he walks for an extended amount of time and resolves with
rest.
On neuro ROS (-), the pt denies headache, loss of vision,
dysarthria, dysphagia, vertigo, or tinnitus. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness. No bowel incontinence or urinary retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bladder habits or ostomy output. No dysuria.
Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
- Hypertension - controlled on low salt diet, without medication
- polyposis (gastric, duodenal, colonic) s/p duodenal/colonic
resections, HTN, AAA s/p repair
- Colon adenocarcinoma and polyposis s/p colectomy and ileostomy
PSHx:
- Segmental Duodenotomy ___ ___
- R hemicolectomy with ileosigmoid anastamosis (OSH remote)
- Completion colectomy with end ileostomy ___
- Cholecystectomy
Social History:
___
Family History:
Father and mother are deceased
4 sons and 3 daughters are all healthy
He has no family history of seizure disorders. No family history
of diabetes, or heart disease. He has a family history of colon
cancer.
Physical Exam:
Vitals: T: 98 P: 74 R: 16 BP: 137/74 SaO2: 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: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, ___ pansystolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, ostomy bag
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history but
has difficulty remembering recent events. Attentive, able to
name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There
were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with end gaze nystagmus ___ beats. 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: (right upper extremity limited by pain)
Normal bulk, tone throughout. No pronator drift on the left.
Slight low amplitude intension tremor No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R na ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response (withdrawal of foot b/l).
-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.
Orthostatics:
lying --> sitting --> standing
118/77 --> 132/88 --> 134/88
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Discharge Exam:
VSS
NAD, comfortable
Breathing nonlabored
MS: alert, oriented, conversing appropriately with good fluency,
comprehension, articulation and prosody
No changes. No deficits.
Pertinent Results:
ADMISSION LABS:
___ 04:45AM BLOOD WBC-5.9 RBC-3.42* Hgb-11.4* Hct-32.7*
MCV-96 MCH-33.4* MCHC-35.0 RDW-13.4 Plt ___
___ 01:25AM BLOOD Neuts-70.0 ___ Monos-6.0 Eos-0.5
Baso-0.3
___ 01:25AM BLOOD ___ PTT-28.4 ___
___ 04:45AM BLOOD Glucose-123* UreaN-15 Creat-0.9 Na-141
K-3.1* Cl-105 HCO3-27 AnGap-12
___ 04:45AM BLOOD ALT-20 AST-32 LD(LDH)-187 CK(CPK)-377*
AlkPhos-59 TotBili-0.6
___ 04:45AM BLOOD Albumin-4.1 Calcium-8.4 Phos-3.7 Mg-1.8
Cholest-156
___ 01:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RELEVANT LABS:
___ 01:25AM BLOOD cTropnT-0.08*
___ 04:45AM BLOOD CK-MB-9 cTropnT-0.04*
___ 04:45AM BLOOD %HbA1c-5.5 eAG-111
___ 04:45AM BLOOD Triglyc-110 HDL-41 CHOL/HD-3.8 LDLcalc-93
IMAGING:
MRI head ___
FINDINGS: There is no hemorrhage, edema, shift of midline
structures, or
evidence of acute infarction. No diffusion abnormality is
detected. Signal
abnormalities in the subcortical and periventricular white
matter are most
consistent with chronic small vessel ischemic disease. The
ventricles and
sulci are mildly prominent, consistent with the patient's age.
The orbits and
periorbital spaces are unremarkable.
IMPRESSION: Findings most consistent with chronic small-vessel
ischemic
disease. No evidence of acute ischemia or prior territorial
infarction.
Carotid ultrasound ___:
FINDINGS: Coarse calcific plaque involving the common carotid
arteries with
extension into the ICA and ECA bilaterally. Peak systolic
velocities on the
right are 127, 169, 102, 81 and 136 cm/sec for the proximal, mid
and distal
ICA and CCA and ECA, respectively. Similar values on the left
142, 123, 94,
71, and 94 cm/sec. There is antegrade flow involving both
vertebral arteries.
The ICA/CCA ratio is 2.0 on the right and left.
IMPRESSION: Findings as stated above which indicate
approximately 60% right
ICA stenosis, 40-59% left ICA stenosis.
TTE ___:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 0.78
Mitral Valve - E Wave deceleration time: *262 ms 140-250 ms
TR Gradient (+ RA = PASP): *35 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or
PFO by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
AR vena contracta is <0.3cm.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 3 iv
injections of 8 ccs of agitated normal saline, at rest, with
cough and post-Valsalva maneuver. Suboptimal image quality -
patient unable to cooperate.
Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). 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. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: No ASD or PFO. Normal global and regional
biventricular systolic function.
Brief Hospital Course:
Mr. ___ is an ___ yo M with hx of HTN, AAA, paroxysmal Afib,
who presents
with syncopal events on a background of several months of
lightheadedness, and discrete transient episodes of L arm/tongue
numbness.
Neurological exam is within normal limits.
On MRI, no acute ischemia or prior infarct; chronic small vessel
ischemic disease. Preliminary EEG read is of no epileptiform
activity. TTE w/bubble study is normal. No events on tele.
Carotid ultrasound is notable for bilateral carotid stenosis but
not exceeding 60%.
At this point, it is not clear what caused Mr. ___ symptoms.
He might have suffered a syncopal event, seizure or TIA. If
there was a syncopal event, it could be related to an arrhthymia
(eg pAfib), orthostatism,
or could simply reflect vasovagal syncope in the setting of
possible straining (perhaps during micturition although there
were no
witnesses during the event). Complex seizure remains
possible, especially in light of the prolonged confusion.
It is also possible
that his tongue and hand symptoms represent partial seizure
activity triggered by the ischemic focus.
We will discharge Mr. ___ home with ___ monitoring for 48
hours. If this is negative, tilt table testing should probably
be pursued.
For the carotid atherosclerosis, we would recommend medical
management with aspirin or clopidogrel at this point. However,
the decision to initiate antiplatelet therapy should be weighed
against the increased bleeding risk in this gentleman with an
extensive GI surgery history.
Mr. ___ lipid profile is: total cholesterol 156, LDL 93, HDL
41, ___ 110. We will start simvastatin 20 mg daily.
During this hospitalization, Mr. ___ was also evaluated by
occupational and physical therapy. Although rehab is not
currently necessary, he is functioning below his optimum, and we
have given prescriptions for outpatient physical and
occupational therapy.
Medications on Admission:
Omeprazole 20 mg Cap, Delayed Release (One) Capsule(s) by mouth
once a day
cholecalciferol (vitamin D3) 1,000 unit Chewable Tab
1 (One) Tablet(s) by mouth once a day
meclizine 12.5 mg tablet Oral1 tablet(s) , as needed
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Outpatient Occupational Therapy
5. Outpatient Physical Therapy
6. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Loss of consciousness: syncope vs seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were evaluated at ___ for
an episode of loss of consciousness and confusion. In the
context of your described light-headedness for the past ___ weeks,
and based on the description of the event, you were evaluated
for a stroke, stroke risk factors, seizure activity, and
syncope. You had an MRI of your brain that showed no acute or
previous stroke. We monitored your brain activtiy with EEG due
to the concern for seizures and we did not see any activity
concerning for seziures on short-term monitoring.
To assess your risk factors for stroke we ran a number of tests.
You had a carotid ultrasound to evaluate the vessels in your
neck, which showed that your right internal carotid artery is
60% stenosed and your left internal carotid artery is 40-59%
stenosed. We would not advise surgery to fix these narrowings at
this time, because you have been asymptomatic and it does not
meet the clinical standard to operate, which is 70% stenosis. If
you experience any symptoms related to your carotids such as
transient loss of vision in one eye -- then you should return to
the hospital for further evalutation. You had an echocardiogram
to assess your heart function that showed that the structure and
function of your heart are both normal. Your heart rate has been
monitored continuously on telemetry, and we have not seen any
concerning abnormalities, including atrial fibrillation.
However, as it is possible to have an abnormal heart rhythm like
atrial fibrillation transiently, we have set you up for heart
rate & rhythm monitoring via a ___ monitor. You can pick up
your ___ monitor at 3:30 pm today.
On discharge, you will continue to wear a ___ monitor for 3
days to monitor your heart rate. This will give us further
information, so that we can be sure you do not have any
irregularities in your heart rate that may predispose you to
strokes or syncope. Namely, it will look will for paroxysmal
atrial fibrillation and any other arrhythmias. You will also
have a tilt table to test to assess how well your blood vessels
react to change in position, as problems with this process can
predispose you to syncope.
Because of your carotid stenosis, we recommend that you take a
blood thinner medication such as clopidogrel (Plavix) or
aspirin. We understand that you have been told before that you
shouldn't have apirin. We will give you a prescription for
clopidogrel (Plavix). You should discuss with your other
physicians the benefits and risks of taking this medication.
Your physicians may decide that either clopidogrel (Plavix) or
an aspirin daily will be the best choice for you.
We also assessed your cholesterol. Your "bad" cholesterol is a
little high for someone who has carotid atherosclerosis, so we
will start a medication called simvastatin at 20 mg daily for
this.
On discharge please pick up your ___ monitor today at 3:30 ___
on the ___ Floor of the Deaconess ___ and attend the
appointments listed below.
It was a pleasure taking care of you, and we wish you all the
best.
Followup Instructions:
___
|
19642407-DS-5
| 19,642,407 | 20,813,798 |
DS
| 5 |
2137-08-13 00:00:00
|
2137-08-13 17:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ yo female with pmhx s/f systolic CHF w/ EF as low as
10% s/p BiV ICD placement ___ years ago with most recent echo
demonstrating EF 40-45%, 2+ MR, LBBB, HTN, CKD with baseline
creatinine 2.5 of undocumented cause, no hx of angiography
presents with SOB at 5am this morning. Pt's family had recently
halved lasix under their own discretion due to frequent pt
urination, held lasix yesterday since they did not want her to
urinate too much when they flew from ___ to ___.
Yesterday, ate high salt diet with multiple drinks and dinner at
___. Felt fine last night, but pt woke up this
morning at 5am with shortness of breath, feeling unable to
breathe, and came to Emergency Department. Family notes
increase in swelling and appearance of struggling to breathe,
audible wheezing, orthopnea. Denies chest pain, n/v.
.
In the ED, initial vitals were T96.1 P83 BP 163/79 RR 24 90% RA,
initally received combivent neb with no relief. Pt placed on
bipap for 1.5 hours with great relief, then weaned off at 10:35
am to 4L NC w/ O2 sat remaining between 94-97% 4L NC. Pt
received 325 mg PO ASA in ED, 0.4 mg SL NTG, and 80 mg IV Lasix.
240 cc urine oupt. NTG gtt infusing at 3.4 mcg/kg/min. Before
leaving ED, pt's T97.4, P 62, paced 133/43, RR 22 97%4L NC
.
On the floor, pt states she feels much better than this morning.
No complaints of SOB, lightheadedness, CP.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PACING/ICD: YES
3. OTHER PAST MEDICAL HISTORY:
TIA
Hypertension
Hyperlipidemia
Osteoporosis
CHF
Colon Cancer ___ s/p hemicolectomy ___
Pacemaker ICD placement, ___ years ago
L cataract removal ___ years ago
Social History:
___
Family History:
Non-contributory in ___ yo female.
Physical Exam:
VS: T= afebrile BP= 125/65 HR= 60 RR= 30 O2 sat= 97%
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 with JVP of 15 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Inaudible heart sounds over Mitral area
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases with
scattered wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
On Discharge:
CTA, no adventitious sounds. However, JVP still elevated to
jaw. No swelling. Pain on palpation of right
metatarsophalangeal joint. Otherwise, no changes on exam.
Pertinent Results:
On Admission:
___ 10:20AM WBC-7.0 RBC-2.98* HGB-9.0* HCT-27.5* MCV-92
MCH-30.1 MCHC-32.6 RDW-15.0
___ 10:20AM NEUTS-74.5* ___ MONOS-3.1 EOS-2.0
BASOS-0.3
___ 10:20AM GLUCOSE-118* UREA N-41* CREAT-2.9* SODIUM-141
POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
___ 05:05PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.2
___ 10:20AM proBNP-6525*
Cardiac Enzymes:
___ 10:20AM cTropnT-0.01
___ 05:05PM CK-MB-2 cTropnT-0.02*
___ 05:05PM CK(CPK)-31
BMP:
___ 07:00AM BLOOD Calcium-9.1 Phos-5.2* Mg-2.3
___ 07:00AM BLOOD Glucose-103* UreaN-53* Creat-3.5* Na-136
K-4.0 Cl-89* HCO3-37* AnGap-14
Anemia:
___ 05:40AM BLOOD calTIBC-260 ___ Ferritn-101 TRF-200
___ 10:00AM BLOOD Ret Aut-2.2
SPEP: Normal
Thyroid:
___ 05:40AM BLOOD Free T4-2.0*
___ 05:40AM BLOOD TSH-0.41
Urine:
___ 12:21PM URINE U-PEP-NO PROTEIN
Urine culture: Negative
CXR:
Moderate congestive heart failure and small right pleural
effusion.
Assessment for a left pleural effusion is limited by the
presence of an overlying pacer/AICD generator.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
___ yo female with pmhx significant for CHF w/ most recent EF
35%, but historically EF of 10% with LBBB, s/p ICD/pacer
placement with episodes of non-sustained VT placed on
amiodarone, dyslipidemia, htn, presents in acute
systolic/diastolic on chronic heart failure after stopping lasix
and engaging in high salt meal.
.
# Acute diastolic CHF: Most likely ___ to increased salt and
inadequate diuresis after holding lasix. BNP 6525. CXRay shows
pulmonary edema. Pt net negative 5.5 L while in hospital. Lost
5 kg from admission weight. Diuresed aggresively on lasix drip
and metolazone. Ambulating well without dyspnea and good O2
saturation of >95%. Transitioned to PO lasix 80 mg daily.
Previously pt was only taking 40 mg daily. This can be
uptitrated as pt is fairly diuretic resistant and may partake in
dietary discretions. Pt was informed of the ability to
uptitrate, but should at the very least, take 80 mg daily. JVP
still elevated and still coughing from time to time but more
diuresis limited by patient's worsening kidney function.
Maintain carvedilol, olmesartan, lovastatin.
.
#Rhythm:
Has pacer which is currently A-V sequential pacing. On
amiodarone 200 mg daily for non sustained VT.
.
# Renal Function: Baseline creat 2.9 on admission, now elevated
to 3.5 and stable. Initially, this was thought to be due to
poor renal perfusion ___ to poor heart function from pt's
volume; on descending portion of starling curve and high venous
pressure across renal artery and vein leading to poor renal
perfusion. However, creatinine worsened with aggressive
diuresis. Pt most likely prerenal. This is probably her new
baseline creatinine. I would be very hesitant to give back
fluids given her presentation and even though she still probably
has mild pulmonary edema as she is coughing and still has JVP
elevation, do not want to further diurese.
SPEP/UPEP negative
.
# Toe pain-Right metatarsophalangeal joint: Likely due to gout.
Uric acid elevated to 12.2. This probably resulted from
aggressive diuresis. Was given colchicine x2 with great
improvement in pain. Will discharge on topical diclofenac per
patient request as this has helped with he gout in past.
.
# Normocytic anemia: Few months ago, at HCT of 34-35, now
stable around 28.4. This is of unclear cause. Iron studies
normal, not anemia of chronic disease by labs, no evidence of
hemolysis, + stool guaiac x1 but no gross melena or hematochezia
and had hemicolectomy in past. I think this is most likely due
to her chronic kidney disease. Retic index poor at 0.6% which is
very low. There is possibility of myelofibrosis. Will leave
this at discretion of PCP whether to workup further with bone
marrow biopsy. SPEP/UPEP negative
.
# HTN:
Continue home meds. Only change was increasing lasix 80 mg.
.
# HLD: Continue home meds. No change
.
# Glaucoma:
Continue Latanoprost 0.005% 1 drop each eye QHS and Combigan
eye drops 1 drop L eye BID
.
.
Transitional: Will have labs drawn ___. See PCP on
___. Will be going to ___ over weekend. Will follow up
with doctors in ___ as well. No evidence of ischemic heart
disease as pt has never had cath--probably no need to start
aspirin given GI bleed risk.
#CODE: DNR/DNI
#CONTACT: Patient, Daughter, Granddaughter
Phone: ___
.
___ on Admission:
Benicar 20 mg Daily
Latanoprost 0.005% 1 drop each eye QHS
Combigan eye drops 1 drop L eye BID
Boniva 1 tablet monthly
Lovastatin 20 mg QHS
Amiodarone 200 mg Daily
Methocarbamol 1 QHS PRN leg cramps
Furosemide 40 mg Daily
Carvedilol 25 mg BID
Discharge Medications:
1. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime.
3. Combigan 0.2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a
day: just for LEFT eye.
4. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
5. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QHS (once
a day (at bedtime)) as needed for leg cramps.
8. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Take BID if weight gain or increase salt and fluid intake.
Disp:*90 Tablet(s)* Refills:*0*
9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
Disp:*2 units* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
13. Voltaren 1 % Gel Sig: Four (4) grams Topical four times a
day as needed for pain.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute on chronic systolic and diastolic heart failure,
Acute on Chronic Renal Failure, Gout
Secondary: Dyslipidemia, Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were found
to be in acute heart failure from stopping your lasix and eating
high salt foods. We treated this with aggressive diuresis with
lasix and metolazone. You greatly improved in your breathing
and you lost more than 10 pounds.
Your renal function worsened while you were here. This was most
likely due to aggressive diuresis. It has stabilized over the
past 24 hours. You should have close follow up of your renal
function to make sure that it doesn't worsen.
You were also found to have what is most likely an acute gouty
attack. This improved with treatment with tylenol and
colchicine.
Lastly, you were found to be anemic. Your anemia is worse now
than it was a few months ago. However, while you were here,
your anemia was stable.
The following changes were made to your medications:
INCREASED Furosemide to 80 mg daily
TAKE topical Diclofenac for your gout pain
START Albuterol as needed for shortness of breath or wheezing
Please also weigh yourself every morning and call MD if weight
goes up more than 3 lbs. You can titrate your furosemide. If
your weight starts going up or you decide to have something with
salt, you can take a pill twice a day instead of just once a
day.
Followup Instructions:
___
|
19642507-DS-9
| 19,642,507 | 28,039,112 |
DS
| 9 |
2151-07-09 00:00:00
|
2151-07-09 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
APML
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
History of Present Illness:
___ No significant PMH presented to PCP for easy bruising, found
to have pancytopenia so referred to ED, admitted to ___ service
for presumed APML
Patient noted that she has been fatigued for the past few weeks
and noted that she had easy bruising and bleeding gums. As a
result she went to her PCP where labs revealed pancytopenia so
was referred to ED. She noted that she is anxious given presumed
diagnosis, and has a left sided headache x4 hours which worsened
in the emergency department and did not improve with PO Tylenol.
She noted that she is nauseas but has not vomited.
Past Medical History:
None
Social History:
___
Family History:
Breast Cancer, Great Uncle had unknown "blood cancer"
Physical Exam:
___ 0011 Temp: 98.6 PO BP: 132/84 HR: 89 RR: 18 O2 sat: 99%
O2 delivery: Ra
Gen: Pleasant, NAD, calm but appears overwhelemed
EYES: No icterus, EOMI, PERRLA
HENT: MMM. OP clear.
CV: regular. No MRG. normal distal perfusion
LUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi.
normal RR
ABD: NABS. Soft, NT, ND.
EXT: warm and well perfused, no edema
SKIN: has large bruising on lower extremities
NEURO: A&Ox3. fluent speech
LINES: peripherals both arms
Pertinent Results:
___ 04:15PM FIBRINOGE-90* ___
___ 04:15PM ___ PTT-26.4 ___
___ 04:15PM ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+*
MICROCYT-1+* POLYCHROM-1+* OVALOCYT-1+* TEARDROP-1+* RBCM-SLIDE
REVI
___ 04:15PM NEUTS-30* BANDS-2 LYMPHS-60* MONOS-4* EOS-1
BASOS-0 ATYPS-2* ___ MYELOS-0 BLASTS-1* NUC RBCS-4.0*
OTHER-0 AbsNeut-0.54* AbsLymp-1.05* AbsMono-0.07* AbsEos-0.02*
AbsBaso-0.00*
___ 04:15PM WBC-1.7* RBC-3.39* HGB-10.4* HCT-28.4* MCV-84
MCH-30.7 MCHC-36.6 RDW-13.3 RDWSD-38.6
Brief Hospital Course:
SUMMARY:
==============================================================
___ previously healthy female who presented to her PCP for easy
bruising, found to have pancytopenia and referred to ED,
admitted to ___ service for APML and completed induction therapy
with ATRA/arsenic regimen (per Lo-Coco protocol). Throughout the
course of the induction therapy, pt initially had brief episode
of headache (most likely ___ ATRA) and also developed grade III
hepatotoxicity after 6 days of treatment. Treatment was held
until LFT normalized and pt was restarted at 50% dose reduction
and back on full dose as of ___. In addition, pt developed L
breast cellulitis with purulent discharge (culture growing S.
aureus) and pt was treated with Vanc, transitioned to PO
Bactrim, with significant improvement of symptoms.
TRANSITIONAL ISSUES:
==============================================================
[] Bone marrow biopsy results pending
[] Will need to re-establish care with a gynecologist as she
changed insurance
New meds: ATRA/Arsenic, atovaquone, acyclovir, famotidine,
prednisone
Held meds: none
Changed meds: none
#APML: Pt initially presented with fatigue, bruising and
epistaxis, and was ultimately found to have pancytopenia and
coagulopathy concerning for APML (confirmed by peripheral 15;17
PCR). Pt was started on ATRA/Arsenic (per Lo-Coco protocol). Pt
was also started on prophylaxis for differentiation syndrome,
including hydroxyurea (which was d/c'ed once WBC <~10).
Prednisone was maintained at 60 mg (0.5 mg/kg per Lo-Coco
protocol) and she was discharged with a taper. Dose reduction by
50% was needed due to hepatotoxicity on ___, but therapy was
resumed at full dose on ___. Pt was also continued on
atovaquone. Overall, pt tolerated the therapy well, except for
episode of headache initially (most likely ___ ATRA) and L
breast cellulitis as detailed below.
#Cellulitis: Pt developed L breast cellulitis with purulent
discharge and was initially started on PO Bactrim given h/o
amoxicillin/PCN allergy (MRSA/MSSA coverage, but with limited
strep coverage) and pt transitioned to IV Vanc per ID recs due
to the expanding area of erythema and immunosuppresion. US
breast was obtained to rule out abscess, which revealed
superficial fluid collection, with no need for I&D. Culture
ultimately grew coag + staph aureus. Pt was transitioned back to
PO Bactrim.
#Hepatotoxicity - Pt developed grade III hepatotoxicity after 6
days of treatment; held treatment until liver enzymes normalized
and pt was restarted at 50% dose reduction and back on full dose
as of ___. Acyclovir was briefly held i/s/o hepatotoxicity
and restarted upon normalization of LFT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MedroxyPROGESTERone Acetate Dose is Unknown IM Q3MONTHS
Discharge Medications:
1. Acyclovir 400 mg PO BID
RX *acyclovir 400 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*3
2. Famotidine 20 mg PO Q12H
RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth
twice a day Disp #*180 Tablet Refills:*1
3. Oxymetazoline 1 SPRY NU BID:PRN nosebleed Duration: 3 Days
RX *oxymetazoline [Afrin Sinus (oxymetazoline)] 0.05 % 1 spray
nasal twice a day Disp #*1 Bottle Refills:*0
4. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 6 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*0
5. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth up to three times a day Disp #*30 Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0
7. Tretinoin (ATRA, All-Transretinoic Acid) 50 mg PO Q12H
8. MedroxyPROGESTERone Acetate 150 mg IM Q3MONTHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
===================================
Acute promyelocytic leukemia
SECONDARY
===================================
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why were you admitted to the hospital?
=============================
- You were admitted to the ___ due to Acute promyelocytic
leukemia.
What was done while you were at the hospital?
=============================
- You received a chemotherapy regimen called ATRA and Arsenic
during your hospitalization.
- You had a skin infection which was treated with IV
antibiotics. You were then transitioned to an oral regimen.
Ultrasound imaging was performed and the results show that the
infection was superficial.
- You also had a series of routine lab draws during your
chemotherapy to monitor your response to the therapy.
What should you do when you leave the hospital?
=============================
- Take all of your medications as prescribed.
- Follow up with all of your physicians as directed.
Yours sincerely,
The ___ Care Team
Followup Instructions:
___
|
19642655-DS-8
| 19,642,655 | 29,043,847 |
DS
| 8 |
2145-08-01 00:00:00
|
2145-08-01 14:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
lisinopril / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Left foot drop and low back pain
Major Surgical or Invasive Procedure:
T 10-L1 laminectomy for tumor resection ___
History of Present Illness:
Patient is a ___ year old woman with history of many years of
low back pain and left foot drop for over a year who as part of
an outpatient evaluation underwent an MRI scan of the lumbar
spine which showed a large intradural lesion at the
thoraco-lumbar junction. She was called by her neurologist to go
to the ED at ___ for further evaluation. She reports no other
symptoms at this time. She does state that due to her foot drop
she has had her leg feel like it has given out on her at times.
She denies nausea, vomiting, dizziness, changes in vision,
hearing, or speech. She denies changes in bowel or bladder
function.
Past Medical History:
Depression, hypertension, history of alcoholism (over ___ years
ago), status post hysterectomy, appendectomy, surgery for fluid
in the lungs.
Social History:
___
Family History:
Mother breast cancer, father unknown history, brother CVA
Physical ___:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Decreased sensation on left dorsal, lateral, and
medial foot. Sensory loss is most significant at left medial
aspect of foot. Otherwise intact to light touch bilaterally
Rectal exam normal sphincter control
On discharge:
___:
AAO x 3, pleasant. Sutures CDI. Some blistering noted in
inferior portion of wound, but overall intact.
Upper extremity strength ___.
Lower extremity:
D B T WE WF IP Q H AT ___ G
Pertinent Results:
___ MR head with and without contrast:
No focus of abnormal enhancement in the brain parenchyma or
meninges.
A few small nonspecific cerebral white matter changes, may
relate to small vessel ischemic changes, postinflammatory
sequela etc. Correlate clinically for risk factors.
Slightly hypointense marrow signal, can relate to cellular
marrow.
Correlate with hematology labs for anemia, systemic disease,
myeloproliferative or infiltrative changes.
___ MR ___ spine with and without contrast
Numbering used for the present study shown on series 4, image 3,
based on
counting from C2 downwards with possibility of transitional
anatomy at the lumbosacral region.
This is different from the one used on the recent MRI L-spine
study.
Based on this numbering,
1. At T11 and T12 levels, an ovoid heterogeneous lesion, in the
spinal canal, likely partly intramedullary as the conus cannot
be identified separate from this lesion as described above;
displacement of the cauda equina nerves with some crowding.
Possibilities include intramedullary the lesion such as
ependymoma,
astrocytoma, metastases, paraganglioma, etc; however, there is
also less
likely possibility of extramedullary lesion such as schwannoma
based on some images. No other foci of abnormal enhancement
noted in the spinal cord in the cervical or thoracic regions.
2. Multilevel, multifactorial degenerative changes in the
cervical, thoracic and lumbar spine as described above.
Mild canal narrowing at C3-4, C4-5, C5-6 levels.
Mild to moderate foraminal narrowing also noted at multiple
levels on the
axial images with disc, uncovertebral and possible facet
changes.
Mild multilevel degenerative changes in the thoracic spine.
L-spine:
L3-4: Bilateral moderate foraminal narrowing
L4-5: Mild canal and Moderate to severe right and mild to
moderate left
foraminal narrowing
3. Renal cysts, inadequately assessed.
4. Tortuous left cervical internal carotid artery indenting the
left side of the oropharynx
5. Multiple small nodes in the neck, some of which are mildly
prominent
however inadequately assessed as not targeted. Correlate
clinically and if necessary consider dedicated imaging for
better assessment.
___ CT chest
Indeterminate subcentimeter pulmonary nodules, measuring up to 4
mm in the left lower lobe. Short interval follow-up is
recommended.
Right lower lobe predominant ground-glass opacities, septal
thickening and pleural thickening, which may be posttraumatic in
nature given the associated old healed right posterior ninth rib
fracture.
Abnormal soft tissue in the spinal canal at T11-T12 corresponds
to the
patient's known intradural tumor.
___ CT abdomen/pelvis with contrat
1. No evidence of metastatic disease in the abdomen or pelvis.
2. No vertebral osseous changes adjacent to the spinal mass.
3. Incidental findings suggestive of mild chronic colitis
involving the
proximal ascending colon and cecum. If the patient is
asymptomatic, these
findings may not be clinically significant. Correlation with
prior
colonoscopies is suggested.
___ CT Tspine
1. Status post T10-L1 laminectomy with resection of intradural
mass. Expected postoperative changes are present. No abnormal
fluid collection or postoperative complication identified.
2. Small bilateral pleural effusions with adjacent atelectasis.
___ MRI T/L spine
1. Interval postoperative changes of T10 through L1 laminectomy
with removal of previously described spinal mass.
2. Associated postoperative fluid collections at the laminectomy
sites, with small foci of air, which communicate with the
epidural space and narrow the spinal canal, likely due to
postoperative fluid collection or
pseudomeningocele. . There is anterior displacement of the
spinal cord with increased signal at the T11-12 level which
could be secondary to myelomalacia
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service on ___ for
further work-up of her T11-12 spinal mass. She was ordered for
a CT scan of the chest, abdomen and pelvis to rule out any
metastatic disease. She was admitted the neurosurgery inpatient
ward where she could be closely monitored. Her home medications
were administered and she was given a diet. Physical therapy
was consulted due to safety concerns secondary to her left foot
drop.
On ___, The patient went to the OR with Dr ___ a T 10-L1
laminectomy for intradural mass resection. The patient was taken
to the icu post operatively for q 1 hour neurological
assessment. The patient was given 10 mg decadron
intraoperative. Post operatively the patient was started on
Decadron 4 mg TID. The patient was placed on flat bed rest for
48 hours. A CT of the Thoracic spine was performed and was
consistent with expected post operative changes .
___ Patient was neurologically stable on examination. She was
transferred from the ICU to the floor. She continues on flat
bedrest. She continues on a decadron taper.
On ___ Patient's head of bed was slowly elevated. Her pain was
well controlled.
On ___ Patient's activity was advanced. ___ evaluated the
patient. Her foley was discontinued.
On ___, ___ recommended rehab and she was screened for rehab
placement.
Mrs. ___ continued to recover well. Based on physical
therapy's evaluation, the patient would benefit from a short
stay in a rehabilitation facility to regain her strength. She
was discharged to rehab on the afternoon of ___. She was
afebrile, hemodynamically and neurologically stable. Per the
discharge instructions, the patient should follow up with Dr.
___ in BTC (Neuro-oncology) clinic at the appointment
provided.
Medications on Admission:
Amlodipine 10mg QD, Atenolol 50mg QD, Losartan 25mg QD,
Paroxetine 30mg QD
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Amlodipine 10 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY
5. Dexamethasone 2 mg IV Q12H Duration: 24 Hours
6. Dexamethasone 2 mg IV DAILY Duration: 24 Hours
7. Famotidine 20 mg PO BID
8. Gabapentin 300 mg PO Q8H
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Losartan Potassium 25 mg PO DAILY
12. Paroxetine 30 mg PO DAILY
13. Senna 8.6 mg PO BID
14. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Spinal intra-dural mass, schwannoma
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:
Spine Surgery
Dr. ___
o Do not smoke.
o Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery ___.
o Dressing may be removed on Day 2 after surgery.
o No pulling up, lifting more than 10 lbs., or excessive
bending or twisting.
o Limit your use of stairs to ___ times per day.
o Have a friend or family member check your incision daily
for signs of infection.
o Take your pain medication as instructed; you may find it
best if taken in the morning when you wake-up for morning
stiffness, and before bed for sleeping discomfort.
o Do not take any medications such as Aspirin unless
directed by your doctor.
___ Unless you had a fusion, you should take Advil/Ibuprofen
400mg three times daily
o Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
o Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
o Pain that is continually increasing or not relieved by
pain medicine.
o Any weakness, numbness, tingling in your extremities.
o Any signs of infection at the wound site: redness,
swelling, tenderness, and drainage.
o Fever greater than or equal to 101° F.
o Any change in your bowel or bladder habits (such as loss
of bowl or urine control).
Followup Instructions:
___
|
19642783-DS-19
| 19,642,783 | 27,085,088 |
DS
| 19 |
2120-03-20 00:00:00
|
2120-03-20 12:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Right hand numbness and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old right handed gentleman with a
history of HIV diagnosed ___ years ago, last CD4 ct 3 ___ ago
was around 500 per report, also with questionable history of
hypertension, who presents with right hand and forearm numbness
and weakness since this morning at 08:00 am.
He was awake all night, and overnight took "G"
(gamma-hydroxy-butyric acid), and this morning at 7am, he
injected crystal meth into his right upper arm (pointed to the
area between biceps and triceps, slightly below the deltoid). He
used the usual supply and the usual quantity, as he injects
himself every week. One hour later, he tried to pick something
up and felt that he was unable to make a grip and tightly hold
the object. The symptoms did not improve throughoutt the day,
and he presented to the ED in the afternoon for further
evaluation. He did not have a facial droop or facial numbness,
but reported that his hand and his distal forearm felt "funny",
as if heavy. A stroke code was called.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HIV dx ___ years ago, last CD4 count 3 months ago was >500, and
viral load was undetectable.
- Reports mild hypertension.
- History of a cervical vertebral "dislocation" years ago, s/p
surgical repair.
Social History:
___
Family History:
Negative for hypercoagulability and strokes in young family
members.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score was 1
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0 (not given the point because was able
to
maintain his arm extended for at least 10 seconds. He does have
weakness however on exam, please see below)
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. 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 and write without difficulty. Speech was not
dysarthric.
Able to follow both midline and appendicular commands. The pt.
had good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick and cold
sensation.
VII: No facial droop, facial musculature symmetric. (ED
attending
concerned for right facial droop, which i did not see on my
exam.
patient activates muscles symmetrically).
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. There is a very mild
pronation without clear drift on the right, but no orbiting
around the right arm or the right index finger.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 5 5 5 5 5 5 5
5 5
R 5 ___ 4 4 4 4 5 5 5 5
5 ___nd flexion, as well as finger
flexion/extension,
thumb flexion/extension, finger adduction and abduction all ___.
-Sensory: Has decreased sensation to light touch, pinprick, cold
sensation and vibration in a glove distribution on the right,
more prominent on the palmar surface, likely in a C6 and C7
dermatome area, but also not sparing part of the C8 area. Dorsum
of hand and forearm had almost normal sensation.
He had normal proprioception in all extremities, and had normal
graphestesia and object recognition on the right.
___ and ___ tests were checked and were negative.
-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.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
___ 05:30AM BLOOD WBC-6.6 RBC-4.85 Hgb-14.9 Hct-44.4 MCV-92
MCH-30.7 MCHC-33.5 RDW-12.7 Plt ___
___ 05:30AM BLOOD Plt ___
___ 02:20PM BLOOD ___ PTT-29.2 ___
___ 05:30AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-137
K-4.3 Cl-100 HCO3-30 AnGap-11
___ 05:30AM BLOOD Calcium-9.4 Cholest-PND
___ 05:30AM BLOOD %HbA1c-5.8 eAG-120
___ 02:28PM BLOOD Glucose-83 Na-138 K-4.7 Cl-100 calHCO3-27
IMAGING STUDIES:
CTA Head / Neck
IMPRESSION:
1. There is no evidence of acute intracranial process.
2. There is no evidence of vascular stenosis, dissection, or
aneurysms.
3. Multilevel degenerative changes throughout the cervical
spine with
interbody fusion at C6/C7 level.
MRI Brain PENDING
Brief Hospital Course:
Neurologic:
On presentation, Mr. ___ was noted to have paresthesias from
the thenar eminence to the dorsal aspect of the right hand, with
weakness in the extensor muscles from the wrist to the distal
digits. One day later, weakness was still present but per the
patient's account and our examination, his strength has improved
from 4+ to 4+, 5- on a 5-point scale. The patient declined
working with ___ for further strengthing.
Psychologic:
After speaking to the patient's PCP/Psychiatrist, Dr. ___,
___ noted his presentation secondary to drug abuse has been an
issue for over ___ years, suggested setting up rehabilitation
services which the patient subsequently refused. On his
discharge information, the patient was provided with information
to contact the ___ Program which deals
specifically with rehabilitation for the LGBT community.
Medications on Admission:
1. Atorvastatin 10 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Lopinavir-Ritonavir 2 TAB PO BID
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Lopinavir-Ritonavir 2 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right Radial Nerve Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were treated at the ___ for
right hand weakness and numbness which began on ___ in the
morning. CT and MRI studies were performed which noted no
intracranial pathology, which means the likelihood of a stroke
or blood clot causing these symptoms is low.
We also spoke with your outpatient physician ___ we
updated with respect to your ___. Dr. ___ was able to help
us address your request for rehabilitation services,
recommending the ___ Triangle Program which per your
request can be contacted as an outpatient via the following
number ___.
Followup Instructions:
___
|
19642952-DS-5
| 19,642,952 | 23,290,974 |
DS
| 5 |
2122-08-21 00:00:00
|
2122-08-21 15:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust
Attending: ___.
Chief Complaint:
Dizziness, Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male who presents with dizziness and anemia from
___ clinic. The patient is referred over for 1
month of dizziness and conern for anemia. The acuity of the
anemia is somewhat questionable, given that in OMR the
hematocrit on presentation is unchanged from his discharge last
___, and when same-day comparisons between atrius' and our
hematocrits are so markedly different (all cell lines) it is
hard to compare.
The patient underwent a TURP on ___ and since then has been
dizzy, and having hip exertional pain when ambulating. He states
he used to be able to walk blocks, but now can only walk a block
without stopping. The dizziness is only when getting up from a
chair and then resolves if he sits again.
In clinic they had drawn labs and demonstrated a marked drop in
his hematocrit, although here at ___ his labs are constistent
with his prior ___ labs. Of note his prednisone was tapered
from 60 to 10mg since ___ for his giant cell arteritis.
Past Medical History:
DM (diabetes mellitus), type 2 with ophthalmic complications
Prostatic hypertrophy, benign
HYPERCHOLESTEROLEMIA
Hearing loss, sensorineural
DIABETIC RETINOPATHY
SCREENING FOR COLON CANCER
HERNIA - VENTRAL, UNSPEC
RHEUMATIC FEVER
SCREENING FOR CARDIOVASC DISEASE
HORNER'S SYNDROME, UNSPEC
NEAR SYNCOPE
Obesity
Macular degeneration (senile) of retina
Cataract
Amblyopia
Advance directive discussed with patient
___
Vitamin d deficiency
PMR (polymyalgia rheumatica)
Hearing loss
DISH (diffuse idiopathic skeletal hyperostosis)
Giant cell arteritis
Screening for osteoporosis
Social History:
___
Family History:
Father - throat cancer
Uncle - DM
___ - Unknown Type
Father Cancer
Physical ___:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.2, 116/57, 72, 18, 98%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, 1+ edema
NEURO: CAOx3, Left ptosis, motor ___ ___ Spread
flex/ext
Pertinent Results:
___ 07:50AM BLOOD WBC-7.4 RBC-3.10* Hgb-7.2* Hct-24.6*
MCV-79* MCH-23.1* MCHC-29.1* RDW-14.9 Plt ___
___ 06:50PM BLOOD WBC-7.4 RBC-3.22* Hgb-7.4* Hct-26.2*
MCV-82 MCH-23.1* MCHC-28.3* RDW-15.0 Plt ___
___ 06:50PM BLOOD Neuts-72.6* ___ Monos-6.6 Eos-1.0
Baso-0.3
___ 07:50AM BLOOD ESR-22*
___ 06:50PM BLOOD Ret Aut-1.9
___ 07:50AM BLOOD Glucose-241* UreaN-14 Creat-0.8 Na-140
K-4.8 Cl-102 HCO3-28 AnGap-15
___ 06:50PM BLOOD Glucose-220* UreaN-16 Creat-0.8 Na-138
K-4.6 Cl-102 HCO3-25 AnGap-16
___ 06:50PM BLOOD LD(LDH)-172 CK(CPK)-38*
___ 06:50PM BLOOD cTropnT-<0.01
___ 06:50PM BLOOD proBNP-187
___ 06:50PM BLOOD Iron-12*
___ 06:50PM BLOOD calTIBC-413 Hapto-259* Ferritn-8.2*
TRF-318
___ 07:50AM BLOOD CRP-7.1*
Brief Hospital Course:
Mr. ___ is an ___ with history of giant cell arteritis,
polymyalgia rheumatica, diabetes, and recent TURP presenting
with anemia and possible claudication.
1. Iron Deficiency Anemia
Patient was found to have HCT 26% at ___ which was below their
baseline, though prior HCTs at ___ were in a similar range.
Referred given concern for bleeding, though no evidence on exam,
guaiac negative in ED. Was found to have a ferritin 8, with
reticulocyte index 0.58 suggesting profound iron deficiency
anemia. The patient was given iron IV and was started on folate,
B12, iron po, and vitamin C. Patient was continued on his bowel
regimen given the iron supplementation.
2. Possible Claudication
Patient reporting bilateral hip pain with exertion for the past
few weeks since his surgery. Unclear etiology, though thought to
be PMR in the setting of reduced prednisone dose for surgery
(from 40mg to 10mg dialy). Exertional component was somewhat
unusual and may represent peripheral vascular disease given
comorbidities, though lower extremity pulses were strong on
exam. Patient was discharged on increased dose of prednisone.
3. Dizziness
This is most likely due to his iron deficiency anemia, and given
low ESR and mildly elevated CRP (note these are also quite
different between ___ and ___ labs by a factor of 3 for CRP)
this is unlikely flair of his arteritis. There was no concern of
stroke/TIA, and the chronicity makes this more of a chronic
issue than an acute inpatient workup.
4. Type 2 Diabetes Uncontrolled without complications
The patient was continued on home glarine. Oral hypoglycemics
were held during his stay, though restarted on admission.
Patient was encouraged to share ___ glucoses from home with his
PCP given the increased dose of prednisone and likely resultant
hyperglycemia.
5. Positive UA
Patient was found to have 3+ leukesterase on ___ urinalysis.
Possibly represents cystitis, though patient is asymptomatic. A
digital rectal exam was performed and was without tenderness or
induration suggestive of prostatic abscess or infection in
setting of recent prostate surgery.
6. BPH without obstruction
Patient was continued on home finasteride.
7. Hyperlipidemia
Patient was continued on home simvastatin.
TRANSITIONAL ISSUES
-consider ABIs given unclear claudication symptoms, as above
-discuss home fingerstick glucoses, sugars may be elevated in
setting of prednisone use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
2. Finasteride 5 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
7. Acetaminophen 650 mg PO Q4H:PRN fever, pain
8. Docusate Sodium 100 mg PO BID
9. Senna 17.2 mg PO HS
10. Glargine 23 Units Bedtime
11. GlipiZIDE XL 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Glargine 23 Units Bedtime
6. PredniSONE 40 mg PO DAILY
7. Senna 17.2 mg PO HS
8. Simvastatin 20 mg PO QPM
9. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. GlipiZIDE XL 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
13. Ferrous Sulfate 325 mg PO BID
Please take with vitamin C to increase the absorption of this
medication.
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
14. Ascorbic Acid ___ mg PO BID
Please take with iron pill.
RX *ascorbic acid ___ mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
15. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Iron-deficiency anemia
Secondary diagnosis:
Polymyalgia rheumatica
Diabetes mellitus, type II uncontrolled on insulin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were admitted to the hospital after your blood
counts were found to be low and you were having pain in your
hip. Your low blood count is likely due to low iron. In the
hospital, you received IV iron. Your primary doctor ___
continue to follow your blood counts. With regard to your hip
pain, this is most likely secondary to your chronic inflammatory
disease and may improve with increased prednisone.
Please follow-up with your primary doctor, appointment
information is below.
You may find that your blood sugars are increased for the next
few days. Please monitor and discuss with your primary doctor.
It was a pleasure participating in your care, thank you for
choosing ___!
Followup Instructions:
___
|
19643038-DS-18
| 19,643,038 | 25,486,533 |
DS
| 18 |
2161-03-17 00:00:00
|
2161-03-18 09:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Cephalosporins / Keflex
Attending: ___
Chief Complaint:
Hypercalcemia, Anemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of ESRD ___ HTN and FSG s/p SCD renal transplant on
___, diabetes, and secondary hyperparathyroidism on
cinacalcet presents as a transfer from ___ after
being found at home with an altered mental status and
hypercalcemia. Reportedly, he was last seen well on ___
___. Wife reports that he's been in his bedroom over the past
several days, has not been showering or eating, and has had
increased confusion with difficulty following commands. CT head
was negative at OSH and labwork was significant for an elevated
calcium at 14.7. He was given IVF and calcitonin prior to
transfer.
Pt does have reported hx of hypercalemia and has been treated
with cincalcet in the past. He was recently admitted to ___ in
early ___ for anemia and unknown viral illness.
In the ED, initial VS were 99.2 99 115/69 18 98% RA
VS prior to transfer were 98.5 73 120/76 21 99% RA. On the
floor, he is alert and oriented but his speech is tangential.
Review of Systems:
Otherwise negative in detail
Past Medical History:
ESRD (home HD via left brachiobasilic fistula) ___ HTN and
focal segmental glomerulosclerosis
anxiety
vertigo
toxoplasmosis antibodies
Hx of malaria
Hx of alcohol abuse
Social History:
___
Family History:
Father with hypo-osmolar DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- 98.1 143/78 78 18 100% RA
General- Alert, oriented, tangential speech and somewhat
paranoid
HEENT- Sclera anicteric, dry MM, 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, III/VI systolic
murmur throughout
Abdomen- soft, non-tender, non-distended, bowel sounds present.
well healed surgical scar, transplanted kidney nontender
Rectal- deferred
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Patient is slightly confused, but follows commands, alert and
oriented x3, speech tangential
DISCHARGE PHYSICAL EXAM:
========================
VS - 99.1 114/74 78 18 100%RA
General: AAOx3. NAD. Answers promptly & appropos to questions.
HEENT: NCAT, clear OP, MMM
CV: II/VI SEM best heart at LUSB, RRR
Lungs: CTA b/l, no w/r/r
Abdomen: Soft, NT, ND, +BS
GU: no Foley
Neuro: face symmetric, moves all 4 limbs appropriately
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:35AM BLOOD WBC-5.0 RBC-3.93* Hgb-9.5* Hct-30.0*
MCV-76* MCH-24.2* MCHC-31.7 RDW-17.0* Plt ___
___ 12:35AM BLOOD Neuts-76.6* Lymphs-14.3* Monos-5.3
Eos-3.1 Baso-0.7
___ 12:35AM BLOOD Glucose-116* UreaN-30* Creat-1.5* Na-133
K-3.8 Cl-98 HCO3-22 AnGap-17
___ 12:35AM BLOOD Albumin-4.6 Calcium-13.7* Phos-2.2*
Mg-1.9
PERTINENT LABS:
===============
___ 10:40AM BLOOD PTH-58
___ 03:45PM BLOOD PTH-60
___ 12:35AM BLOOD 25VitD-15*
___ 10:40AM BLOOD rapmycn-20.2*
___ 05:05AM BLOOD rapmycn-8.2
___ 11:00AM BLOOD Ret Aut-1.0*
___ 05:30PM BLOOD calTIBC-189* Ferritn-1024* TRF-145*
___ 05:30PM BLOOD PEP-NO SPECIFIC ABNORMALITIES SEEN
___ 10:01PM URINE U-PEP-NO PROTEIN DETECTED
NEGATIVE FOR ___ PROTEIN
DISCHARGE LABS:
===============
___ 06:29AM BLOOD WBC-3.9* RBC-2.98* Hgb-7.4* Hct-22.6*
MCV-76* MCH-24.9* MCHC-32.8 RDW-17.5* Plt ___
___ 06:29AM BLOOD Glucose-91 UreaN-9 Creat-1.2 Na-135
K-3.1* Cl-102 HCO3-27 AnGap-9
___ 06:29AM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.0* Mg-1.6
MICROBIOLOGY:
=============
UCx No Growth
BCx x2 NGTD
IMAGING:
========
___ Renal U.S.: IMPRESSION:
1. Interval increase in size of transplant kidney with mild
fullness of the renal calyces and scant amount of surrounding
fluid. No frank hydronephrosis or significant perinephric
collection identified.
2. Transplant kidney vasculature is patent and normal.
Brief Hospital Course:
___ PMHx ESRD s/p renal transplant ___, DM, HTN, secondary
hyperparathyroidism, presents with altered mental status and
hypercalcemia, also found to be anemic.
ACTIVE ISSUES:
==============
# Hypercalcemia/AMS: Ca ___, Albumin 4.6 on admission. He was
given IVF for 48hrs, with improvement in his calcium level to
10.2 (corrected), and correction of his altered mental status.
His albumin level also fell to 3.1; as his values were
consistently 3.1-3.4, this may represent his true albumin
baseline. His PTH was measured twice for question of progression
to tertiary hyperparathyroidism, returning at 58 and 60. (For a
calculated eGFR of 59, his goal PTH is between 35 and 70pg/mL,
so his values here are at goal). His Vitamin D level, which had
been 15 - 24 in the past, again returned low at 15 (goal ___.
He is not on Vitamin D replacement therapy, but given his marked
hypercalcemia and within-goal PTH, he was not started on Vitamin
D supplementation. He was on cinacalcet as an outpatient; it is
not clear if he missed doses while mentally altered. He was
restarted on this medication here. For marked hypercalcemia in
the absence of elevated PTH, PTHrP and SPEP/UPEP were sent.
SPEP/UPEP were negative. PTHrP was pending on discharge.
# Anemia: Progressive microcytic anemia here, most likely with
substantial hemodilutional component. However, he has been iron
deficient in the past, so repeat iron studies were sent, which
returned most consistent with an anemia of inflammation, to be
expected in this patient s/p renal transplant. He was started on
Epogen before discharge, and will continue this medication as an
outpatient. He was highly recommended to follow-up with a
Hematologist for further evaluation and management of his
anemia.
# End-Stage Renal Disease due to Hypertension and Focal
Segmental Glomerulosclerosis, s/p Renal Transplant ___:
Creatinine was 1.2 on discharge, better than recent baseline
1.6-1.7. He was continued on his home sirolimus, mycophenolate
mofetil, as well as prophylaxis with Bactrim and fluconazole
(the latter for a positive histoplasmosis antigen in the past).
CHRONIC ISSUES:
===============
# Hypertension: Continued home cardedilol.
# Diabetes: Continued home basal-bolus insulin.
TRANSITIONAL ISSUES:
====================
# Hypercalcemia: Not on Vitamin D supplementation. Also, PTHrP
pending on discharge.
# Anemia: In-hospital iron studies consistent with anemia of
inflammation. On daily iron supplementation as well as MWF
Epogen. Recommended to follow-up with ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Carvedilol 12.5 mg PO BID
2. Cinacalcet 60 mg PO TID
3. Ferrous Sulfate 325 mg PO TID
4. Fluconazole 200 mg PO Q24H
5. Glargine 10 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Mycophenolate Mofetil 1000 mg PO BID
7. Sirolimus 2 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Ascorbic Acid ___ mg PO BID
10. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Carvedilol 12.5 mg PO BID
3. Cinacalcet 60 mg PO TID
4. Fluconazole 200 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Glargine 10 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Mycophenolate Mofetil 1000 mg PO BID
8. Sirolimus 2 mg PO DAILY
Daily dose to be administered at 6am
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Outpatient Lab Work
Please Draw: Weekly labs starting ___ at the ___
___. Please check CBC, Chem10, Albumin.
ICD-9:V42.0
12. Epoetin Alfa 4000 UNIT SC QMOWEFR
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypercalcemia and Altered Mental Status
Secondary: s/p Deceased Donor Kidney Transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___. You were admitted for altered mental status,
thought most likely due to your hypercalcemia. You received IV
hydration while here, with resolution of your elevated
hypercalcemia. The renal physicians commenced an evaluation of
your hypercalemia, that will be completed and reviewed with you
as an outpatient.
You were noted to be anemic while in the hospital, but your
hemoglobin and hematocrit were stable, and you did not have
evidence of bleeding. It is thought that your anemia reflects
your body's reaction to chronic inflammation. Should you develop
a bleed, please return to the hospital for evaluation. You will
be scheduled for Epo injections as an outpatient as well.
You will need to have labs drawn on a weekly basis. Please check
labs weekly at the ___ Renal ___ starting on
___.
Please see below for your appointments and medications. Again,
thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19643089-DS-18
| 19,643,089 | 29,106,236 |
DS
| 18 |
2119-03-18 00:00:00
|
2119-03-18 15:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubated ___
Extubated ___
History of Present Illness:
This patient is a presumed ___ year old male with unknown history
who presented with acute agitated, intubated ___ the setting
acute
agitation.
Per EMS report, "at ___ with erratic behavior, rambling,
pressured speech, agitated." Patient presented agitated and
incoherent and intubated quickly.
___ the ED, he was quickly intubated and sedated. No further
history obtained. However notably, patient had dextromethorphan
and Chlorpheniramine ___ blister packs ___ his belongings.
Initial Vitals: T97.5 HR 130 BP 143/93 RR 18 96% RA
Exam:
-Agitated, CN11-12 intact, no clonus present
Labs:
CBC: WBC 12.2 Hgb 15.2 Plt 313
ETOH 127
Chemistry: Na 144, K3.6 BUN 13 Sr Cr 1.1
O2 sat 97%
pH 7.36 pCO2 45 pO2 246
Utox:
Urine Benzos Pos
Urine Opiates Pos
Urine Cocaine Pos
Serum tox: negative
Imaging:
CXR ___:
The pulmonary vasculature is normal. Lung volumes are low.
Mild
patchy opacities are noted ___ the lung bases likely reflective
of
atelectasis, without consolidation.
Consults: None
Interventions:
-Intubated, sedated
-Haloperidol
-Lorazepam
-NS IVF
-Propofol
-Dilaudid 0.5mg
VS Prior to Transfer: 98.8 HR92 BP136/86 97% intubated
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Anxiety
Bipolar 1 disorder
Depression
Schizophrenia
Multidrug coingestions (cocaine, alcohol, BDZ, opiates,
dextromethorphase and chlorpheniramine containers/pill packs,
anticholinergics)
*First contact with psychiatry ___, has had several evaluations
___ this region including several inpatient admissions (>10)
*Has history upon discharge from a facility to return to the
street and doesn't take his medication or engage ___ on-going
treatment
*Treatments tried: thorazine, clonidine, zyprexa, sertraline
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed ___ metavision
GEN: intubated, sedated
HEENT: Pupils equal ___ size, dilated, minimally reactive
NECK: No JVD
CV: RRR, no murmurs appreciated
RESP: ROnchorous breath sounds bilateral
GI: Abdomen soft, non distended, normoactive bowel sounds
MSK: No obvious rashes, trauma
SKIN: No obvious skin breakdown
NEURO: No focal neurologic deficits, no clonus
PSYCH: Unable to assess
DISCHARGE PHYSICAL EXAM:
========================
VSS
GEN: awake, alert, interacting normally
HEENT: PERRL, EOMI
NECK: No JVD
CV: RRR, no murmurs appreciated
RESP: Normal work of breathing, clear bilaterally
GI: Abdomen soft, non distended, normoactive bowel sounds
MSK: No obvious rashes, trauma
SKIN: No obvious skin breakdown
NEURO: No focal neurologic deficits, no clonus
PSYCH: Good attention, intermittently agitated, denies
hallucinations and suicidal ideation
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-12.2* RBC-5.17 Hgb-15.2 Hct-48.2
MCV-93 MCH-29.4 MCHC-31.5* RDW-13.4 RDWSD-45.9 Plt ___
___ 01:41AM BLOOD WBC-10.1* RBC-4.89 Hgb-14.5 Hct-45.7
MCV-94 MCH-29.7 MCHC-31.7* RDW-13.6 RDWSD-46.1 Plt ___
___ 09:30PM BLOOD Neuts-71.9* ___ Monos-8.0
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.77* AbsLymp-2.36
AbsMono-0.98* AbsEos-0.04 AbsBaso-0.02
___ 09:30PM BLOOD Glucose-82 UreaN-13 Creat-1.1 Na-144
K-3.6 Cl-102 HCO3-23 AnGap-19*
___ 01:41AM BLOOD ALT-29 AST-35 LD(LDH)-280* CK(CPK)-870*
AlkPhos-102 TotBili-0.4
___ 01:41AM BLOOD CK-MB-8 cTropnT-<0.01
___ 01:41AM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.5 Mg-2.2
___ 01:41AM BLOOD Osmolal-300
___ 09:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 01:41AM BLOOD ASA-NEG Ethanol-41* Acetmnp-NEG
EtGlycl-<10 Tricycl-NEG
___ 09:34PM BLOOD ___ pO2-246* pCO2-45 pH-7.36
calTCO2-26 Base XS-0
___ 01:57AM BLOOD ___ Rates-15/ Tidal V-500 PEEP-5
FiO2-50 pO2-101 pCO2-51* pH-7.30* calTCO2-26 Base XS--1
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 03:16AM BLOOD Type-ART Rates-17/ Tidal V-500 PEEP-5
FiO2-40 pO2-61* pCO2-47* pH-7.34* calTCO2-26 Base XS-0
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 03:16AM BLOOD Lactate-1.9
___ 09:34PM BLOOD O2 Sat-97
___ 01:41AM BLOOD ALCOHOL PROFILE-
-- ALCOHOL, METHYL (B) NONE DETECTED
-- ALCOHOL, ETHYL (B) 30 H
-- ALCOHOL, ETHYL (B) 0.030 H
___ 02:20AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 02:20AM URINE Blood-LG* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD*
___ 02:20AM URINE RBC-46* WBC-48* Bacteri-FEW* Yeast-NONE
Epi-0
___ 02:20AM URINE Mucous-MANY*
___ 12:35AM URINE bnzodzp-POS* barbitr-NEG opiates-POS*
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
=================
___ 04:06AM BLOOD WBC-9.8 RBC-4.80 Hgb-14.2 Hct-45.4 MCV-95
MCH-29.6 MCHC-31.3* RDW-13.6 RDWSD-47.8* Plt ___
___ 04:06AM BLOOD ___ PTT-29.7 ___
___ 04:06AM BLOOD Glucose-90 UreaN-9 Creat-1.0 Na-138 K-3.7
Cl-102 HCO3-26 AnGap-10
___ 04:06AM BLOOD ALT-24 AST-26 AlkPhos-106 TotBili-0.3
___ 04:06AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1
MICROBIOLOGY:
==============
___ 01:41AM BLOOD Trep Ab-PND
___ 06:49AM URINE CT-NEG NG-NEG
___ URINE URINE CULTURE-NO GROWTH
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ 9:25 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
IMAGING:
==========
CXR ___
Standard positioning of the endotracheal and enteric tubes. Low
lung volumes with probable bibasilar atelectasis.
CT HEAD NC ___
No acute intracranial abnormality.
Brief Hospital Course:
Patient Summary for Admission:
===============================
Mr. ___ is a ___ year old male with history of anxiety,
bipolar 1 disorder, depression and schizophrenia who presented
with altered mental status after multiple drug coingestions
requiring intubation due to concern for airway. Self-extubated
on ___.
ACUTE ISSUES
===============
# Acute Respiratory Failure: Patient was intubated ___ the
setting of polysubstance abuse and multiple ingestions. CXR on
presentation with bibasilar atelectasis but less suspicion for
primary pulmonary process as no documented hypoxia. He was
extubated ___ overnight without subsequent oxygen
requirement. On discharge, SCx pending but without growth.
Patient denied dyspnea, cough, fevers, chills. Perhaps there was
an aspiration at time of intubation. Do not suspect patient
clinically has pulmonary infection.
# Altered Mental Status: Carries psychiatric diagnoses include
schizophrenia. Patient acutely agitated prior to presentation ___
the setting of multiple ingestions including benzos, cocaine,
opiates and the above mentioned dextromethorphan and
chlorpheniramine. Toxicology was consulted given co-ingestions
and supportive care pursued. Regarding acute agitation,
Psychiatry was consulted and patient was felt not to be a danger
to himself or others. No ___ was pursued. Social work was
consulted for aid ___ drug and alcohol cessation programs.
# Schizophrenia vs Bipolar Disorder
# Anxiety, Depression: Patient with multiple hospitalizations
previously but denied current medication use. Psychiatry was
consulted and inpatient admission was not felt to be necessary
and no ___ pursued. Patient was felt not to be a danger
to himself or others at time of discharge. Patient denied active
SI or HI and felt self for discharge to home. Arrangement was
made for intake to an outpatient treatment program for ___.
# Metabolic Acidosis, AG: AG 19 on presentation of unclear
etiology. Resolved to 10 prior to discharge.
# Leukocytosis: WBC 12.2 on admission without clear source. No
infectious etiology identified and no antibiotics required. He
was noted to have penile discharge but gonorrhea/chlamydia
negative. Syphillis testing pending at discharge. Given empiric
2.4million units of PCN prior to discharge for suspected
syphillis.
# ST Elevations: Present I V1-V3, increased from presentation.
Discussed with Cardiology, did not meet criteria for acute STEMI
and no associated troponinemia.
# Prolonged QTc: QTc initially 550 reportedly by ED with
normalization prior to discharge.
TRANSITIONAL ISSUES:
[ ] Treponemal Ab pending at discharge; given empiric treatment
with 2.4million ___ on ___ prior to discharge.
[ ] SCx pending at discharge but do not suspect pulmonary
infection. BCx pending on discharge.
[ ] Patient provided with resources from ___ regarding alcohol
and drug use cessation.
[ ] Recommend PCP follow up.
[ ] Patient reported he is to take olanzapine and thorazine
outpatient but does not adhere to this; will benefit from
outpatient follow up with Psychiatry if able.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ChlorproMAZINE 100 mg PO QHS
2. OLANZapine 15 mg PO QHS
**PATIENT DOES NOT TAKE THESE REGULARLY***
Discharge Medications:
1. ChlorproMAZINE 100 mg PO QHS
2. OLANZapine 15 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
Acute Respiratory Failure
Multiple Toxic Ingestions
Secondary Diagnosis:
====================
Schizophrenia vs. Bipolar disorder
Anxiety
Depression
Polysubstance Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why was I admitted to the hospital?
- You were admitted to the hospital because you were very
agitated and your breathing was affected.
What was done for me while I was ___ the hospital?
- You were placed on a breathing machine until you were safe to
breathe on your own.
- We monitored your labs very closely while you were ___ the
hospital.
- Our Psychiatry team evaluated you and felt you were safe to go
home.
What should I do when I leave the hospital?
- Please continue taking your medications as prescribed.
- We have provided you with some resources to help with drug
abuse.
- Please go to your Arbour intake appointment tomorrow ___
___ @ 9am at ___ Floor JP ___.
- Please call your primary care doctor to schedule a follow up
appointment after discharge.
It is extremely important you do not continue using drugs such
as opioids, cocaine and benzodiazepines. These medications are
extremely dangerous, especially ___ combination and resulted ___
your critical condition.
We wish you the best!
Your ___ treatment team
Followup Instructions:
___
|
19643214-DS-22
| 19,643,214 | 23,341,504 |
DS
| 22 |
2134-02-11 00:00:00
|
2134-02-11 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, tachycardia and chest pain
Major Surgical or Invasive Procedure:
Midline placed and removed
History of Present Illness:
PCP: Dr. ___
.
CC: ___ loss and tachycardia
___ with ETOH child A cirrhosis with stage III fibrosis, chronic
n/v with poor PO intake, from PCP office for evaluation of chest
pain, palpitations, sinus tachycardia and ST depressions seen in
initial EKG in clinic. she has an ongoing history of difficulty
swallowing malnutrition and weight loss over the past year or
two. She was admitted at the end of ___ where she had
an EGD performed and an NGT placed to the left nare for enteral
nutrition. She at first reported taking 5 cans of tube feeds
daily. She cannot remember the name of her tube feeds. However
with persistent questioning she reports that she has not taken
her tube feeds for at least two days because her pump was not
working. She also expresses a dislike of the tube feeds since
she has to be hooked up to it for 14 hours a day. She also
states that the spokes of the IV pole make it difficult for her
to get around. She continues to have 8 wine coolers per week.
Whenever she tries to have solid food, it gets stuck in her
throat and she regurgitates it back up. She describes that her
difficulty tolerating solid food began ___ years ago when her
brother was very sick in the hospital at ___. She thought he
was going to die and she would come to the hospital and sit at
her brother's bedside and not eat. She would just sit with him.
Since then she has had difficulty eating.
She had followup scheduled with her PCP ___ today to
determine need for ongoing studies regarding the difficulties
with p.o. intake. She felt somewhat weaker generally than usual
this morning and went to ___ to see her nutritionist. She
states that between her nutritionist appointment and her PCP
appointment this afternoon, she started to feel palpitations and
felt "not right". She denied chest pain, fainting, but does
report intermittent non bloody emesis. She was discharged on
lactulose after hospitalization in ___. This resulted in
significant diarrhea and thus her lactulose was held. She now
has intermittent diarrhea but is very vague as to the timing ?
___ times per day. She also has daily nausea and vomiting. Of
note she recently appreciated a mass in her R axilla. No strange
foods or fevers. + falls and syncopal episode in ___.
She also fell in the tub in ___ when taking a shower. She
attributes her fall to a loss of balance.
On arrival to the ___ office, she was found to be tachycardic to
130s and EKG at ___ office demonstrated STDs to some lateral
leads and I. She was referred to ED for evaluation.
.
On arrival to ED she was triggered for rapid heart rate. EKG in
ED demonstrated sinus tachycardia with improved but persistent
<1mm STDs to v4-5.
.
18ga Rt AC via ultrasound was placed.
.
In ER: (Triage ___ |97.4 |130 |160/100 |18|100% RA )
She was given 4L IVF, potassium, magnesium and ceftriaxone. A
CXR was performed which was negative. ECG demonstrated SR at 82
bpm with TWI in lead V1 and V2. Two sets of cardiac enzymes were
negative. No consults were called.
.
PAIN SCALE: ___
CONSTITUTIONAL: As per HPI + for weight loss
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [+] L chest pain and tingling focused around the
nipple
GI: As per HPI
GU: [X] All normal- no dysuria
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [+] generalized weakness
HEME/LYMPH: [+] mass in R axilla
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
- Depression
- Hepatitis C: per OMR h/o +antibodies, viral load ___
undetectable
- Tobacco use
- Osteopenia
- Colon polyps
- Hepatitis B
- H/O EXTENSIVE BURNS TO TRUNK SUSTAINED AT AGE ___
Social History:
___
Family History:
Mother with breast cancer, dx in ___ per OMR but pt tells me
that her mother died in a NH at age ___ after having a stroke.
Physical Exam:
Vitals: 98.4 PO 186 / 95 R Sitting 84 18 99 RA Weight = 111.9
lbs
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
CV: s1s2 rrr SEM at RUSB without radiation
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
MSK:no c/c/e 2+pulses
SKIN: chronic thickening and scaring of skin at site of remote
burns on torso and abdomen.
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
2 cm mobile mass appreciated in R axilla
Pertinent Results:
___ 09:40PM cTropnT-<0.01
___ 03:10PM URINE HOURS-RANDOM
___ 03:10PM URINE UHOLD-HOLD
___ 03:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD
___ 03:10PM URINE RBC-1 WBC-26* BACTERIA-FEW YEAST-NONE
EPI-4
___ 03:10PM URINE HYALINE-16*
___ 03:10PM URINE MUCOUS-MOD
___ 03:08PM LACTATE-1.7
___ 02:40PM GLUCOSE-104* UREA N-9 CREAT-0.9 SODIUM-144
POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-25 ANION GAP-23*
___ 02:40PM estGFR-Using this
___ 02:40PM ALT(SGPT)-23 AST(SGOT)-46* ALK PHOS-83 TOT
BILI-0.6
___ 02:40PM LIPASE-31
___ 02:40PM cTropnT-<0.01
___ 02:40PM ALBUMIN-4.8 CALCIUM-9.0 PHOSPHATE-3.9
MAGNESIUM-1.5*
___ 02:40PM WBC-6.4 RBC-3.44* HGB-11.4 HCT-34.1 MCV-99*
MCH-33.1* MCHC-33.4 RDW-14.6 RDWSD-53.0*
___ 02:40PM NEUTS-61.6 ___ MONOS-8.3 EOS-0.2*
BASOS-0.6 IM ___ AbsNeut-3.95 AbsLymp-1.86 AbsMono-0.53
AbsEos-0.01* AbsBaso-0.04
___ 02:40PM PLT COUNT-98*
___ 02:40PM ___ PTT-25.0 ___
___ 12:10PM GLUCOSE-90
___ 12:10PM UREA N-9 CREAT-0.8 SODIUM-143 POTASSIUM-2.7*
CHLORIDE-96 TOTAL CO2-22 ANION GAP-28*
___ 12:10PM estGFR-Using this
___ 12:10PM ALT(SGPT)-25 AST(SGOT)-51* ALK PHOS-86 TOT
BILI-0.5
___ 12:10PM ALBUMIN-5.0 CALCIUM-9.2
___ 12:10PM TSH-3.1
___ 12:10PM AFP-13.5*
___ 12:10PM WBC-6.1 RBC-3.66* HGB-11.9 HCT-36.6 MCV-100*
MCH-32.5* MCHC-32.5 RDW-14.7 RDWSD-55.0*
___ 12:10PM NEUTS-67.8 ___ MONOS-6.9 EOS-0.3*
BASOS-0.5 IM ___ AbsNeut-4.11 AbsLymp-1.47 AbsMono-0.42
AbsEos-0.02* AbsBaso-0.03
___ 12:10PM PLT COUNT-101*
Ultrasound
Area palpable concern by the patient in the right axilla
corresponds to a
normal appearing lymph node.
KUB
The enteric tube loops around and terminates in the stomach.
There are no
abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no
gross
pneumoperitoneum. Osseous structures are unremarkable.
Multiple surgical clips project over lower abdomen.
IMPRESSION:
The enteric tube terminates in the stomach. Normal bowel gas
pattern.
==========
CXR: No acute disease- images reviewed by author
___ 05:47AM BLOOD WBC-3.5* RBC-2.69* Hgb-8.7* Hct-27.6*
MCV-103* MCH-32.3* MCHC-31.5* RDW-15.3 RDWSD-56.6* Plt Ct-56*
___ 12:52PM BLOOD WBC-3.4* RBC-2.69* Hgb-9.1* Hct-28.2*
MCV-105* MCH-33.8* MCHC-32.3 RDW-15.1 RDWSD-58.6* Plt Ct-70*
Brief Hospital Course:
The patient is a ___ year old female with ongoing weight loss
(despite using tube feeds intermittently), ongoing alcohol use,
hep B exposure and Hep C negative alcoholic cirrhosis with stage
III fibrosis who presents with hypomagnesemia, hypokalemia,
tachycardia, as well as chest pain and continued weight loss.
HYPOMAGNESEMIA/HYPOKALEMIA/DEHYRATION
- most likely secondary to poor po intake secondary to poor
compliance with tube feeds and alcohol intake
- electrolytes repleted during admission.
WEIGHT LOSS FAILURE TO THRIVE
Patient endorses significant anorexia, hates the way that "food
tastes". Some foods "don't feel right" going down. Seen by
speech and swallow service, who found no risk for aspiration
based on her exam and symptoms and advised that she continue
thin liquids and regular diet. She was ordered a regular diet
here, and was seen eating about a ___ of the food on her tray
She admits to not using tube feeds as recommended. She does not
use them at all ___ days a week, and then other days may not use
them for the fully recommended time. She dislikes the lifestyle
interruption and complains the tube feeds give her diarrhea.
The nutrition service saw her here and recommended a different
tube feed formulation - TwoCal HN (Nutren is the equivalent that
___ will provide her at home) - which she tolerated well but
had mild bloating and nausea a the end of her cycle. She
received it at goal with 200 cc of water every four hours. She
was able to complete nearly the entire 12 hours of feeds but
feeds did need to stop at the end of each cycle due to nausea.
She only uses 80 cc of water flushes every 6 hours at home. I
advised her to continue this; it is possible that the extra
water that we gave her here in the hospital contributed to
bloating, fullness and nausea and slightly early termination of
tube feeds.
She received Zofran for her nausea. QTc in the hospital was 460
msec. I gave her a prescription for Zofran, and advised to use
it sparingly, only for severe nausea. if outpatient providers
want to continue Zofran, would need to recheck qtc.
CHEST PAIN
- The etiology of her chronic chest pain in not clear. She has
had some subacute falls - ? trauma but her chest pain seems to
predate this. I am reassured that her d-dimer is negative and
two sets of cardiac enzymes are negative. For now will treat
symptomatically with low dose Tylenol. Had resolved by time of
discharge
.
HYPERTENSION:
Patient noted elevated blood pressures at home on amlodipine 2.5
mg, and she had several blood pressures systolic 160-170 in the
hospital, so her amlodipine dose was increased to 5 mg daily.
.
GERD/GASTRITIS:
-continued PPI
.
PRESUMD COPD
Only spirometry from ___ demonstrates a restrictive ventilatory
defect with a FEV1/FVC of 120%. She denied dyspnea, used
albuterol prn
.
DEPRESSION:
Continue Mirtazapine 15 mg PO QHS and sertraline. She endorsed
a lot of sadness and frustration over her body image. She has
an outpatient psychiatrist who she sees regularly. Feels that
mirtazapine has helped helped her sleep but she is unsure if it
increased her appetite, which is chronically poor. She endorses
low mood, and that she is compliant with mirtazapine and
sertraline about ___ days of the week. We encouraged consistent
compliance for optimal results.
Thrombocytopenia: Chronic. No splenomegaly seen on images
(even with history of cirrhosis). Improved over course of
admission
Venous access: patient adamant that she have a port placed for
blood draws: midline placed while she was hospitalized,
discussed with venous access team; she is at higher risk of
hematoma, bruising around the port with platelets in the 50Ks,
so given it was not urgent, port deferred.
Alcohol abuse: Discussed with patient that she should not
consume any alcohol given her cirrhosis, and that alcohol abuse
is likely depressing her platelet count, and that his delays her
obtaining the port that she wants.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. amLODIPine 2.5 mg PO DAILY
3. ammonium lactate 12 % topical DAILY:PRN
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Nabumetone 500 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Potassium Chloride 40 mEq PO Q 3 DAYS?
11. Sertraline 100 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Tube and Connector Kit (miscellaneous medical supply) 5
cans miscellaneous DAILY
Discharge Medications:
1. Ondansetron ODT 4 mg PO DAILY:PRN severe nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. ammonium lactate 12 % topical DAILY:PRN
5. FoLIC Acid 1 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Pantoprazole 40 mg PO Q12H
8. Sertraline 100 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11.Tube feed
Nutren 2.0 at 80 ml/hour over 12 hours via ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Malnutrition
2. Weight loss
3. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation because you have been losing
weight at home. We feel that this is happening because you
have not been using the tube feeds as prescribed. You have been
tolerating the tube feeds well. If you develop nausea when
using tube feeds, turn them off, and restart them in an hour.
For severe nausea, you can take a tablet of Zofran, but use NO
MORE than one a day.
PLease stop drinking ALL alcohol. We think it is affecting your
body's ability to make cells.
Once your platelet (these are the cells that help you clot)
count improves, we agree that you should have a PORT placed for
blood draws. Dr ___ help arrange this.
Your blood pressures were very high in the hospital, so we had
to increase your amlodipine dose. Please take 5 mg a day.
We have changed your tube feeding formulation. Please take the
new feeding Nutren, and use it at 80 cc/hour for 12 hours.
Please flush the feeding tube with 80 cc of sterile water 3
times a day as well as before and after feeds.
Followup Instructions:
___
|
19643415-DS-10
| 19,643,415 | 20,360,186 |
DS
| 10 |
2140-08-17 00:00:00
|
2140-08-18 16:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bee Sting Kit / Shellfish Derived / Clindamycin
Attending: ___.
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with CLL and stage IV metastatic gastric cancer
who is C2D11 of palliative chemotherapy: Epirubicin Oxaliplatin
Capecitabine presents w/ worsening nonbloody diarrhea x>1 week
and R sided abdominal pain. The patient states that he has a
history of chronic abdominal pain secondary to his gastric
cancer
but this is more severe. His diarrhea has been continuous since
his last chemotherapy on ___.
He reports intermittent chest pain for years, unchanged. No new
chest pain. He had negative cardiac catheter in the past for
pain. No history of blood clots, no pleuritic component. Chronic
dyspnea and cough secondary to COPD, unchanged.
Of note recent admission ___ for parainfluenza infection
and COPD exacerbation where he was treated with prednisone taper
and levofloxacin, with prednisone taper ending today.
In the ED, initial VS were: 98.2 113 110/60 18 98% RA
-Labs were notable for: WBC 2 (78% pmn) Ht 29 Plt 138, normal
chem10 and LFTs, elevated glucose to 237, lactate 1.9, trops neg
x2.
-Imaging included: CT abd/pel w contrast, showing Gaseous
distention of the large bowel, predominantly the transverse
colon
measuring up to 8 cm.
Treatments received: ASA 325 and morphine IV in addition to his
home medications.
vitals prior to transfer 98.3 90 106/62 18 97% RA
On arrival to the floor, patient says he had some relief from
oxycodone but only for about an hour.
REVIEW OF SYSTEMS:
(+) chronic pain all stable; says he had thrush last week that
has resolved with BID nystatin; increased burping
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain, nausea,
vomiting, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Past Medical History:
Oncologic History:
Gastric cancer stage IV and synchronous CLL
- Long history heartburn and reflux since his ___
- ___ Started omeprazole for GI symptoms with good effect
- ___ Underwent lap banding for weight loss and reflux
- ___ Lap band ruptured due to cough
- ___ to ___ Received BR x 6 cycles for CLL
- ___ CT torso to assess response to therapy for CLL
showed only a gastrohepatic ligament.
- ___ CT torso to assess CLL showed new regions of
ill-defined hypoensity, particularly in hepatic segments V and
VI, may be due to focal fatty infiltration. However,
infiltrative disease/neoplasm is on the differential diagnosis.
Previously described gastrohepatic ligament lymph node is not
seen on the current study. Some new pulmonary nodules.
- ___ MR abdomen showed ill-defined 5.8 x 1.2 cm
hypoenhancing lesion along the proximal aspect of the lesser
curvature of the stomach, adjacent to the fundoplication site,
with enlarged gastrohepatic, gastroepiploic, and left paraaortic
lymph nodes, adjacent fat stranding, and numerous liver lesions,
concerning for metastatic gastric neoplasm. Severe hepatic
steatosis.
- ___ EGD showed an infiltrative and ulcerated 4 cm mass
with stigmata of recent bleeding of malignant appearance at the
gastroesophageal junction and lesser curve. Also found to have
esophageal candidiasis. Biopsies showed poorly differentiated
signet ring adenocarcinoma.
- ___ PET CT showed multiple foci of FDG avidity
throughout the liver are most consistent with metastatic
disease. Two subcentimeter FDG avid paraaortic lymph nodes.
Innumerable subcentimeter lung nodules and ___ opacities
in the peripheral lung parenchyma demonstrate minimal FDG
avidity
most
consistent with infection or aspiration.
- ___ EUS and biopsy of a liver lesion showed metastatic
disease
- ___ to ___ Palliative XRT
- ___ C1D1 EOX (epirubicin 50 mg/m2, oxaliplatin 130
mg/m2, capecitabine 1500 mg BID)
PAST MEDICAL HISTORY:
- Asthma/COPD
- TBM s/p tracheoplasty in ___
- C1 through C7 fusion,
- Insulin dependant diabetes.
- Depression
- HL
- Morbid obesity (BMI 38, 300 lbs)
Social History:
___
Family History:
No family hx of GI cancers
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1, BP 120/76, HR 105, RR 20, 98% RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, heart sounds distant, ___ systolic
murmur
LUNG: Wheezing throughout, prolonged expiratory phase, talking
in
long sentences easily
ABD: Obese, +BS, disteneded and tympanitic, tender diffusely,
especially lower quadrants, no rebound or guarding
EXT: No lower extremity pitting edema
NEURO: CN II-XII intact, moving all extremities equall
SKIN: Warm and dry, without rashes; has many tattoos
===============================================================
DISCHARGE PHYSICAL EXAM:
VS: ___ 20 94%
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, heart sounds distant, ___ systolic
murmur
LUNG: Wheezing throughout, prolonged expiratory phase, improved
cough,
ABD: Obese, +BS, disteneded and tympanitic, tender diffusely,
especially lower quadrants and LUQ, no rebound or guarding
EXT: No lower extremity pitting edema
NEURO: CN II-XII intact, moving all extremities equall
SKIN: Warm and dry, without rashes; has many tattoos
Pertinent Results:
INITIAL LABS:
___ 11:30AM BLOOD WBC-2.0*# RBC-3.77* Hgb-10.4* Hct-29.6*
MCV-79* MCH-27.5 MCHC-35.0 RDW-21.3* Plt ___
___ 11:30AM BLOOD ___ PTT-75.5* ___
___ 11:30AM BLOOD Glucose-237* UreaN-15 Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-23 AnGap-17
___ 11:30AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.5* Mg-1.7
___ 11:35AM BLOOD Lactate-1.9
===========================================================
DISCHARGE LABS:
___ 04:31AM BLOOD WBC-2.0*# RBC-3.26* Hgb-9.0* Hct-26.2*
MCV-80* MCH-27.7 MCHC-34.5 RDW-22.2* Plt ___
___ 04:31AM BLOOD Neuts-54 Bands-2 Lymphs-14* Monos-22*
Eos-7* Baso-1 ___ Myelos-0
___ 04:31AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL
Ovalocy-1+ Stipple-OCCASIONAL Tear ___
___
___ 04:31AM BLOOD Plt Smr-NORMAL Plt ___
___ 04:31AM BLOOD Glucose-213* UreaN-10 Creat-0.9 Na-135
K-4.2 Cl-100 HCO3-25 AnGap-14
___ 04:31AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.8
==============================================================
___ ECG Sinus tachycardia. Diffuse minor non-specific
repolarization abnormalities. Compared to the previous tracing
of ___ no significant change.
___ CT ABDOMEN AND PELVIS IMPRESSION: 1. Gaseous distention
of the large bowel, predominantly the transverse colon measuring
up to 8 cm without evidence of obstruction. 2. Ill-defined
hypodense wall thickening along the proximal lesser curvature of
the stomach measuring up to 3.6 x 1.4 cm compatible with known
gastric malignancy. This was better evaluated on prior MRI. 3.
Extensive hepatic metastatic disease with multiple enlarged
mesenteric and retroperitoneal lymph nodes. Given differences in
imaging modality, no significant interval change.
___ PA LATERAL FINDINGS: PA and lateral views of the chest
provided. Port-A-Cath resides over the left chest wall with
catheter tip in the region of the mid SVC unchanged. The lungs
appear clear. No large effusion or pneumothorax.
Cardiomediastinal silhouette is normal. Bony structures appear
intact. DISH related changes of the T-spine noted. No free air
below the right hemidiaphragm.
=
================================================================
MICRO:
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
BLOOD CULTURE- NGTD
Brief Hospital Course:
___ male with CLL and stage IV metastatic gastric cancer
who is C2D11 of palliative chemotherapy: Epirubicin,
Oxaliplatin, Capecitabine presents w/
diarrhea and neutropenia
#diarrhea: CT abdomen with gaseous distention of the large
bowel. C. diff and stool cultures negative thought to be related
to enterotoxicity from chemo, mainly cepcitabine. Started on
loperamide, opium tincture and octreotide for refractory
diarrhea. Diarrhea much improved on discharge.
#Abdominal pain: Worsening of chronic abdominal pain. Pain meds
uptitrated on discharge.
#neutropenia: found to be neutropenic from chemotherapy.
Afebrile through admission, no localizing s/sx of infection. ANC
on discharge 1080.
#severe COPD: patient with cough and wheezing though per his
report at baseline. Continued home meds
#Diabetes: several episodes of hypoglycemia during this
admission with nadir in the ___ likely due to difference in diet
while in hospital. Fixed doses of insulin were held and pt
remained on sliding scale. He may need to restart his long
acting in the outpatient setting.
# Stage ___ Metastatic gastric cancer: Admission was C2D11
Epirubicin Oxaliplatin Capecitabine (he last received chemo
___ with palliative intent. Cepcitabine held during this
admission and on discharge.
# Anxiety/Depression: continued citalopram, ativan
# HTN: continued diltiazem
#GERD: continued PPI
TRANSITIONAL ISSUES:
#follow up diarrhea
#followup diabetes and restart long acting if BS are elevated
#ANC at discharge 1080
#uptitrated pain regimen please downtitrate as tolerated
CODE: DNR/ DNI
EMERGENCY CONTACT HCP: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
5. Lorazepam 0.5 mg PO Q8H:PRN nausea
6. Montelukast 10 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
11. Pyridoxine 100 mg PO DAILY
12. Senna 17.2 mg PO BID:PRN constipation
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraZODone 50-100 mg PO QHS:PRN sleep
15. Loratadine 10 mg PO DAILY:PRN allergy
16. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN sore
throat
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Ondansetron 8 mg PO Q8H:PRN nausea
19. Prochlorperazine 10 mg PO Q6H:PRN nausea
20. Pseudoephedrine 60 mg PO Q6H:PRN allergy
21. 70/30 65 Units Breakfast
70/30 65 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
22. Capecitabine 1500 mg PO Q12H
23. Nystatin Oral Suspension 5 mL PO BID
24. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
Discharge Medications:
1. Octreotide Acetate 100 mcg SC Q8H
RX *octreotide acetate 100 mcg/mL 100 mcg IM every eight (8)
hours Disp #*50 Ampule Refills:*0
2. Citalopram 40 mg PO DAILY
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
7. Lorazepam 0.5 mg PO Q8H:PRN nausea
8. Montelukast 10 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nystatin Oral Suspension 5 mL PO BID
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*30 Tablet Refills:*0
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*50 Tablet Refills:*0
14. Pyridoxine 100 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraZODone 50-100 mg PO QHS:PRN sleep
17. Diphenoxylate-Atropine 1 TAB PO Q6H
RX *diphenoxylate-atropine [Lomotil] 2.5 mg-0.025 mg 1 tablet(s)
by mouth every six (6) hours Disp #*50 Tablet Refills:*0
18. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q4H
RX *opium tincture 10 mg/mL (morphine) 10 mL by mouth every four
(4) hours Refills:*0
19. DiphenhydrAMINE 25 mg PO QHS:PRN allergies
20. Docusate Sodium 100 mg PO TID
21. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
22. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
23. Loratadine 10 mg PO DAILY:PRN allergy
24. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN sore
throat
25. MetFORMIN (Glucophage) 1000 mg PO BID
26. Methylnaltrexone 12 mg SUBCUT QAM:PRN constipation
27. Prochlorperazine 10 mg PO Q6H:PRN nausea
28. Senna 17.2 mg PO BID:PRN constipation
29. Pseudoephedrine 60 mg PO Q6H:PRN allergy
30. LOPERamide 2 mg PO QID
RX *loperamide [Anti-Diarrhea] 2 mg 1 tab by mouth four times a
day Disp #*50 Tablet Refills:*0
31. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*100
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Final Diagnosis:
Diarrhea associated with chemotherapy
neutropenia
metastatic gastric cancer
Secondary Diagnosis:
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with diarrhea and abdominal
pain which is most likely due to your chemotherapy. We did not
find any infections that could cause your symptoms. Your white
blood cells were also low because of your chemotherapy. It is
most likely the diarrhea was from the chemotherapy. We treated
your diarrhea with medications and your white cells returned to
normal.
It was a pleasure taking care of you while you were in the
hospital.
We stopped your fixed insulin doses because you were
hypoglyecmic and for now we recommend that you just use sliding
scale. It is possible you may need to restart your fixed doses.
Check your blood sugars and if they are elevated please call
your PCP because you may need to restart your long acting
insulin.
Hold off on taking your Capecitabine 1500 mg PO Q12H until you
see your oncologist.
-your ___ care team-
Followup Instructions:
___
|
19643415-DS-12
| 19,643,415 | 27,105,850 |
DS
| 12 |
2140-09-10 00:00:00
|
2140-09-11 14:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bee Sting Kit / Shellfish Derived / Clindamycin
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
PRIMARY ONCOLOGIST: ___
PRIMARY DIAGNOSIS: CLL, gastric cancer (poorly differentiated
signet ring adenocarcinoma)
TREATMENT REGIMEN: C3D1 of palliative chemotherapy: Epirubicin
Oxaliplatin Capecitabine
CC: malaise, diarrhea,low grade fever
HISTORY OF PRESENTING ILLNESS:
___ male with CLL and stage IV metastatic gastric cancer
who is C2D11 of palliative chemotherapy: Epirubicin Oxaliplatin
Capecitabine. Of note he was recent admitted ___ for fever,
thought to be ___ GI source was discharge on course of
Cipro/Flagyl. He had been feeling well after discharge, walked
the dog yesterday. Then today he started to feel clammy, dizzy
and mildly confused. These are his usual symptoms when he has a
fever, so his wife checked his temperature and it was 101.2. He
called and was sent to the ED for further evaluation.
Of note he was hospitalized with fever ___ and diagnosed with
paraflu. He was recently d/c on ___ after presenting with
fever, abdominal pain and diarrhea thought to be enterotoxicity
from chemo and parainfluenza. Immunoglobulin levels were were
and he was given a dose of IVIG.
In the ED, initial VS were: T101.6 ___ BP142/71 RR16 O2 Sat 90%
2L. Labs were notable for WBC 8.0 normal diff, Hgb 9.5, normal
Chem 7 (glucose 181), Lactate 2.3, albumin 2.8. VBG 7.45/53.
Patient was given IVF and repeat lactate was 1.9. CT showed no
PE, small airway disease and stable hepatic metastatic disease.
He was given vanc/zosyn, hydromorphone and his home
oxycodone/oxycontin.
On the floor, pt states that he was starting to feel confused,
but his symptoms have improved since he came to the ED.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, chest pain, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Oncologic History:
Gastric cancer stage IV and synchronous CLL
- Long history heartburn and reflux since his ___
- ___ Started omeprazole for GI symptoms with good effect
- ___ Underwent lap banding for weight loss and reflux
- ___ Lap band ruptured due to cough
- ___ to ___ Received BR x 6 cycles for CLL
- ___ CT torso to assess response to therapy for CLL
showed only a gastrohepatic ligament.
- ___ CT torso to assess CLL showed new regions of
ill-defined hypoensity, particularly in hepatic segments V and
VI, may be due to focal fatty infiltration. However,
infiltrative disease/neoplasm is on the differential diagnosis.
Previously described gastrohepatic ligament lymph node is not
seen on the current study. Some new pulmonary nodules.
- ___ MR abdomen showed ill-defined 5.8 x 1.2 cm
hypoenhancing lesion along the proximal aspect of the lesser
curvature of the stomach, adjacent to the fundoplication site,
with enlarged gastrohepatic, gastroepiploic, and left paraaortic
lymph nodes, adjacent fat stranding, and numerous liver lesions,
concerning for metastatic gastric neoplasm. Severe hepatic
steatosis.
- ___ EGD showed an infiltrative and ulcerated 4 cm mass
with stigmata of recent bleeding of malignant appearance at the
gastroesophageal junction and lesser curve. Also found to have
esophageal candidiasis. Biopsies showed poorly differentiated
signet ring adenocarcinoma.
- ___ PET CT showed multiple foci of FDG avidity
throughout the liver are most consistent with metastatic
disease. Two subcentimeter FDG avid paraaortic lymph nodes.
Innumerable subcentimeter lung nodules and ___ opacities
in the peripheral lung parenchyma demonstrate minimal FDG
avidity
most
consistent with infection or aspiration.
- ___ EUS and biopsy of a liver lesion showed metastatic
disease
- ___ to ___ Palliative XRT
- ___ C1D1 EOX (epirubicin 50 mg/m2, oxaliplatin 130
mg/m2, capecitabine 1500 mg BID)
-admission ___ for diarrhea from enterotoxicity, capecidabine
d/c'd
-admission ___ for fever and persistent diarrhea which
resolved, was d/c'd on cipro/flagyl
Social History:
___
Family History:
No family hx of GI cancers
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
VS: T 98.8 BP 136/72 97 22 96%RA
GENERAL: alert, resting comfortably in bed NAD
HEENT: NC/AT, dry MM, no oral ulcers
CARDIAC: RRR, ___ SEM over RSB, no rubs or gallops
LUNG: scattered bilateral expiratory wheezes, no rales or
rhonchi
ABD: Obese, +BS, distended but soft, TTP over upper abdomen, no
rebound or guarding
EXT: WWP, no ___ edema
NEURO: CN II-XII intact, strength and sensation grossly normal,
gait not assessed
SKIN: Warm and dry, without rashes; has many tattoos.
Lines: Left port C/D/I
===========================
DISCHARGE PHYSICAL EXAM
===========================
VS: Tc 97.9, Tm 98.5, BP 110-140/60-80, HR 92-100, 95% RA
GENERAL: alert and oriented x3, NAD
HEENT: sclera anicteric, NC/AT, MMM, thrush improved, + apthous
ulcer
CARDIAC: RRR, no murmurs, normal S1 and S2
LUNG: faint b/l wheezes, no rales/rhonchi
ABD: Obese, +BS, distended but soft, mild tenderness throughout
but most prominent in LUQ, no rebound or guarding
EXT: WWP, no peripheral edema
NEURO: strength and sensation grossly normal, gait not assessed
SKIN: Warm and dry, without rashes; has many tattoos.
Lines: Left port c/d/i
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 08:39AM BLOOD WBC-8.0# RBC-3.42* Hgb-9.5* Hct-30.5*
MCV-89 MCH-27.8 MCHC-31.1* RDW-26.2* RDWSD-80.4* Plt ___
___ 08:39AM BLOOD Neuts-84.8* Lymphs-4.4* Monos-9.6
Eos-0.4* Baso-0.1 Im ___ AbsNeut-6.81*# AbsLymp-0.35*
AbsMono-0.77 AbsEos-0.03* AbsBaso-0.01
___ 08:39AM BLOOD ___ PTT-32.3 ___
___ 08:39AM BLOOD Glucose-181* UreaN-8 Creat-0.8 Na-134
K-4.3 Cl-97 HCO3-27 AnGap-14
___ 08:39AM BLOOD ALT-27 AST-48* AlkPhos-152* TotBili-0.3
___ 08:39AM BLOOD proBNP-453*
___ 08:39AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.1 Mg-1.7
___ 09:12AM BLOOD ___ pO2-37* pCO2-53* pH-7.45
calTCO2-38* Base XS-10
___ 08:50AM BLOOD Lactate-2.3*
___ 05:41PM BLOOD Lactate-1.9
==================
IMAGING
==================
___ TTE IMPRESSION: Suboptimal image quality. No obvious
vegetations. Minimal aortic stenosis
___ CTA torso
1. No evidence of pulmonary embolism. No acute aortic
pathology.
2. New ill-defined centrilobular ground-glass nodular opacities
in the right upper lobe are compatible with small airways
disease, either infectious or inflammatory in etiology.
3. Unchanged hepatic metastatic disease.
___ CXR
1. Low lung volumes with left basilar atelectasis.
2. Port catheter tip terminates in the mid SVC
___ RENAL US
1. Normal renal ultrasound. No evidence of hydronephrosis.
2. Heterogeneous and increased hepatic echogenicity consistent
with steatosis as seen on recent CT.
___ CXR
The left-sided Port-A-Cath is unchanged. Heart size is upper
limits of
normal. There is coarsening of the bronchovascular markings
without focal consolidation, pleural effusion, or overt
pulmonary edema. Bilateral chronic rib deformities are seen.
=================
MICRO
=================
___ BCx NO GROWTH x3
___ 12:02 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
___ BCx NO GROWTH
___ LEGIONELLA NEGATIVE
___ CRYPTOCOCCAL AG NEGATIVE
___ BCx NO GROWTH
___ 12:13 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
___ 10:07 pm 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).
___ 1:15 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
=======================
DISCHARGE LABS
=======================
___ 05:17AM BLOOD WBC-12.0* RBC-2.97* Hgb-8.3* Hct-26.8*
MCV-90 MCH-27.9 MCHC-31.0* RDW-22.3* RDWSD-73.0* Plt ___
___ 05:17AM BLOOD Glucose-182* UreaN-42* Creat-4.1* Na-130*
K-4.3 Cl-91* HCO3-28 AnGap-15
___ 05:17AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical history of
CLL and stage IV metastatic gastric cancer who is s/p C2
palliative chemotherapy: Epirubicin, Oxaliplatin, Capecitabine
(last received chemo ___, capecitabine d/c'd due to
enterotoxicity) who presented with isolated fever at home.
Patient underwent an infectious workup which revealed a positive
B-glucan. Hospital course was complicated by acute renal failure
from contrast induced nephropathy. Hospital course is outlined
below by problem:
# Fever: He had an isolated fever before admission and none
during his hospital stay. Urine and blood cultures were
negative. CT torso showed new ill-defined centrilobular
ground-glass nodular opacities in the right upper lobe which
were compatible with small airways disease, either infectious or
inflammatory in etiology. Echo showed no vegetations. He was
empirically started on vanc, zosyn, and levofloxacin. His
antibiotics were eventually discontinued as the concern for
infection was low. The patient remained afebrile while off
antibiotics.
# ___: On hospital day 2 pt developed ___, Cr went up to 3
(baseline normal) FeNa>1% with a bland urine sediment and one
muddy brown cast. His creatinine continued to uptrend and it was
felt this was most likely related to contrast nephropathy. Renal
was consulted to help manage his renal failure. He received IVF
however there was no improvement in his renal function. He also
received a dose of lasix IV while he was hypervolemic, however
his renal function worsened with that intervention. His
electrolytes were monitored closely and his creatinine peaked at
5.0 on ___. He made adequate UOP and did not require dialysis.
His creatinine decreased to 4.1 at the time of discharge. He
will have him follow up in the ___ clinic as an outpatient.
# Positive B-glucan: as part of the infectious workup a B-glucan
was sent and it returned positive at 248. Given the patient's
history of CLL, bendamustine administration, COPD, and gastric
cancer, there was concern for PCP. ID and pulm were consulted. A
repeat B-glucan was sent. ___ reviewed his chest imaging with
radiology and the concern for PCP was low. Multiple attempts
were made to obtain induced sputums and they were unsuccessful.
We had a discussion regarding the need for bronchoscopy, however
the patient was considered to be a high risk for bronchoscopy
due to co-morbidities. The repeat B-glucan returned the day of
discharge and was 147. This was ultimately attributed to a false
positive result. The patient should have a CT chest performed in
___ weeks per ___ recommendations.
# Aphthous ulcer/mucositis: patient complained of mouth sores
which he has had in the past. He was started on oral mouth care.
Patient was also noted to have thrush and was started on
nystatin.
CHRONIC ISSUES
# Abdominal pain - continued oxycontin, oxycodone
# Normocytic anemia - likely ___ marrow suppression from chemo
and ACD from malignancy. His Hct was stable.
# Hx CLL - He completed six cycles of bendamustine and Rituxan
in ___, currently in remission.
# Stage ___ Metastatic gastric cancer: C2D11 Epirubicin
Oxaliplatin Capecitabine (he last received chemo ___,
capecitabine has been discontinued) - his outpatient oncologist
was involved in his inpatient care
# COPD - continued home inhalers, Duonebs prn
# IDDM - continued home lantus while inpatient
# Anxiety/Depression - continued citalopram, ativan prn
# HTN - continued home diltiazem hold SBP <110
# GERD: continued home PPI
TRANSITIONAL ISSUES
======================
- B-glucan was pending at the time of discharge. This returned
and the results were relayed to his outpatient oncologist and
inpatient consultants.
- patient has a PCP appointment on ___. He should have his
electrolytes and renal function checked at that time.
- ___ recommends repeat CT chest in ___ weeks
CODE: DNR/DNI
EMERGENCY CONTACT HCP: ___ (wife)
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Diltiazem Extended-Release 300 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
7. Loratadine 10 mg PO DAILY:PRN allergy
8. Lorazepam 0.5 mg PO Q8H:PRN nausea
9. Montelukast 10 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
14. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Pseudoephedrine 60 mg PO Q6H:PRN allergy
17. Pyridoxine 100 mg PO DAILY
18. Senna 17.2 mg PO BID:PRN constipation
19. Tiotropium Bromide 1 CAP IH DAILY
20. Ciprofloxacin HCl 750 mg PO Q12H
21. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
22. DiphenhydrAMINE 25 mg PO QHS:PRN allergies
23. Diphenoxylate-Atropine 1 TAB PO Q6H
24. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
25. Methylnaltrexone 12 mg SUBCUT QAM:PRN constipation
26. TraZODone 50-100 mg PO QHS:PRN sleep
27. Nystatin Oral Suspension 5 mL PO BID
28. Lantus (insulin glargine) 10 units subcutaneous QHS
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Diltiazem Extended-Release 300 mg PO DAILY
3. DiphenhydrAMINE 25 mg PO QHS:PRN allergies
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
8. Lorazepam 0.5 mg PO Q8H:PRN nausea
9. Montelukast 10 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Nystatin Oral Suspension 5 mL PO BID
12. Omeprazole 20 mg PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Pseudoephedrine 60 mg PO Q6H:PRN allergy
17. Pyridoxine 100 mg PO DAILY
18. Senna 17.2 mg PO BID:PRN constipation
19. Tiotropium Bromide 1 CAP IH DAILY
20. TraZODone 50-100 mg PO QHS:PRN sleep
21. hydrocodone-homatropine ___ mg/5 mL oral Q4H:PRN cough
22. Lantus (insulin glargine) 10 units subcutaneous QHS
23. Loratadine 10 mg PO DAILY:PRN allergy
24. Methylnaltrexone 12 mg SUBCUT QAM:PRN constipation
25. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
26. Caphosol 30 mL ORAL QID:PRN mouth sore
RX *saliva substitution combo no.2 [Caphosol] 30 mL four times
a day Refills:*0
27. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
28. FIRST-Mouthwash BLM (___)
200-25-400-40 mg/30 mL mucous membrane Q6H:PRN mouth sores
RX ___ [FIRST-Mouthwash ___] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL 5 mL every 6 hours Disp #*237
Milliliter Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: metastatic gastric cancer, fever, acute kidney injury
Secondary: COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because of a fever. You were worked up for the
cause and were started on antibiotics and completed the
antibiotics while you were in the hospital. You did not have
evidence of a fever in the hospital which was reassuring. While
you were here your kidneys were not working well due to contrast
you were given for recent scans. We consulted the kidney doctors
and your ___ were monitored closely. We also spoke to the
Infectious Disease doctors as one of your microbiology labs came
back abnormal. This was repeated and was pending at the time of
discharge. Dr. ___ will follow this up as an outpatient.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19643415-DS-17
| 19,643,415 | 29,039,375 |
DS
| 17 |
2141-03-12 00:00:00
|
2141-03-15 06:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bee Sting Kit / Shellfish Derived / Clindamycin
Attending: ___
Chief Complaint:
altered mental status; pain crisis
Major Surgical or Invasive Procedure:
Received 5 fractions of XRT to rib mets over course of this
admission, refer to Rad-Onc notes for further detail.
History of Present Illness:
___ male with metastatic gastric cancer in the setting
of CLL and CVID on palliative chemotherapy on hold for toxicity.
Saw Dr. ___ ___, he was given IVIG and zometa
and referred to rad/onc for palliative tx for his bone mets. Was
confused at the time and suspected it was related to increased
narcotics. MR head was arranged for ___. Patient's daughter
___ (___) called office to report her father is
having extreme pain, but patient's wife is not letting his
daughter take him to the hospital because she promised not to
take him because he did not want to die in the hospital. He is
confused, yelling, not making sense. His mental status has been
waxing and waning as well as associated with agitation. Speech
is at baseline, no focal deficits seen. No fever/chills (other
than his usual), no constipation or diarrhea recently.
Patient has been taking methadone and oxycodone ___ mg QID
PRN (requiring round the clock). On ___ ___
changed methadone to 20mg TID from 30mg TID (thought not
effective) and increased oxycodone to 30mg TID from 20mg TID. He
has been getting this medication regularly, no changes in doses
since then. Refered to ED for evaluation.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR, last clinic note ___
Gastric cancer stage IV and synchronous CLL
- Long history heartburn and reflux since his ___
- ___ Started omeprazole for GI symptoms with good effect
- ___ Underwent lap banding for weight loss and reflux
- ___ Lap band ruptured due to cough
- ___ to ___ Received BR x 6 cycles for CLL
- ___ CT torso to assess response to therapy for CLL
showed only a gastrohepatic ligament.
- ___ CT torso to assess CLL showed new regions of
ill-defined hypoensity, particularly in hepatic segments V and
VI, may be due to focal fatty infiltration. However,
infiltrative
disease/neoplasm is on the differential diagnosis. Previously
described gastrohepatic ligament lymph node is not seen on the
current study. Some new pulmonary nodules.
- ___ MR abdomen showed ill-defined 5.8 x 1.2 cm
hypoenhancing lesion along the proximal aspect of the lesser
curvature of the stomach, adjacent to the fundoplication site,
with enlarged gastrohepatic, gastroepiploic, and left paraaortic
lymph nodes, adjacent fat stranding, and numerous liver lesions,
concerning for metastatic gastric neoplasm. Severe hepatic
steatosis.
- ___ EGD showed an infiltrative and ulcerated 4 cm mass
with stigmata of recent bleeding of malignant appearance at the
gastroesophageal junction and lesser curve. Also found to have
esophageal candidiasis. Biopsies showed poorly differentiated
signet ring adenocarcinoma.
- ___ PET CT showed multiple foci of FDG avidity
throughout the liver are most consistent with metastatic
disease.
Two subcentimeter FDG avid paraaortic lymph nodes. Innumerable
subcentimeter lung nodules and ___ opacities in the
peripheral lung parenchyma demonstrate minimal FDG avidity most
consistent with infection or aspiration.
- ___ EUS and biopsy of a liver lesion showed metastatic
disease
- ___ to ___ Palliative XRT
- ___ C1D1 EOX (epirubicin 50 mg/m2, oxaliplatin 130
mg/m2, capecitabine 1500 mg BID)
- ___ C2D1 EOX (epirubicin 50 mg/m2, oxaliplatin 130
mg/m2, capecitabine 1500 mg BID)
- ___ to ___ Admitted with diarrhea, capecitabine
held
- ___ Admitted for fevers again. CT resulted in contract
induced nephropathy, which required several weeks to improve.
Underwent work up of elevated D-B-glucan. Discharged ___.
- ___ C1D1 FOLFOX6 (ci5FU 1800 mg/m2/46 hours) D1,15
PAST MEDICAL HISTORY:
-COPD
-CVID
-CLL
-___ ___ contrast induced nephropathy
-DM
-GERD
-HTN
Social History:
___
Family History:
No family hx of GI cancers
Physical Exam:
ADMISSION:
VITAL SIGNS - Temp 97.7 F, BP 130/70 mmHg, HR 100 BPM, RR 18X',
O2-sat 97% RA
GENERAL - well-appearing man in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pale, no cyanosis of the oral mucosa. No
xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Bibasilary wheezes (insp/exp) all lung fields, worse
bases. good air movement, resp unlabored, no accessory muscle
use
HEART - PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Tachy 100.
ABDOMEN - NABS, soft/ND, pain on deep palpation in LUQ, no
masses or HSM, no rebound/guarding. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
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
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE:
Pertinent Results:
ADMISSION/IMPORTANT LABS:
___ 01:50PM BLOOD WBC-15.9*# RBC-3.91* Hgb-11.1* Hct-36.0*
MCV-92 MCH-28.4 MCHC-30.8* RDW-19.6* RDWSD-65.6* Plt ___
___ 01:50PM BLOOD Glucose-205* UreaN-19 Creat-0.9 Na-135
K-3.7 Cl-98 HCO3-22 AnGap-19
___ 01:50PM BLOOD ALT-132* AST-184* AlkPhos-687*
TotBili-0.9
LABS AT DISCHARGE:
-----------------
___ 04:36AM BLOOD ALT-125* AST-227* LD(LDH)-950*
AlkPhos-440* TotBili-8.5*
___ 04:36AM BLOOD WBC-11.2* RBC-3.11* Hgb-8.2* Hct-27.8*
MCV-89 MCH-26.4 MCHC-29.5* RDW-21.2* RDWSD-67.7* Plt ___
___ 05:21AM BLOOD Neuts-80.7* Lymphs-9.9* Monos-7.1 Eos-1.6
Baso-0.2 Im ___ AbsNeut-8.83* AbsLymp-1.08* AbsMono-0.78
AbsEos-0.17
IMAGING/OTHER STUDIES:
Head CT non-con ___. No evidence of mass effect, given the limitations of a
noncontrast
enhanced examination. MRI is more sensitive in evaluating for
metastatic
lesions and can be considered if there is persistent clinical
concern.
RUQ U/S ___. Innumerable masses within the liver compatible with known
metastases.
2. No intra or extrahepatic biliary dilatation.
3. Patent main portal vein
4. Trace perihepatic ascites
5. Stable splenomegaly
Brief Hospital Course:
___ male with metastatic gastric cancer to LNs and Liver
previously on palliative chemo prior to admission with history
of CLL, CVID, DM admitted with severe pain and AMS. Now with
worsening liver dysfunction likely ___ to known mets.
#Liver dysfunction: Progressive transaminitis developed over
course of hospitalization in setting of known liver mets
consistent with progression of disease. RUQ U/S performed which
demonstrated patent flow to portal vein, no biliary process, and
known mets to liver parenchyma. Patient experienced waxing and
waning hepatic encephalopathy with asterixis noted. Lactulose
given and titrated to ___ bowel movements a day, but patient
with persistent waxing and waning delirium.
#Pain: has 4.7 x 1.9 cm destructive lytic lesion in the
posterior left seventh rib with associated soft tissue component
compatible with metastasis which is painful on exam in addition
to abdominal pain. He is on methadone 20mg TID and oxycodone
___ mg PO Q6H:PRN pain at home. Pain regimen uptitrated on
this admission to methadone 30mg TID. Continued on break through
concentrated liquid morphine and Ibuprofen 400mg TID. Patient
completed 4 of 5 fractions of XRT for lytic bone lesions. He
could not complete his last fraction because of behavioral
issues and family elected to have patient home for hospice care
prior to completion.
#Altered Mental Status: waxing and waning mental status
throughout admission. CT head unchanged from prior. Neuro exam
significant for poor attention and limited as pt intermittently
following commands but overall nonfocal. Leading ddx is Hepatic
encephalopathy but also includes side effect from narcotics,
delirium in setting of pain vs. meds. No signs of infection with
negative UA, CXR, and blood cultures. As per palliative care
recs, patient started on thorazine at time of discharge to help
stabilize behavior for safe home hospice.
#Metastatic Gastric cancer: stage IV, has received EOX and
FOLFOX chemotherapy with palliative intent on hold currently ___
toxicities. Progressive disease off therapy with new bone
metastasis. Most recently pursuing radiation for left chest
pain. S/p zometa for bone lesions. 4 out of 5 XRT fractions as
above. Extensive family meetings with family and primary
oncologist with decision to pursue home hospice care.
#CLL: in remission.
#CVID: ___ CLL and treatment. receiving IVIG monthly with last
on ___
#COPD: continued home regimen. Recently treated with ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Lorazepam 0.5 mg PO TID:PRN nausea, anxiety
3. Methadone 20 mg PO TID
Tapered dose - DOWN
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 40 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN low grade nausea
8. Pyridoxine 100 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Fluconazole 200 mg PO Q24H
11. Docusate Sodium 100 mg PO BID
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
13. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1
puff oral twice a day Disp #*1 Disk Refills:*3
2. Ibuprofen 400 mg PO Q8H
RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/SOB
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 ml
neb every six (6) hours Disp #*30 Ampule Refills:*3
4. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ML by mouth three times a day
Disp #*900 Milliliter Refills:*0
5. Methadone 30 mg PO TID
RX *methadone 10 mg 3 tablets by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Morphine Sulfate (Oral Soln.) ___ mg PO Q3H:PRN breakthrough
pain
RX *morphine 10 mg/5 mL 5 ML by mouth Q3H Refills:*0
7. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff
oral daily Disp #*1 Capsule Refills:*3
9. Zofran ODT (ondansetron) 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
10. ChlorproMAZINE 50 mg PO QHS
RX *chlorpromazine 50 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
11. ChlorproMAZINE 25 mg PO TID agitation/confusion
RX *chlorpromazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
12. ChlorproMAZINE 25 mg IM DAILY pain
may repeat x 1 dose in 24hours
RX *chlorpromazine 25 mg/mL 1 ml IM DAILY Disp #*6 Ampule
Refills:*0
13. Syringe 3cc/22Gx1 (syringe with needle (disp)) 3 mL 22 x 1
IM DAILY
RX *syringe with needle (disp) [MedSaver Syringe 3cc/22Gx3/4"]
22 gauge X ___ ONCE DAILY Disp #*6 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: metastatic gastric carcinoma with involvement of bone
and liver; hepatic dysfunction; delirium; pain crisis
secondary: COPD; supraventricular tachycardia
Discharge Condition:
Waxing and waning mental status ranging from extremely confused
to calm/oriented x2. Level of consciousness ranging from
hyperactive delirium to minimally responsive to moderately
impaired but directable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___. You were admitted to the hospital for worsening
pain and confusion and were given medications to help these
symptoms. You also received radiation therapy to your ribs where
the cancer had spread in order to help control your pain.
Unfortunately, your blood tests showed that your liver function
has worsened due to the cancer. After a family meeting with your
oncologist, Dr. ___ was decided that further
chemotherapy would be too toxic and that further medical care
would focus on comfort.
As determined by your family, health care proxy, and medical
team, you will be discharge to an ___ facility.
Dr. ___ will continue to oversee further medical
management with attention to your goals of care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19643415-DS-7
| 19,643,415 | 26,261,450 |
DS
| 7 |
2140-06-06 00:00:00
|
2140-06-06 14:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bee Sting Kit / Shellfish Derived / Clindamycin
Attending: ___.
Chief Complaint:
Foot Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CLL s/p 6 cycles of bendamustine and Rituxan, and very
recently found to have new gastric adenocarcinoma with signet
ring morphology in the lower esophagus. Was scheduled to be seen
by GI onoclogy tomorrow but presented to ___ ED s/p fall found
to have ankle fracture.
Around 9 ___ last night, 7 hours prior to arrival to the ER, he
slipped and fell down the stairs, landing on his left ankle and
buttocks. Currently complaining of left ankle pain. Patient also
endorses ongoing abdominal discomfort and constipation for 4
days in the setting of opiate usage. Also endorses mild left arm
pain after the fall but no focality. Denies head straight, neck
pain, additional complaints at this time.
- In the ED, initial VS were 98.6 101 154/73 16 95% RA.
- Labs were notable for normal chem pael, hct 35, wbc 10,
lactate 1.7, normal UA.
- Imaging was notable for XR L ankle which showed comminuted
fibular fracture, no mortise widening, XR L elbow showed no
acute process. ED noted will splint and have f/u with ortho,
non-weight bearing. Also had a normal CXR and tib/fib xray.
- Patient was given oxycodone, duonebs, azithromycin and
prednisone.
- Patient was admitted to OMED given new fracture (will need ___,
likely to fail crutches given 300 lbs), ___ pain, COPD
exacerbation, some confusion per pt and wife, and unsafe at
home.
- VS prior to ED 10 99.8 102 140/64 17 96% RA.
Past Medical History:
PAST ONCOLOGIC HISTORY: CLL s/p 6 cycles of bendamustine and
Rituxan, and very recently found to have new gastric
adenocarcinoma. He underwent restaging scans in ___ as he
developed a mild anemia. He was found to have a gastric mass. He
underwent an endoscopy on ___ with biopsy and was found to
have an adenocarcinoma with signet ring morphology in the lower
esophagus. EUS on ___ also showed a liver mass.
PAST MEDICAL HISTORY:
- Asthma/COPD
- TBM s/p tracheoplasty in ___
- C1 through C7 fusion,
- Insulin dependant diabetes.
- depression
- hld
- morbid obesity (BMI 38, 300 lbs)
Social History:
___
Family History:
-ve for gi malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.1 138/82 101 18 92 ra
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: mild wheezes bilarerally, no crackles, rales, resp
distress
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; left foot in
dressing
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities, gait
normal
DISCHARGE EXAM:
VS: 98.4 140/70 104 18 94 RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: mild wheezes bilarerally, no crackles, rales, resp
distress
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; left foot in
CAST
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities, gait
normal
Pertinent Results:
ADMISSION:
___ 06:31AM BLOOD WBC-10.5 RBC-4.32* Hgb-12.3* Hct-35.2*
MCV-81* MCH-28.4 MCHC-34.9 RDW-16.8* Plt ___
___ 06:31AM BLOOD Neuts-84.4* Lymphs-8.3* Monos-5.5 Eos-1.8
Baso-0
___ 06:31AM BLOOD Glucose-189* UreaN-16 Creat-1.0 Na-133
K-4.6 Cl-94* HCO3-29 AnGap-15
___ 06:31AM BLOOD ALT-43* AST-43* AlkPhos-98 TotBili-0.6
___ 06:31AM BLOOD Lipase-10
___ 06:36AM BLOOD Lactate-1.7
___ 06:01AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:01AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:01AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
DISCHARGE:
___ 07:15AM BLOOD WBC-9.3 RBC-4.24* Hgb-12.1* Hct-35.0*
MCV-83 MCH-28.4 MCHC-34.4 RDW-16.3* Plt ___
___ 07:15AM BLOOD Glucose-218* UreaN-18 Creat-0.9 Na-133
K-4.2 Cl-94* HCO3-30 AnGap-13
LEFT ANKLE/TIB-FIB XRAY: Oblique, nondisplaced fracture through
the lateral malleolus.
CT HEAD NON CON:
1. No evidence of mass effect or acute intracranial hemorrhage.
2. Grossly stable soft tissue lesion adjacent to the right
superior rectus muscle.
3. Unchanged age-related involutional changes and mild sinus
disease.
4. Within limits of this noncontrast exam, no definite
intracranial mass
identified. Please note MRI of the brain with contrast is more
sensitive for the evaluation of intracranial metastatic disease.
ELBOW XRAY: No acute fracture, dislocation, or joint effusion.
CHEST PA LAT: No definite focal consolidation.
Brief Hospital Course:
___ w/ CLL in remission now w/ newly diagnosed signet cell adeno
in lower esophagus here s/p fall and ankle fracture. Was seen by
ortho. non-dsiplaced fracture. Was fitted with a cast. Did well
with ___. Dc-ed home in stable condition.
# Left ankle frature: s/p fall. Fitted for a case. Cleared by pt
to go home. Ortho consulted who recommended the cast, non
operative management. Increased oxycodone dose for pain control.
# COPD Exacerbation: mild, cxr shows no acute process. Continued
home spiriva, advair, combivent and started azithro X 5 days but
held off steroids. Continued home loratadine
# IDDM: continued daibetic diet, home insulin regimen but held
metformin while inpatient
# HLD: continued simvastatin
# Anxiety/Depression: continued citalopram, clonazepam
# New GI Malignancy: recent diagnosis, EUS also showed liver
mass so potentially metastatic. New outpatient team emailed
regarding need for further workup and will see him in clinic on
___.
# HTN: continued home dilt as short acting
# GERD: continued ppi
# Back Pain: increased home oxycodone dose
FEN:
- diabetic diet
PAIN: see above
BOWEL REGIMEN: senna/colase/magcitrate (last BM 4 days ago)
DVT PROPHYLAXIS: Lovenox 40mg sc qd
ACCESS: PIV
CODE STATUS: FC
CONTACT INFORMATION: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. Montelukast 10 mg PO DAILY
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Omeprazole 20 mg PO DAILY
6. Diltiazem Extended-Release 300 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Tiotropium Bromide 1 CAP IH DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Simvastatin 40 mg PO QPM
11. HumaLOG (insulin lispro) 35 units subcutaneous TID W/MEALS
12. insulin detemir 60 units subcutaneous QAM
13. HumuLIN 70/30 (insulin NPH and regular human) 30 units
subcutaneous QHS
14. Ferrous Sulfate 325 mg PO DAILY
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth q4 Disp #*60 Tablet
Refills:*0
9. Simvastatin 40 mg PO QPM
10. Tiotropium Bromide 1 CAP IH DAILY
11. Diltiazem Extended-Release 300 mg PO DAILY
12. HumaLOG (insulin lispro) 35 units subcutaneous TID W/MEALS
13. HumuLIN 70/30 (insulin NPH and regular human) 30 units
subcutaneous QHS
14. insulin detemir 60 units subcutaneous QAM
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Azithromycin 250 mg PO Q24H Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
17. Outpatient Physical Therapy
Bariatric Rolling Walker. Patient with ankle fracture.
18. Montelukast 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ankle Fracture
CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after you fell and fractured your ankle. You
were discharged home in a stable condition.
Followup Instructions:
___
|
19643517-DS-2
| 19,643,517 | 21,813,116 |
DS
| 2 |
2148-11-03 00:00:00
|
2148-11-03 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever/cough and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION AND TRIGGER NOTE .
REASON FOR TRIGGER ON THE FLOOR: Tachycardia to 160 when walking
to the bathroom
___
Time: ___ AM
_
________________________________________________________________
PCP: Name: ___
Location: ___
Address: ___, ___
Phone: ___
Fax: ___
.
_
________________________________________________________________
HPI:
___ w/ 2 weeks of URI sx including cough, initially a sore
throat which has since resolved, SOB when climbing 3 flights of
steps- she is an athlete at baseline- along with an
intermittently productive cough. She went to the ___
___ 8 days ago and was diagnosed with sinusitis and
given amoxicillin/prednisone 60 mg along with flovent inhaler.
She then returned to ___ 3 days PTP and her steroid was stopped
but the abx was continued. 3 days PTP she started having brown
loose stools with associated b/l lower quadrant abdominal
cramping. No nausea or vomiting except upon arrival to the floor
when she vomited x 1. Since being in the ED her diarrhea has
worsened such that she has moved her bowel several times per
hour- non bloody stool. Her abdominal pain worsens with eating.
Over the last 2d has been getting sob. fever to 101.3.
congestion, cough w/ yellow/white mucus. no ST. LMP 2 weeks ago.
+ flu shot this year. + pleuritic chest pain. no hemoptysis, no
unilateral leg swelling. no stiff neck, no meningismus. slight
HA. took 2 advil before coming to the ED today. She has not been
bedbound. She has not been on road trips or plane flights. No
sick contacts. + fatigue and malaise. No family history of blood
clots but she does take OCPs.
In ED
"tachy to 140s, spo2 ___rackles
- no wheezing
- no abd pain
[] u/a, ucg
[] labs
[] tylenol
[] IVF 3L bolus
[] ekg for tachy (likely sinus)
[] cxr
[] levoquin (was on amox)
- still tachycardic s/p 4L IVF and antipyretics, thus admitted
to medicine.
In ER: (Triage Vitals: 3 100.2 142 127/79 20 99% ra )
Meds Given:
Acetaminophen 500mg Tablet 2 ___.
___ 19:39 Levofloxacin 750mg Premix Bag 1 ___.
___ 19:40 Ibuprofen 600mg Tablet
Fluids given: 4L NS
Radiology Studies: CXR
.
PAIN SCALE: ___ b/l lower quadrant and below the umbilicus.
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ +] Chills [ ] Sweats [ +] Fatigue [ +]
Malaise [ ]Anorexia [ ]Night sweats
[ -] _____ lbs. weight loss/gain over _____ months
Eyes [X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[x ] Shortness of breath [X ] Dyspnea on exertion [ ] Can't
walk 2 flights [x] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [X]
Chest Pain [X] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[+ ] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling
[+] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
NKDA
[X]all other systems negative except as noted above
Past Medical History:
Ashtma- exercise induced
Atypical nevus
HR = 105 in clinic in ___
Social History:
___
Family History:
Mother with HTN and father in good health with no medical
problems. PGM died of an MI but was a heavy smoker. PGF died of
Alzheimer's dementia. MGF died in her ___ after CCY.
Physical Exam:
1. VS: T = 97.6 P ___ BP 131/93 RR 18 O2Sat on _100% RA__
GENERAL: Thin young female laying in bed. Her boyfriend is at
the bedside.
Nourishment: good
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [X] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate\
4. Cardiovascular [] WNL
[] Regular [X] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[x] Edema LLE None
2+ DPP pulses b/l
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
NABS, soft, no rebound, b/l lower quadrant and lower
periumbilical tenderness
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[X] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
[] Warm [] Dry [] Cyanotic [X] Rash: none[ ] Cool [] Moist []
Mottled [] Ulcer: None
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [x]WNL
[X] No cervical ___ [] No axillary ___ [] No supraclavicular
___ [] No inguinal ___ [] Thyroid WNL [] Other:
Pertinent Results:
___ 06:20PM URINE HOURS-RANDOM
___ 06:20PM URINE UCG-NEGATIVE
___ 06:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:15PM GLUCOSE-83 UREA N-14 CREAT-0.9 SODIUM-134
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16
___ 05:15PM GLUCOSE-83 UREA N-14 CREAT-0.9 SODIUM-134
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16
___ 05:15PM estGFR-Using this
___ 05:15PM WBC-18.5* RBC-5.15 HGB-15.1 HCT-44.3 MCV-86
MCH-29.2 MCHC-34.0 RDW-12.8
___ 05:15PM NEUTS-90.5* LYMPHS-5.0* MONOS-4.1 EOS-0.1
BASOS-0.3
___ 05:15PM PLT COUNT-251
___ 05:10PM LACTATE-1.3
Admission CXR: Images reviewed by author:
1. Patchy posterior basilar opacity, most likely in the right
lower lobe, suggesting pneumonia, although the side is not
entirely certain.
2. Mildly bulging left mid mediastinal contour, suggesting
enlargement of the left atrial appendage. Other etiologies
could yield this contour too, such as a thymic cyst.
Correlation with prior films may be helpful if available
clinically.
Brief Hospital Course:
The patient is a ___ year old health female with h/o ashtma who
presents with URI sx, shortness of breath, fever found to have
PNA on CXR. On presentation to the ED pt had tachycardia to
150s. She was hydrated and remained tachycardic.
Pt was admitted to the hosptialist service. She was started on
levofloxacin for penumonia. Over the course of her stay here
her tachycardiac greatly improved. She came down to ___
overnight, then 90-100 in the day at rest, 110s with walking.
Pt developed diarrhea on admit with multiple liquids stools per
day. This improved with decrease in frequency and they became
to form up. There was noted a small amount of blood, but this
also improved. Cdiff was negative. Stool cx were sent, but
remained negative. Pt's antibiotic for pneumonia (levo) will
also over common stool pathogens.
Pt began to take good PO and was able to d/c to home with family
support and outpt follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aviane *NF* (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg
Oral daily
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
2. Aviane *NF* (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg
Oral daily
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
4. Acetaminophen 1000 mg PO Q6H:PRN pain
three 325mg tabs, 3 times/day.check over the counter meds that
have tylenol to prevent overdose
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia with diarrhea
Discharge Condition:
improved, ambulating normally
Discharge Instructions:
increase your activities as you feel up to them
be sure to rest up and drink plenty of liquids
Followup Instructions:
___
|
19643838-DS-11
| 19,643,838 | 27,381,839 |
DS
| 11 |
2120-02-28 00:00:00
|
2120-03-04 12:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / aspirin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Bilateral Nephrostomy tube replacement
History of Present Illness:
___ year old male with history of prostate cancer presents for
fever. He felt feverish with chills last night and today. He
also noticed suprapubic pain and some mild back pain around his
nephrostomy tubes. Patient states he was at his PCP for ___
routine appointment and spiked a fever there. Patient states he
feels generally weak and tired. He denies nausea or vomiting,
dyspnea, or chest pain. He does report intermittent
nonproductive cough. The patient has a history of frequent
urinary tract infections, especially after nephrostomy tube
placement.
.
In the ED, initial vitals were 98.6 92 120/67 18 94%RA. Labs
showed hematocrit of 37, creatinine of 1.4, bicarbonate of 20.
Lactate was 2.5. AST was 102 and ALT was 77. Urinalysis from
nephrostomy tubes showed >182 WBC, 55 RBC, moderate bacteria, 0
epis, large leuks, small blood, positive nitrites and 100
protein. Patient received 400 mg IV ciprofloxacin x 1 and
acetaminophen 650 mg PO x 1. Chest X-ray showed no acute
cardiopulmonary process. Blood and urine cultures were sent.
.
On the floor, patient reports feeling better. He is currently
not feeling feverish.
.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
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.
Denies arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
Castrate-Resistent Prostate Cancer s/p prostatectomy, bilateral
percutanous nephrostomy tubes, currently receiving chemotherapy
Diabetes Mellitus
Hypertension
Hernia repair
Social History:
___
Family History:
Father: prostate cancer
Physical Exam:
*ADMISSION EXAM*
Vitals: T: 98.5 BP: 117/73 P: 77 R: 20 O2: 98%RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MM slightly dry.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: 2+ edema bilaterally to ___ up shins, no clubbing or
cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
.
*DISCHARGE EXAM*
Vitals - Tc 98.5 BP 115/60 (110-115/60-68) HR 81 (72-81) RR 18
SaO2 95% RA
GENERAL: resting comfortably in bed, no acute distress
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: PERRLA, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: nephrostomy tubes in place, draining clear urine,
dressings bilaterally clean and intact
EXTREMITIES: 2+ DP pulses bilaterally, no edema or cycanosis
NEURO: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS
--------------
___ 06:00PM BLOOD WBC-9.4 RBC-4.38* Hgb-12.6* Hct-37.3*
MCV-85 MCH-28.8 MCHC-33.8 RDW-14.3 Plt ___
___ 06:00PM BLOOD Neuts-84.5* Lymphs-10.0* Monos-5.1
Eos-0.2 Baso-0.2
___ 06:00PM BLOOD Plt ___
___ 06:00PM BLOOD Glucose-197* UreaN-15 Creat-1.4* Na-136
K-3.8 Cl-102 HCO3-20* AnGap-18
___ 03:05PM BLOOD ALT-77* AST-102* AlkPhos-88 TotBili-0.7
___ 03:05PM BLOOD PSA-9.5*
___ 06:10PM BLOOD Lactate-2.5*
U/A:
___ 06:45PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:45PM URINE RBC-26* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
.
DISCHARGE LABS
--------------
___ 07:30AM BLOOD WBC-5.4 RBC-3.62* Hgb-10.3* Hct-30.3*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.1 Plt ___
___ 07:30AM BLOOD Glucose-141* UreaN-18 Creat-1.4* Na-136
K-3.6 Cl-105 HCO3-23 AnGap-12
___ 07:00AM BLOOD ALT-35 AST-44* AlkPhos-58 TotBili-0.4
___ 07:30AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9
.
MICROBIOLOGY
------------
Blood cultures x 2 on admission: no growth
Urine culture on admission:
URINE CULTURE (Final ___:
PSEUDOMONAS PUTIDA . >100,000 ORGANISMS/ML..
IDENTIFICATION PERFORMED ON CULTURE # ___
(___).
sensitivity testing performed by Microscan.
SULFA X TRIMETH (>=4 MCG/ML) AND CEFEPIME (<= 2 MCG/ML)
AND
MEREPENEM (,=1 MCG/ML).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS PUTIDA
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CEFEPIME-------------- S
CEFTAZIDIME----------- 2 S
CEFTRIAXONE----------- 8 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S <=0.5 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=1 S =>8 R
MEROPENEM------------- S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- <=8 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- R
VANCOMYCIN------------ 2 S
.
IMAGING
-------
KUB ___:
IMPRESSION:
1. The right nephrostomy tube appears to be lateral but still
likely in
place. The left nephrostomy tube is in place.
.
CXR ___:
IMPRESSION: no acute cardiopulmonary process
Brief Hospital Course:
Impression: ___ year old male with history of castrate-resistant
prostate cancer and nephrostomy tube placement presents with
fever.
.
*ACTIVE ISSUES*
# Fever: urinalysis with evidence of UTI, most likely source of
fever. CXR was negative and blood cultures were sent. He
remained hemodynamically stable throughout hospital course. He
was started on empiric ciprofloxacin but transitioned to
ceftriaxone when he continued to spike temperatures up to 102.
Patient has bilateral nephrostomy tubes in place but KUB showed
tubes may be displaced. ___ took patient to replace tubes with
stents, but patient spike a temperature at the suite and so
nephrostomy tubes were simply replaced. Urine culture showed
pansensitive pseudomonas putida and patient was transitioned to
cefpodoxime. He was discharged with a 14 day course. Patient
will follow-up with ID to determine whether he should remain on
prophylactic antibiotics, given UTIs are recurrent problems for
him. He will follow-up with ___ to replace nephrostomy tubes with
stents in ___.
.
*CHRONIC ISSUES*
# Prostate cancer: patient continued on home dose of leuprolide.
He will follow-up with Dr. ___ as scheduled.
# Chronic kidney disease: currently at baseline. Nephrostomy
tubes in place.
# Transaminitis: chronic, and stable related to prior labs.
# Diabetes mellitus: held home glimepiride while patient in
hospital, started sliding scale. Discharged with home meds.
# Hypertension: not currently on therapy, patient
hemodynamically stable.
.
*TRANSITIONAL ISSUES*
- bilateral nephrostomy tube replacement on ___
- urine cultures pan-sensitive pseudomonas putida (except
Bactrim), pt to complete ___efpodoxime (will finish
on ___
- f/u in ___ clinic for recurrent UTI management
- ___ to replace nephrostomy tubes with stents on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. dutasteride *NF* 0.5 mg Oral daily
4. Ferrous Sulfate 325 mg PO DAILY
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
6. glimepiride *NF* 1 mg ORAL DAILY
7. Leuprolide Acetate 22.5 mg IM Q 3 MONTHS
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*23 Tablet Refills:*0
5. Leuprolide Acetate 22.5 mg IM Q 3 MONTHS
6. glimepiride *NF* 1 mg ORAL DAILY
7. dutasteride *NF* 0.5 mg Oral daily
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Urinary Tract Infection
Secondary: Castration Resistant Prostate Cancer
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 an infection from the urine from your nephrostomy
tubes. Your tubes were replaced during your stay and you were
started on the antibiotic, cefpodoxime. Please continue this
medication for an additional 11 days, as directed. Please
follow-up with your primary oncologist as listed below.
The last day of your antibiotics is ___
It was a pleasure taking care of you during your stay.
Followup Instructions:
___
|
19643838-DS-12
| 19,643,838 | 25,611,998 |
DS
| 12 |
2120-04-11 00:00:00
|
2120-04-11 15:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / aspirin
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
___ procedure just prior to admission ___:
Uncomplicated change of bilateral 10 ___, 26 cm
nephroureteral stents. No evidence of clot within the ureters.
Severe bilateral stenosis at both ureterovesical junctions with
moderate bilateral stenosis at both ureteropelvic junctions.
Abnormal appearing bladder.
History of Present Illness:
___ year old male h/o metastatic prostate cancer s/p
prostatectomy ___, radiation ___, bilateral percutaneous
nephrostomy tubes placed ___ with recurrent UTIs since then
with chief complaint of hct drop from 37.1 to 23.5 in 25 days
(hct 37.1 on ___. Baseline hct ___.
.
Ten days ago pt had bilateral nephroureteral stents placed and
left ureteroplasty by ___. Today in ___, b/l nephrostograms
demonstrated severe stenosis at both UPJ and UVJ's.
.
Pt reports that he has had thick blood coming from his tubes for
weeks, though has been somewhat improved since procedure ten
days ago.
.
Pt has been feeling a little more dyspneic over the past week
but denies cough/cp. Denies f/c, LH, HA, n/v/d/abd pain,
brbpr/melena. Still occasionally has some bloody urine come from
his penie.
.
In ED, af, vss. Given 1 unit prbcs and admitted to OMED.
Past Medical History:
Castrate-Resistent Prostate Cancer s/p prostatectomy, bilateral
percutanous nephrostomy tubes, currently receiving chemotherapy
Diabetes Mellitus
Hypertension
Hernia repair
Social History:
___
Family History:
Father: prostate cancer
Physical Exam:
Physical Examination:
VS: 98.0 106/66 80 20 95%RA
GEN: Alert, oriented to name, place and situation. no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
bilateral nephrostomy tubes draining red urine with no frank
blood or clots
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
___ 06:55PM GLUCOSE-106* UREA N-16 CREAT-1.5* SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-11
___ 06:55PM WBC-3.7* RBC-2.67* HGB-6.9* HCT-21.7* MCV-81*
MCH-25.8* MCHC-31.8 RDW-14.4
___ 06:55PM NEUTS-56.9 ___ MONOS-6.8 EOS-6.5*
BASOS-0.5
___ 06:55PM PLT COUNT-264
___ 06:55PM ___ PTT-30.0 ___
___ 01:05PM estGFR-Using this
___ 01:05PM ___
___ 07:10AM BLOOD WBC-4.3 RBC-3.12* Hgb-8.3* Hct-25.0*
MCV-80* MCH-26.6* MCHC-33.2 RDW-14.8 Plt ___
___ 07:10AM BLOOD Glucose-130* UreaN-16 Creat-1.4* Na-137
K-4.1 Cl-108 HCO3-25 AnGap-8
___ 07:10AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0
Brief Hospital Course:
Mr. ___ was admitted for evaluation and treatment of his
acute anemia. He received 1 unit of PRBCs in the ER and another
unit after admission. After transfusion he reports feeling much
better. He was having lightheadedness when standing up which has
now resolved. There was no apparent source of acute blood loss
other than the bleeding he has been having into his nephrostomy
tubes. He continues to have red tinged urine. His case was
discussed with ___ and this is expected to clear in the next few
days, after which he has been instructed to cap the nephrostomy
tubes to see if urine will flow to his bladder. He has followup
appointments with his oncologist and with ___ and will make an
appointment with his PCP for ___ blood count check in 1 week. He
will continue all of his medicines as they were prior to
admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Avodart (dutasteride) 0.5 mg Oral daily
2. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
Leuprolide
Discharge Medications:
1. Avodart (dutasteride) 0.5 mg Oral daily
2. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
3. Lupron
Discharge Disposition:
Home
Discharge Diagnosis:
acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after developing anemia in the
last month. You reported ongoing bleeding from your nephrostomy
tubes over the past several weeks, and this is presumed to be
the cause of your anemia since no other source of bleeding was
found. You received 2 units of red blood cells and report that
the lightheadedness you were feeling when you stood up has now
resolved. Your nephrostomy tubes continue to have a small amount
of blood but this is improving and the urine is expected to run
clear in the next several days. After 2 days, if there is clear
urine draining from at least one of the tubes you can cap the
tubes and see if you get urine flow into your bladder.
Followup Instructions:
___
|
19643838-DS-6
| 19,643,838 | 21,493,460 |
DS
| 6 |
2118-12-22 00:00:00
|
2118-12-31 23:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
___- Nephrostomy tubes exchanged by interventional radiology
___ Picc line placed
History of Present Illness:
Mr. ___ is a ___ year old man with a history of metastatic
prostate cancer s/p bilateral nephrostomy tube who presents with
weakness. He states the weakness has been progressive over the
past week with more significant weakness over the past day. He
recently started Abiraterone in ___ with prednisone.
He notes that his blood sugars have been elevated in the past
few weeks (were 300 this morning). He has been more sleepy
during the day. He denies fevers but notes occasional chills.
He denies pain. He has no shortness of breath or cough. He has
occasional nausea without vomiting. He reports more difficulty
eating and poor appetite.
In the emergency department, initial vitals: 98.8 80 119/69 16
98% 2L. He was found to have a positive UA and was given 1 gram
of Ceftriaxone. Potassim was 3.0 and he was given 40 meq of PO
K+ and 20 meq of IV K+.
On the floor, he feels tired but is otherwise comfortable.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Castrate-Resistent Prostate Cancer s/p protatectomy, bilateral
percutanous nephrostomy tubes, currently receiving Abiraterone
Diabetes Mellitus
Hypertension
Hernia repair
Social History:
___
Family History:
multiple family members with prostate cancer.
Physical Exam:
VS: 98.1 BP 101/73 HR 82 RR18 95%2L
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
Bilateral nephrostomy tubes with yellow urine.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
Pertinent Results:
___ 04:05PM BLOOD WBC-14.0* RBC-4.27* Hgb-13.4* Hct-40.3
MCV-94 MCH-31.5 MCHC-33.3 RDW-13.0 Plt ___
___ 04:05PM BLOOD Neuts-89.7* Lymphs-5.5* Monos-4.6 Eos-0
Baso-0.1
___ 04:05PM BLOOD Glucose-308* UreaN-19 Creat-1.4* Na-132*
K-3.0* Cl-95* HCO3-26 AnGap-14
___ 04:05PM BLOOD Calcium-8.4 Phos-2.5*# Mg-1.6
___ 04:17PM BLOOD Lactate-1.2
Urine Studies:
___ 05:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:30PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-300 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 05:30PM URINE RBC-25* WBC->182* Bacteri-MOD Yeast-MOD
Epi-0
.
CXR:No acute cardiopulmonary process.
.
Cardiac echo:The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Dilated thoracic aorta. No
definite valvular pathology or pathologic flow identified.
.
Brief Hospital Course:
___ yo man with met prostate ca with bilateral nephrostomy tubes
admitted with malaise/UTI.
.
#UTI: Pt started on ceftriaxone empirically. ___ was consulted
and the nephrostomy tubes were exchanged. Urine cx grew both
staph coag neg reistant to penicillins and enterococc. . Abx
switched to vncomycin and pt to complete 10 days of vancomycin.
Vancomycin levels will be checked at home.Blood cxs remianed
sterile.
.
#DM: Elevated BS prior to admit ,likely because of
infection.Blood sugars overall well controlled prioir to d/c on
home regimen of glipizide and ISS.
.
#Prostate ca: Cont abiraterone, prednisone, and dutasteride.
.
#HTN: D/C HCTZ given hyponatremia and hypokalemia on admit.Pt
remained normotensive throughout hospital and blood pressure to
be followed by PCP.
.
#Hyponatremia/hypokalemia:Likley due to volume depeltion/HCTZ.
Resolved with IVFs.
.
DVT PPx:SC heparin
.
Precautions for: none
.
Lines: picc line placed ___.
.
CODE: DNR/DNI.
.
Medications on Admission:
Abiraterone 1000 mg daily
Dutasteride 0.5 mg daily
Glipizide 2.5 mg once a day (with big meal)
HCTZ
Insulin sliding scale (only takes it if blood sugar elevated)
Lupron every 3 months
Prednisone 5 mg daily
Januvia - pt's diabetic doctor is considering stopping this
Vitamin C
Vitamin D
Iron
Discharge Medications:
1. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous twice
a day for 7 days.
Disp:*7 days* Refills:*0*
2. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. abiraterone 250 mg Tablet Sig: Four (4) Tablet PO daily ().
5. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. insulin sliding scale
humalog insulin sliding scale per chart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Hyponatremia
Hypokalemia
Fever
Metastatic prostate cancer
Diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___, you were admitted because of constitutional symptoms
and you were found to have a urinary tract infection. The urine
culture grew both staph and enterecoccos bacteria. You were
started on I.V antibiotics and interventional radiology changed
the nephrostomy tubes. You will need to continue IV antibiotics
at home.
Change in medications:
vancomycin 750 mg IV BID x 7 days
Discontinue hydrochlorthiazide
Followup Instructions:
___
|
19643838-DS-7
| 19,643,838 | 21,312,091 |
DS
| 7 |
2119-06-20 00:00:00
|
2119-06-28 20:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / aspirin
Attending: ___.
Chief Complaint:
Urosepsis.
Major Surgical or Invasive Procedure:
___: Nephrostomy tubes exchange by interventional radiology.
Uncomplicated.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of metastatic
prostate cancer s/p bilateral nephrostomy tube who presents with
weakness. He has no shortness of breath or cough. He has
occasional nausea without vomiting.
Initial vitals in the ED were 100.6 117 115/67 16. He was noted
to become febrile to 104 and hypotensive to ___. Labs were
notable for Cr 3.4 from 1.9, WBC 15K 85% PMNs and Hct 41.
Lactate was 2.9->2.4 in the ED. He received 5L NS, 10mg IV
dexamethasone, levofloxacin and vancomycin in the ED. His blood
pressure did improve after IVF. Nephrostomy tubes were noted to
drain frank pus. Vitals on transfer were 98.8 117 85/51 37 95%.
On arrival to the MICU, the patient complained of lethargy and
did not have additional complaints. He confirmed his DNR/DNI
status.
Past Medical History:
-Castrate-Resistent Prostate Cancer s/p prostatectomy, bilateral
percutanous nephrostomy tubes, currently receiving chemotherapy
-Diabetes Mellitus
-Hypertension
-Hernia repair
Social History:
___
Family History:
Multiple family members with prostate cancer.
Physical Exam:
Admission physical exam:
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
Bilateral nephrostomy tubes with yellow urine.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
.
Discharge physical exam:
afebrile
GENERAL: alert and oriented, NAD, pleasant well appearing
gentleman on NC
HEENT: No scleral icterus. EOMI. MMM. Neck supple, No LAD. JVD
unable to assess
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
Bilateral nephrostomy tubes with yellow urine (not frankly
purulent)
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
Pertinent Results:
Admission labs:
___ 11:04AM WBC-15.2*# RBC-4.68 HGB-13.9* HCT-42.6 MCV-91
MCH-29.6 MCHC-32.6 RDW-13.8
___ 11:04AM NEUTS-87.4* LYMPHS-6.9* MONOS-5.3 EOS-0.2
BASOS-0.2
___ 11:04AM ___ PTT-30.1 ___
___ 11:04AM WBC-15.2*# RBC-4.68 HGB-13.9* HCT-42.6 MCV-91
MCH-29.6 MCHC-32.6 RDW-13.8
___ 11:04AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
___ 11:04AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 11:04AM GLUCOSE-143* UREA N-39* CREAT-3.4*#
SODIUM-136 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-24 ANION GAP-20
___ 11:05AM LACTATE-2.9*
___ 11:05AM ___ TEMP-38.4 PO2-39* PCO2-35 PH-7.43
TOTAL CO2-24 BASE XS-0 COMMENTS-GREEN TOP
___ 11:14AM URINE RBC-17* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 11:14AM URINE BLOOD-MOD NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 11:14AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 11:21AM URINE MUCOUS-OCC
___ 11:21AM URINE RBC-14* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 11:21AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 11:21AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 12:16PM LACTATE-2.4*
___ Chest X-ray
IMPRESSION: Lower lung volumes without definite acute
cardiopulmonary
process.
___ Renal ultrasound
FINDINGS: The right kidney measures 11.4 cm and the left kidney
measures 13.7 cm. There is severe hydronephrosis and
hydroureter of the left kidney, which is unchanged in appearance
from ___. The left nephrostomy tube is not clearly
delineated. Echogenic debris is seen layering in the proximal
left ureter. The right kidney does not demonstrate
hydronephrosis, stones or masses. There is suggestion of the
right nephrostomy tube partially visualized.
The bladder is only minimally distended; however, echogenic
material is seen within the bladder with no definite vascularity
within it. This could be any combination of debris or clot in
the bladder superimposed on known bladder masses. It is not
well seen on this limited study due to the nondistended bladder.
.
___ CXR
IMPRESSION: Lower lung volumes without definite acute
cardiopulmonary
process.
.
___ PROCEDURES PERFORMED:
1. Bilateral nephrostomy tube check and change.
2. Bilateral antegrade nephrostograms.
IMPRESSION:
1. Partial dislocation of the left-sided nephrostomy with
marked
hydronephrosis of the left-sided collecting system.
2. Fluoroscopy-guided bilateral nephrostomy tube exchange with
placement of two new 8 ___ nephrostomy catheters.
.
MICROBIOLOGY
___ BLOOD CULTURE, NGTD-FINAL
___ URINE CULTURE-FINAL
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ URINE CULTURE- FINAL
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood Culture, No growth (final).
___ Blood Culture, No growth (final).
___ MRSA SCREEN MRSA SCREEN-FINAL (NEGATIVE)
___ BLOOD CULTURE NGTD-FINAL
.
DISCHARGE LABS
___ 06:00AM BLOOD WBC-15.1* RBC-3.56* Hgb-10.9* Hct-32.6*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.2 Plt ___
___ 02:57AM BLOOD ___ PTT-31.1 ___
___ 06:00AM BLOOD Glucose-190* UreaN-55* Creat-1.9* Na-139
K-4.1 Cl-108 HCO3-19* AnGap-16
___ 06:40AM BLOOD Calcium-7.8* Phos-3.8 Mg-2.1
Brief Hospital Course:
>> BRIEF HOSPITAL ISSUES
Mr. ___ is a pleasant ___ year old gentleman with metastatic
prostate carcinoma who presented with urosepsis and was found to
have bilateral obstructed nephrostomy tubes. He was admitted to
the MICU, where he had these tubes exchanged, was started on
antibiotics, and was transferred to medical floor for further
care. He was hemodynamically stable during this hospitalization.
He was discharged on a course of oral antibiotics.
.
>> ACTIVE ISSUES
# Urosepsis: On admission, he met criteria for sepsis
(tachypnea, tachycardia, fever leukocytosis), with frank pus
from nephrostomy tubes. His infection was initially treated with
cefepime, ciprofloxacin (double coverage for pseudomonas) and
vancomycin. Nephrostomy tubes were exchanged by the
Interventional Radiology team. He never required pressors and
was stable for transfer to the medical floor. His urine cultures
grew out e. cloacae and klebsiella, both sensitive to
ciprofloxacin. He was discharged on oral cipro for a total 14
day course.
.
# DM type 2: Elevated BS prior to admission, likely due to
infection. While in the ICU, he received a stress dose of
steroids which increased his serum glucose as well. While in the
hospital, he was covered with a humalog ISS, and home
anti-hyperglycemics were held. Home meds were restarted upon
discharge.
.
# Acute kidney injury: On admission, creatinine was elevated to
3.4, likely secondary to infectious process and septic
physiology. He was given 5.5 liters of fluid in the ED and ICU.
His creatinine was trending downwards on discharge.
.
>> INACTIVE ISSUES
# Prostate CA: Mr. ___ has known metastatic prostate cancer.
He was continued on his home anti-neoplastic medications.
.
# Hypertension: Per his recollection and his medication list, he
is not on any home anti-hypertensives. He did not require
anti-hypertensives in the hospital.
.
>> TRANSITIONAL ISSUES
- Code status: DNR/DNI, but he reports re-thinking this.
Consider re-addressing this with him and his wife.
- Emergency contact: wife, ___ ___.
- Studies pending at discharge: ___ Blood Cultures x2 (No
growth, final).
- Patient will get labs checked and faxed to primary care doctor
after discharge.
- A copy of this discharge summary was faxed to Dr. ___
primary care doctor, at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zytiga *NF* (abiraterone) 1000 mg Oral daily
2. Avodart *NF* (dutasteride) 0.5 mg Oral daily
3. Ascorbic Acid ___ mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. glimepiride *NF* 1 mg Oral daily
6. Ferrous Sulfate 325 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Avodart *NF* (dutasteride) 0.5 mg Oral daily
3. Calcium Carbonate 500 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Zytiga *NF* (abiraterone) 1000 mg Oral daily
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 11 Days
day 1 = ___
RX *ciprofloxacin 500 mg one tablet(s) by mouth twice daily Disp
#*22 Tablet Refills:*0
8. Ferrous Sulfate 325 mg PO DAILY
9. glimepiride *NF* 1 mg ORAL DAILY
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
11. Outpatient Lab Work
Please have CBC/diff, Chem-7 drawn 2 days prior to PCP
appointment, and have results faxed to ___ (Dr. ___,
Fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Urosepsis
Clogged nephrostomy tube
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ICU at ___
___ a severe infection of your nephrostomy tubes (also
called urosepsis). You were treated with several antibiotics,
and did well, so you were transferred to the floor. You were
discharged on antibiotics to treat your infection. Please be
sure to cover your blood sugars with appropriate insulin as
indicated on your discharge paperwork. You should also continue
to take care of your dressings as you had been doing prior to
hospitalization.
It was a pleasure taking care of you. You should follow up with
your Primary care doctor and ___, as well as the
Interventional Radiologists.
While you were here, some changes were made to your medications:
Please START ciprofloxacin 500 mg by mouth twice daily for 11
more days.
Followup Instructions:
___
|
19643838-DS-8
| 19,643,838 | 21,029,134 |
DS
| 8 |
2119-09-30 00:00:00
|
2119-10-01 06:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / aspirin
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/h/o of prostate cancer c/b bladder mets s/p bilateral
percutaneous nephrostomy tubes p/w intermittent fever. Pt
underwent usual trimonthly tube exchange on ___. Pt's
nephrostomy tube was found to be dislodged on ___, pt
underwent replacement of tube on ___ evening. Pt reports
feeling unwell yesterday morning and found to have a fever to
100 responsive to Tylenol which prompted his wife to bring him
to bring him to the ED. Patient has obstructive uropathy
secondary to bladder cancer treated with bilateral percutaneous
nephrostomy tubes. Pt has had 4 UTIs since nephrostomy which
generally happen a few days after tube exchanges. He has a
history of complications including urosepsis and MICU admission.
Pt denies any diarrhea, N/V, abdominal pain, chills, cough, sore
throat, rhinorrhea, or SOB, CP, BRBPR, melena, hematochezia.
In the ED, initial vitals: 98.4 HR: 99 BP: 130/89 Resp: 18
O(2)Sat: 95%RA. Urine and bld cx sent.
Past Medical History:
Castrate-Resistent Prostate Cancer s/p prostatectomy, bilateral
percutanous nephrostomy tubes, currently receiving chemotherapy
Diabetes Mellitus
Hypertension
Hernia repair
Social History:
___
Family History:
Father: prostate cancer.
Physical Exam:
VS: T 98.3, BP 131/77, P 63, R 18 O2Sat98% RA
GENERAL: NAD, comfortable
HEENT: sclerae anicteric, MMM, OP clear
HEART: RR, nl S1/S2, no MRG
LUNGS: CTAB
ABDOMEN: Soft, NT, ND, +BS, no guarding, no CVA tenderness
EXTREMITIES: WWP, no edema
SKIN: no local erythema or exudate around nephrostomy sites;
dressings in place
Pertinent Results:
ADMISSION LABS
___ 02:34AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:34AM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD
___ 02:34AM URINE RBC-76* WBC-82* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:25AM BLOOD WBC-8.4 RBC-3.97* Hgb-11.9* Hct-35.9*
MCV-90 MCH-29.9 MCHC-33.1 RDW-14.4 Plt ___
___ 01:25AM BLOOD Neuts-75.3* Lymphs-15.1* Monos-7.7
Eos-1.5 Baso-0.4
___ 01:25AM BLOOD Plt ___
___ 01:25AM BLOOD Glucose-159* UreaN-19 Creat-1.5* Na-137
K-3.8 Cl-101 HCO3-26 AnGap-14
___ 01:34AM BLOOD Lactate-1.3
DISCHARGE LABS
___ 07:40AM BLOOD Vanco-18.2
Micro: Coag Negative Staph
Brief Hospital Course:
___ p/w w LGF after two recent procedures given dislodging of
newly exchanged PCT. Fevers c/w urinary tract infection, found
to have CNS in urine cultures.
ACTIVE ISSUES
#. Fever: Pt has had UTIs after nephrostomy tube placement.
Based on his last sensitivities pt was treated with ceftriaxone,
and because he was recently instrumented, he was also treated
with vancomycin. He remained afebrible throughout the admission
and felt much better after starting antibiotics Urine cultures
positive for coag negative staph so pt was started on PO
linezolid after brief discussion with ID fellow. He will
follow-up with his PCP to have ___ CBC checked in one week.
CHRONIC ISSUES
#. DMII: HISS during hospital course.
#. Prostate cancer: Continued home medications: zytiga 1000mg
QD, dutasteride 0.5mg QD
TRANSITION ISSUES
-On linezolid, monitor for BM supression w CBC as outpatient on
___
-F/u sensitivities - this will be done by primary inpatient team
-F/u Blood cx
-Per ___, home teaching to insure ___ dressing changes and
avoid dislodging of PCNT - Patient was dicharged home with ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. dutasteride *NF* 0.5 mg Oral daily
3. Calcium Carbonate 500 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Zytiga *NF* (abiraterone) 1000 mg Oral Daily
7. Ferrous Sulfate 325 mg PO DAILY
8. glimepiride *NF* 1 mg Oral daily
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. dutasteride *NF* 0.5 mg Oral daily
4. Ferrous Sulfate 325 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Zytiga *NF* (abiraterone) 1000 mg Oral Daily
8. glimepiride *NF* 1 mg Oral daily
9. Linezolid ___ mg PO Q12H Duration: 7 Days
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth ever 12 hours
Disp #*14 Tablet Refills:*0
10. Insulin
Please take insulin sliding scale as you were previously.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Complicated Urinary Tract Infection
SECONDARY: Metastatic prostate cancer, DMII
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. ___. You
were admitted to the hospital with a fever, which was caused by
an infection in your nephrostomy tube. We treated you with
antibiotics and your symptoms improved. We will send you home
with oral antibiotics for the next week.
Please make the following changes to your medications:
1. Start linezolid ___ mg twice a day for 7 days
Please see below for your follow-up appointments.
Followup Instructions:
___
|
19644097-DS-5
| 19,644,097 | 20,777,873 |
DS
| 5 |
2181-02-10 00:00:00
|
2181-02-10 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine / Novocain
Attending: ___.
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ ia ___ y/o woman with PMH notable for no prior cardiac
disease, HLP, and prior R-sided breast cancer s/p lumpectomy/XRT
admitted from ___ with non-specific chest discomfort and
concern for ventricular tachycardia.
Per patient, she was in her normal state of health until day
prior to admission. In the middle of the night, she describes a
few minutes of a "peculiar" sensation localized, non-radiating
in her substernal region. She endorses being asleep and either
being awoken by this chest discomfort or by her chronic right
arm median nerve neuropathy - cannot remember which. But after a
few minutes, without moving in bed, the sensation went away and
she fell back asleep. She was able to lie flat during this
entire episode and denies any associated symptoms of frank chest
pain, SOB, palpitations, LH, N/V, dizziness, diaphoresis, or
abdominal discomfort. She has never had this sensation before.
On the morning of admission, she was undergoing her regular
routine, showing, eating breakfast and reading the NYT, when
suddenly, while seated, she developed the same "peculiar"
sensation in her chest again. This time, she endorsed associated
generalized weakness, best described a sensation of "not having
the strength to get up." She pressed the life-alert button on
her wrist, which alarmed the staff at her ___
facility to come in. They alerted EMS right away.
At time of EMS arrival, the patient endorsed cessation of her
symptoms (again lasting on the order of minutes), feeling back
to her normal self. Per EMS report, she was found to have BP's
of 110's-130's systolic with HR of 190. She had rhythm strip
showing regular, wide-complex tachycardia with thread pulse and
was started on amiodarone 150mg IV x1 and a gtt at 1mg/min. This
was started prior to arrival to ___ around 1350.
At ___, the patient herself felt ok, but was noted by
staff to be cold, clammy with HR in 160's. She had extensive
laboratory testing sent off and ECG showing possible recurrent
ventricular tachycardia (presumably stable as no report was
given of any hypotensive episodes). She received 0.5mg IV
midazolam x1 with only partial amnestic effect and received DCCV
with 100J x1. Unclear if this converted her to sinus rhythm and
rhythm strip does not include shock. Of note, she continued to
enter this wide complex tachyarrhythmia, which apparently
improved with vagal maneuvers such as bearing down. However, due
to concern for need for EP consultation, she was transferred to
___ for further care.
In the ED initial vitals were:
98.4 67 95/50 18 98% RA
ECG at 1656 from OSH: sinus rhythm with ventricular rate of 66
bpm; normal axis; narrow complex; probable left atrial
abnormality; early RWP; QTc of 434; compared to prior from
stress test on ___, overall similar
ECG at 1658 from OSH per my read on rhythm strip: narrow complex
QRS x1 beat following p wave (?sinus) followed by VPC x1 and
subsequent wide complex tachycardia at ventricular rate of
~190bpm with 1 fusion beat c/f monomorphic VT
ECG at 1652 per my read: sinus rhythm with ventricular response
of ~65bpm; normal axis; slightly early RWP; VPCs x2; overall
similar compared with prior from ___ stress test
ECG at 1657 per my read: regular, wide-complex tachycardia with
ventricular rate of 141 bpm; extreme right axis deviation with
RBBB morphology; no visible P-waves and diffuse non-specific
ST-TW changes c/f ventricular tachycardia; compared to prior
from stress test on ___, rhythm is no longer sinus, rate is
faster, and QRS morphology wide with significantly different
axis; similar QRS morphology to presumed VPCs visualized on
___ 1652 ECG
___ Labs/studies notable for:
-lactate 2.2
-Normal CBC
-Whole blood electrolytes with normal Na, K, glucose (166),
BUN/Cr (___) with baseline Cr of 0.7 in ___.
___ Labs/studies notable for:
-Grossly hemolyzed Chemistries notable for K 7.8, ALT 220, AST
358, LDH 1062, with normal Alk Phos, Tbili, and albumin
-TSH, Free T4 (collected, pending)
-repeat whole blood K of 4.2
-Trop <0.01 x1
-CXR showing:
"Prominent bilateral perihilar vasculature suggests central
pulmonary vascular engorgement. No overt pulmonary edema.
Prominent bilateral costochondral calcifications. Streaky left
base opacity likely represents costochondral calcification and
underlying atelectasis, focal consolidation felt less likely.
If/when patient able, dedicated PA and lateral views would help
further assess."
Patient was given:
-Aspirin 324mg
-Amiodiarone gtt (1mg/min, continued from OSH)
-Mag 2g IV x1
Of note, while in the ED, the patient entered similar (albeit
slower) wide complex tacharrhythmia, asymptomatic. She was
evaluated by cardiology, who recommended admission to CCU for
further monitoring and care.
Upon arrival to the CCU, she endorses the above history and
denies any active complaints. She adds that only thing that has
been bothering her recently has been her right arm median nerve
neuropathy, for which she would like a second opinion. She also
does endorse several months of progressive DOE, which seems to
bother her even when walking from one end of her apartment to
the other. She denies any concurrent ___ swelling, change in her
weight, orthopnea, PND, or chest discomfort. She has not passed
out. She has had TTE in ___ without significant
abnormalities (mild pHTN and mild AS) as well as exercise-stress
___ that was limited by poor exercise tolerance, but without
any signs of ischemic burden.
Past Medical History:
1. CARDIAC RISK FACTORS
-Dyslipidemia
-Stage ___ CKD (GFR ~___ with baseline Cr of ~0.8)
2. CARDIAC HISTORY
-Mild AS
3. OTHER PAST MEDICAL HISTORY
-Vertigo
-Glaucoma
-GERD
-Osteoarthritis s/p b/l knee replacements
-history of ER-positive R-sided infiltrating ductal carcinoma
s/p lumpectomy and radiation without chemotherapy and adjuvant
hormonal therapy (___)
-History of Spindle cell tumor, stomach (probable leiomyoma,
pathology pending) s/p resection (___)
-D&C, endometrial polypectomy in ___
Social History:
___
Family History:
Per patient and review of prior charts, she has mother with MI
at age ___ and no other family members with heart disease. No
family history of members with pacemaker or sudden death.
+family history of prostate and breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.2F, 119/96, HR 70, RR17, 95% on RA
GENERAL: Well appearing, younger than stated age, sitting up in
a bed without any active complaints
HEENT: NC/AT, EOMI, PERRL, MMM, tongue midline on protrusion
with symmetric palatal elevation and smile
NECK: Supple. symmetric. Brisk carotid upstroke. No carotid
bruits bilaterally. JVP flat with patient at 30 degrees
CARDIAC: slowed rate, regular rhythm, ___ harsh, mid-systolic
murmur best heard in ___ without any notable radiation to
carotids or axilla; no r/g
CHEST: pacer pads in place
LUNGS: CTAB, no c/r/w, no increased WOB
ABDOMEN: Soft, non-tender, non-distended. BS+. No r/g
EXTREMITIES: Warm, well perfused. No pitting edema in b/l ___
SKIN: No significant skin lesions or rashes apart from scattered
ecchymotic lesions on extremities near PIV insertion sites.
PULSES: Distal pulses palpable and symmetric.
NEURO: alert, appropriately interactive, CN exam as above;
strength ___ in b/l UE; able to lift both legs up against
gravity and downward pressure b/l; sensation to light touch
grossly intact in b/l UE, torso, and ___
DISCHARGE PHYSICAL EXAM
=========================
VS: 98.3F, 109/60, HR74, RR15, 98% on RA
GENERAL: Well appearing, younger than stated age, sitting up in
a bed without any active complaints
HEENT: NC/AT, EOMI, PERRL, MMM, tongue midline on protrusion
with symmetric palatal elevation and smile
NECK: Supple. symmetric. Brisk carotid upstroke. No carotid
bruits bilaterally. JVP flat with patient at 30 degrees
CARDIAC: slowed rate, regular rhythm, ___ harsh, mid-systolic
murmur best heard in ___ without any notable radiation to
carotids or axilla; no r/g
CHEST: pacer pads in place
LUNGS: CTAB, no c/r/w, no increased WOB
ABDOMEN: Soft, non-tender, non-distended. BS+. No r/g
EXTREMITIES: Warm, well perfused. No pitting edema in b/l ___
SKIN: No significant skin lesions or rashes apart from scattered
ecchymotic lesions on extremities near PIV insertion sites.
Redness at IV site improved.
PULSES: Distal pulses palpable and symmetric.
NEURO: alert, appropriately interactive, CN exam as above;
strength ___ in b/l UE; able to lift both legs up against
gravity and downward pressure b/l; sensation to light touch
grossly intact in b/l UE, torso, and ___
Pertinent Results:
ADMISSION LABS
=================
___ 03:46AM BLOOD WBC-11.7*# RBC-4.06 Hgb-12.5 Hct-37.9
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.1 RDWSD-47.8* Plt ___
___ 03:46AM BLOOD Neuts-67.5 Lymphs-17.5* Monos-12.4
Eos-1.6 Baso-0.5 Im ___ AbsNeut-7.90* AbsLymp-2.05
AbsMono-1.45* AbsEos-0.19 AbsBaso-0.06
___ 03:46AM BLOOD ___ PTT-25.3 ___
___ 05:04PM BLOOD Glucose-149* UreaN-20 Creat-0.8 Na-135
K-7.8* Cl-101 HCO3-23 AnGap-11
___ 05:04PM BLOOD ALT-220* AST-358* LD(LDH)-1062*
AlkPhos-97 TotBili-0.4
___ 05:04PM BLOOD cTropnT-<0.01
___ 05:04PM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.6 Mg-2.1
___ 06:50PM BLOOD TSH-2.4
___ 05:04PM BLOOD Free T4-1.5
INTERVAL LABS
================
___ 03:46AM BLOOD ALT-157* AST-158* LD(LDH)-586* AlkPhos-88
TotBili-0.7
___ 06:29AM BLOOD ALT-138* AST-113* LD(___)-228 AlkPhos-87
TotBili-0.6
___ 04:00AM BLOOD ALT-101* AST-63* AlkPhos-86 TotBili-0.7
MICROBIOLOGY
================
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
IMAGING
=================
CXR ___
Prominent bilateral perihilar vasculature suggests central
pulmonary vascular engorgement. No overt pulmonary edema.
Prominent bilateral costochondral calcifications. Streaky left
base opacity likely represents costochondral calcification and
underlying atelectasis, focal consolidation felt less likely.
If/when patient able, dedicated PA and lateral views would help
further assess.
ECHO ___
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
mitral regurgitation.] Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+) mitral regurgitation is seen. An eccentric jet of
moderate [2+] tricuspid regurgitation is seen directed toward
the interatrial septum. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate to severe mitral regurgitation. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. Moderate pulmolnary artery
systolic hypertension. Moderate tricuspid regurgitation. Minimal
aortic valve stenosis.
CXR ___
Heart size is mildly enlarged, unchanged. Mediastinum is
stable. Interstitial opacities are bilateral, minimally
increased since previous examination and might potentially
represent infectious process. Infant aspiration is less likely.
No evidence of pulmonary edema.
DISCHARGE LABS
==================
___ 02:35AM BLOOD WBC-10.4* RBC-3.96 Hgb-12.2 Hct-36.8
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.5 RDWSD-46.2 Plt ___
___ 02:35AM BLOOD Plt ___
___ 02:35AM BLOOD Glucose-87 UreaN-17 Creat-0.7 Na-140
K-4.4 Cl-104 HCO3-24 AnGap-12
___ 02:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
Brief Hospital Course:
Ms. ___ ia ___ y/o woman with PMH notable for no prior cardiac
disease, HLP, and prior R-sided breast cancer s/p lumpectomy/XRT
admitted from ___ with non-specific chest discomfort and
concern for intermittent, stable, monomorphic ventricular
tachycardia.
# CORONARIES: N/A
# PUMP: EF>55% (___)
# RHYTHM: Sinus bradycardia with intermittent Monomorphic VT
ACTIVE ISSUES:
===============
#Monomorphic VT: Ms. ___ presented with paroxysmal, ?stable
monomorphic ventricular tachycardia, with fusion beats on ECG.
She was symptomatic in the way of self-limited episodes of chest
discomfort without symptoms of hemodynamic compromise. She was
able to self-terminate and was responsive to ___ (by report).
She remained stable after IV amiodarone load. Etiologies
unclear, but given monomorphic etiology, would suspect scar as
underlying cause of ventricular arrhythmia. No prior ischemia or
infarcts per history of evidence of such on cardiogram and no
wall motion abnormalities on TTE. Active ischemia is not
present. She also is not on any particularly arrhythmogenic
medications or taking any such substances. Other infiltrative
diseases such as sarcoid less likely in her without other
signs/symptoms and such late age of presentation. Finally,
despite being right-sided, she has had prior XRT in the ___
for breast CA, unclear if this was targeted field or
left-side-sparing XRT, which could be underlying cause of
myocardial scar, which could conceivably develop and manifest
clinically about 2 decades later. EP consult confirmed VT with
AV dissociation and recommended po amiodarone 200mg daily
without load. Repeat TTE ___ confirmed no wall motion
abnormalities and normal EF, but with moderate-severe MR,
moderate pulm artery systolic HTN, and moderate TR. Still with
runs of NSVT on amio 200mg QD so increased to 400mg daily.
Patient requested not to continue diuresis, but is s/p IV Lasix
20mg x1. Patient will need LFT monitoring, baseline PFTs as
outpatient if continuing amio, and baseline eye exam (already
with ophthalmologist for glaucoma)
#Mild AS:
#Mitral and tricuspid regurgitation
#Progressive DOE: Patient with several months of progressive
DOE, which does not necessitate inpatient work-up, but could be
caused by underlying lung disease (prior smoking history) but
most likely due to cardiac disease (tricuspid and mitral regurg,
possible underlying disease ___ prior XRT as above). Patient
would benefit from additional diuresis but she does not tolerate
it at home. Trialed captopril to reduce afterload with the goal
of improving forward flow to improve shortness of breath,
however BPs dropped to ___. Opted to start isordil 10mg TID
for reduction of afterload instead. Pt will need outpatient PFTs
both for drug monitoring and evaluation of possible underlying
lung disease. Transitioned to ___ at the time of discharge for
daily dosing.
#Opacities on CXR: opacities on CXR w/ hypoxia, no pulmonary
edema. Started on CAP treatment CTX and azithro (___), but
stopped ___ since no infectious symptoms and improved repeat
CXR. No fevers or leukocytosis, and with improved respiratory
status.
#Transaminitis: Patient with markedly elevated AST and ALT,
I/s/o being shocked and on grossly hemolyzed specimen. Given
negative troponin, it is possible that she had leakage of
cardiac enzymes to partially explain ALT elevation, but unlikely
to account for all of it. More likely hemolyzed specimen. LFTs
improved. Will need to be monitored while on amiodarone.
CHRONIC PROBLEMS:
==================
#Stage 2b/3a CKD: Cr remained at baseline.
#HLP: exchanged home simvastatin for atorvastatin while on
amiodarone due to severe medication interactions
#Glaucoma: continued home timolol and latanoprost.
TRANSITIONAL ISSUES
====================
[]Patient discharged on imdur 30mg PO daily. Should titrate down
if lightheaded
[]Patient's home simvastatin changed to atorvastatin given
severe medication interactions with amiodarone
[]Patient's home metoprolol was held at discharge as she was
started on amiodarone with adequate rate control and for fear of
hypotension with her new anti-hypertensive regimen
[]Consider outpatient follow-up with cardiology as outpatient
[]Will need outpatient PFTs while on amiodarone and also to
evaluate for lung disease that may be causing her shortness of
breath.
[]Will need follow-up with ophthalmology if continuing on
amiodarone.
[]Patient's baseline TSH and free T4 were normal this admission
[]Please obtain repeat LFTs within ___ weeks of discharge to
obtain true baseline given initiation of amiodarone
# CODE: Full Code for now
# CONTACT/HCP: ___ (Son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
RX *amiodarone 400 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7.Rolling walker
Rolling walker
Diagnosis: ___.81 weakness
Prognosis: good
Length of need: 13 months
8.Outpatient Lab Work
Please obtain LFTs by ___ and fax results to Dr. ___
(___) at ___. ICD10 code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
monomorphic ventricular tachycardia ___ scar
SECONDARY DIAGNOSES
===================
moderate mitral regurgitation
mild aortic stenosis
hyperlipidemia
Right sided breast cancer s/p lumpectomy/XRT
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
WHY YOU CAME TO THE HOSPITAL
-You were transferred from an outside hospital because of an
abnormal heart rhythm causing you chest discomfort.
WHAT WE DID FOR YOU HERE
-We ruled out a heart attack and determined the most likely
cause for this abnormal rhythm is from scar tissue in your heart
from the radiation treatment you received.
-You received a medication called amiodarone through your IV
that helped normalize your heart rhythm, which was then
transitioned to medication by mouth.
-Your electrolytes were monitoring and repleted
-You had an ultrasound of your heart that showed no damage to
the heart tissue, but did show a leaky valve, a condition called
"mitral valve regurgitation"
-Your chest xray initially showed signs of infection so you were
started on antibiotics to treat pneumonia, but these were
stopped as you didn't seem to have an infection.
-We started you on a medication called isordil to help prevent
fluid buildup in the lungs and to keep your blood pressure
stable.
WHAT YOU SHOULD DO WHEN YOU LEAVE
-You should take your new medicines amiodarone 400mg once daily,
and Imdur 20mg daily
-You should take all your other medications as prescribed
-You should follow up with your primary care doctor within ___
days to make sure you are stable after leaving the hospital
-You should follow up with a cardiologist within a few weeks to
make sure your heart rhythm has remained stable
WHEN YOU SHOULD COME BACK
-If you are experiencing chest pains, shortness of breath,
dizziness, fainting, nausea, vomiting, sweating, or any other
symptoms that concern you
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19644370-DS-2
| 19,644,370 | 20,019,282 |
DS
| 2 |
2129-01-20 00:00:00
|
2129-01-20 11:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
ORIF left ankle ___
History of Present Illness:
___ yr old man fall down 3 stairs while holding lumbar at
construction
job, resulting in immediate L ankle pain. ED ankle fracture,
surgery performed
Past Medical History:
Previous R ankle fracture
RLE cellulitis
Osteoarthritis
Social History:
___
Family History:
N/A
Physical Exam:
AOXO3
splint intact, positive CSM
Pain well controlled, no N/V
Pertinent Results:
___ 08:28PM WBC-9.5 RBC-4.49* HGB-13.7 HCT-41.0 MCV-91
MCH-30.5 MCHC-33.4 RDW-13.8 RDWSD-46.7*
___ 08:28PM GLUCOSE-96 UREA N-13 CREAT-0.7 SODIUM-145
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
___ 08:28PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.9
Brief Hospital Course:
Taken to operating room and underwent surgical fixation of ankle
fracture on ___. No complications. Post op doing well, pain
well controlled. Cleared by ___ to go home without services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Naproxen 500 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN severe nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*8 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours-
(6) hours Disp #*60 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
left ankle fracture, s/p ORIF ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
NWB to LLE
Keep splint dry, in place
Elevate LLE
Follow up in ___ clinic in 2 weeks
Followup Instructions:
___
|
19644467-DS-22
| 19,644,467 | 20,510,907 |
DS
| 22 |
2196-06-14 00:00:00
|
2196-06-16 12:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with hx of COPD, hepatitis C, HTN, DLP, GERD,
fibromyalgia, and gastritis presenting for pyelonephritis.
.
The patient is a poor historian and tells and inconsistent
history, but reports that for the past ___ days, she has
experienced rigth sided low back, flank, and right abdominal
pain radiating to her right groin. She also reports foul
smelling urine and dysuria. Denies hematuria. She also had
nausea/vomiting for the past several days and stopped eating for
the past few days. She denies sick contacts, and reports her
chronic, intermittent diarrhea is unchanged from baseline.
.
In the ED, initial VS: 97.4 124 130/83 16 98%
The patient reportedly complained of lightheadedness in the ED
on intial presentation which resolved after 1L NS and 1L LR with
banana bag. She underwent a CT abd/pelvis that showed bilateral
pyelonephritis. She was given Ceftriaxone 2 gm IV, Ciprofloxacin
400 mg IV, Dilaudid 1 mg IV and 0.5 mg IV. Most Recent Vitals:
98.9po, 96, 20, 140/92, 100%RA
.
On the floor, the patient reported continued right sided flank,
low back, abdominal, and groin discomfort.
.
REVIEW OF SYSTEMS:
Denies 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, hematuria.
Past Medical History:
COPD (never formally dx by spirometry, bullous emphysema on CT
imaging ___
Hepatitis C (stage ___ fibrosis per liver bx ___
HTN (poorly controlled at b/l, non compliant with meds; P-MIBI
negative in ___, stress-Echo ___ EF 60%, trivial MR, no
inducible ischemia)
HLD
Peripheral neuropathy
PVD (L subclavian stenosis seen on CTA ___ and MRA ___
and RE arterial insufficiency; ABI showing minimal disease below
the knee at the tibial level on ___
Depression, requiring hospitalization in past
h/o polysubstance abuse, including cocaine and iv drug use, and
on-going alcohol and tobacco use
Hiatal hernia, s/p nissen fundoplication
GERD
esophageal stricture (Schatzkis ring)
Fe def anemia
Fibromyalgia
Cervical spondylosis
Stress incontinence
Osteoarthritis
Social History:
___
Family History:
Mother: CAD, deceased. 9 siblings, one deceased (cause unknown).
Four children, all healthy.
Physical Exam:
VS - 98.5 133/84 110 18 97%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM
NECK - Supple
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. Left low back pain. (+)CVA tenderness,
R>L.
ABDOMEN - NABS, soft, moderate distension, moderate tenderness
on the right quadrant diffusely
EXTREMITIES - WWP, no c/c/e, 2+ DP pulses.
Pertinent Results:
Admission labs
___ 05:35PM BLOOD WBC-13.0*# RBC-3.83* Hgb-13.0 Hct-36.8
MCV-96 MCH-33.8* MCHC-35.2* RDW-12.7 Plt ___
___ 05:35PM BLOOD Neuts-84.4* Lymphs-9.0* Monos-5.4 Eos-0.2
Baso-1.1
___ 05:35PM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-130*
K-3.4 Cl-98 HCO3-20* AnGap-15
___ 05:35PM BLOOD ALT-26 AST-23 AlkPhos-168* TotBili-0.4
___ 05:35PM BLOOD Albumin-3.6
___ 08:00PM BLOOD Lactate-1.0
CXR ___: Stable cardiac and mediastinal contours. Lungs appear
well inflated. The interstitium is slightly prominent which may
be related to the patient's underlying emphysema, small airways
disease, or age-related changes. No focal airspace consolidation
is seen to suggest pneumonia. There is no evidence of pulmonary
edema. No pneumothorax or pleural effusions. Prominent amount of
gas within the stomach.
CT abd/pelvis ___: Right-sided pyelonephritis; perinephric
inflammation of the left kidney as well.
UCx: ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
___ y/o F with hx of COPD, hepatitis C, HTN, DLP, GERD,
fibromyalgia, and gastritis presenting for pyelonephritis.
.
# Pyelonephritis: CT findings and micro data as above. Was
treated with ceftriaxone and ciprofloxacin, which was later
narrowed to cipro monotherapy. She was asymptomatic by day of
discharge, with stable vital signs, and was discharged with
prescription to complete seven day course of antibiotics. ECG
was checked to assess QTc interval on ciprofloxacin, which was
normal.
.
#. Hyponatremia: Resolved with IV fluids on night of admission.
Likely due to volume depletion in setting of poor PO intake and
nausea.
.
INACTIVE ISSUES:
#. h/o Alcoholism: Pt received banana bag in ED, was written for
___, but did not require any benzodiazepines.
.
#. COPD: Pt took her home regimen of Advair, Tiotropium, and
Albuterol.
.
#. Hepatitis C, Genotype 1: LFTs were normal. Had no RUQ
symptoms.
.
# Hypertension: She continued her home valsartan and
nifedipine.
.
CODE: Confirmed Full Code
.
TRANSITIONAL: Pt was instructed to call her PCP's office to
coordinate follow up appointment. Also, blood cultures were
still pending at time of discharge.
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
dyspnea, wheeze.
2. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation BID (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhlalation Inhalation DAILY (Daily).
9. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, PO DAILY
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn
15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
16. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
17. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID
18. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea for 4
days.
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea,
wheeze.
2. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO three times a day.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1)
Tablet PO every six (6) hours as needed for pain.
15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*11 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Pyelonephritis
.
SECONDARY DIAGNOSES:
Chronic obstructive pulmonary disease (COPD)
Hepatitis C
Hypertension
Hyperlipidemia
Peripheral neuropathy
Peripheral vascular disease
Depression
Polysubstance abuse
Anemia
Fibromyalgia
Osteoarthritis
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 pain in your flank and groin, and
pain with urination, likely due to infection of your urinary
tract and kidney. A CT scan showed that your right kidney was
inflamed. You were given antibiotics, initially through an IV
line, to treat the infection. Before you left, your culture
showed that the infection was due to a bacteria called E. Coli,
but we did not yet have specific information about what
antibiotics it will be susceptible to. Since you are feeling
better, we can presume that the antibiotics are working. Please
discuss this further with your PCP.
.
The following changes were made to your medications:
-Please CONTINUE taking CIPROFLOXACIN 500 mg tablets, one tablet
by mouth every twelve hours (twice daily) for an additional five
days (last dose on the morning of ___. We have checked an
electrocardiogram of your heart to make sure this medication is
safe for you.
-Please discuss your dose of pantoprazole with your PCP. Our
records indicated you were taking a different dose than what you
told us.
.
It is important that you follow up with your primary care
physician ___ at ___
(___) on ___. Please make him aware that one of
your liver enzymes, alkaline phosphatase, was elevated and
should be followed up. Additionally, your antibiotics and some
of your medications can cause changes to your EKG.
Followup Instructions:
___
|
19644467-DS-24
| 19,644,467 | 29,527,425 |
DS
| 24 |
2197-02-05 00:00:00
|
2197-02-07 10:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH PVD, Hep C, COPD, peripheral neuropathy who has had 1.5
weeks of dyspnea, also with increasing pain in RUE and R chest
(with more chronic component as well). The patient states that
the dyspnea was also associated with a profound cough. The
coughing led to worsening pain. Pt states pain started around R
neck and radiates to R arm, R shoulder blade, and R chest wall.
Pain is worse with breathing and is associated with SOB. Also
has had a cough for one week, productive of white and yellow
little sputum and plugs.
R sided weakness/tremor progressive over years. Her mobility has
been more limited, and she can't walk far w/out help. She fell
yesterday she stated and fell on her buttocks, no head strike or
LOC.
Of note, the patient continues to actively smoke. She also has
seasonal allergies, and there has been a large deal of
construction outside of her apartment building, with a good
amount of fine dust (changing bricks). She has kept her windows
open despite this for fresh, cool air.
In the ED, initial VS were: 97.2 96 152/112 22 100% RA
On exam, weak in RUE, RLE with decreased sensation. Wheezes.
Pain to palpation in R shoulder. She received solumedrol,
azithromycin and duonebs in the ED. Received tylenol and
morphine x2 for pain. CXR was unrevealing. Troponin t was
negative x2. CBC and Chem 7 were unremarkable. UA was
unremarkable.
On arrival to the floor, the patient is cooperative and able to
give a coherent history.
REVIEW OF SYSTEMS:
(+) loose stools for weeks, R arm weakness and tremor, periodic
mild nausea; periodic mild abdominal pain
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
COPD (never formally dx by spirometry, bullous emphysema on CT
imaging ___
Hepatitis C (stage ___ fibrosis per liver bx ___
HTN (poorly controlled at b/l, non compliant with meds; P-MIBI
negative in ___, stress-Echo ___ EF 60%, trivial MR, no
inducible ischemia)
HLD
Peripheral neuropathy
PVD (L subclavian stenosis seen on CTA ___ and MRA ___
and RE arterial insufficiency; ABI showing minimal disease below
the knee at the tibial level on ___
Depression, requiring hospitalization in past
h/o polysubstance abuse, including cocaine and iv drug use, and
on-going alcohol and tobacco use
Hiatal hernia, s/p ___ fundoplication
GERD
esophageal stricture (Schatzkis ring)
Fe def anemia
Fibromyalgia
Cervical spondylosis
Stress incontinence
Osteoarthritis
Social History:
___
Family History:
Mother: CAD, deceased. 9 siblings, one deceased (cause unknown).
Four children, all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.6 149/84 22 98%RA
GENERAL - comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, some tenderness to
palpation of R side of neck
LUNGS - scant wheeze bilaterally, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, no masses or HSM, no rebound/guarding,
mild tenderness to quadrant RUQ
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Some tenderness to palpation of R shoulder area.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact aside from
increased sensation on R side of face; muscle strength ___
throughout aside from ___ strength of R quad, and R biceps; ___
strength interosseous muscles, sensation grossly intact
throughout
DISCHARGE PHYSICAL EXAM:
VS - 97.7 125/87 81 18 99%RA
GENERAL - comfortable, appropriate, minimally distress, holds R
shoulder when coughing
HEENT - NCAT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, some tenderness to
palpation of R side of neck
LUNGS - scant wheeze bilaterally, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, NT no masses or HSM, no
rebound/guarding, mild tenderness to quadrant RUQ
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Some tenderness to palpation of R shoulder area.
SKIN - no rashes or lesions
NEURO - AAOx3, CNs II-XII grossly intact; muscle strength ___
throughout aside from ___ strength of R quad, and R biceps; ___
strength interosseous muscles, sensation grossly intact
throughout
Pertinent Results:
ADMISSION LABS:
___ 07:06PM LACTATE-3.4*
___ 06:20AM GLUCOSE-248* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-17* ANION GAP-24*
___ 06:20AM WBC-6.0 RBC-4.09* HGB-13.4 HCT-40.1 MCV-98
MCH-32.8* MCHC-33.5 RDW-13.2
___ 06:20AM PLT COUNT-252
___ 12:30AM cTropnT-<0.01
___ 09:05PM URINE HOURS-RANDOM
___ 09:05PM URINE GR HOLD-HOLD
___ 09:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 07:33PM GLUCOSE-119* UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
___ 07:33PM estGFR-Using this
___ 07:33PM cTropnT-<0.01
___ 07:33PM WBC-7.8 RBC-4.23 HGB-13.8 HCT-40.7 MCV-96
MCH-32.6* MCHC-33.9 RDW-13.2
___ 07:33PM NEUTS-58 ___ MONOS-7 EOS-4 BASOS-0
___ 07:33PM PLT COUNT-271
Imaging:
CXR: No acute cardiopulmonary process. No significant change
since
the prior study.
Xray R shoulder: no acute fracture or dislocation
CTA Chest: CONCLUSION:
1. There is no pulmonary embolism and no acute aortic syndrome.
2. There is no acute pulmonary process.
3. Pulmonary emphysema is severe.
Discharge Labs:
___ 06:20AM BLOOD WBC-10.8# RBC-3.91* Hgb-12.9 Hct-38.6
MCV-99* MCH-32.9* MCHC-33.3 RDW-13.8 Plt ___
___ 06:20AM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-139
K-3.9 Cl-99 HCO3-26 AnGap-18
___ 06:20AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
___ 10:37AM BLOOD Lactate-3.6*
Brief Hospital Course:
___ PMH PVD, Hep C, COPD, peripheral neuropathy who presents
with dyspnea and has had 1.5 weeks increasing pain and weakness
in RUE, RLE in relation to her cough who was found to have a
COPD exacerbation.
Active Issues:
# Dyspnea: Patient has COPD and her 10 day history of dyspnea
and increased cough is most likely a COPD exacerbation, likely
triggered by environmental agents (construction dust, cigarette
smoke, seasonal allergens). After receiving steroids, nebs and
azithromycin in the ED, she states that her symptoms
substantially improved. Pt has had no fevers, leukocytosis, or
x-ray findings of consolidation, thus PNA is highly unlikely. Pt
has been ruled out for MI w/ two negative EKGs and troponin
markers. Given patient's chest pain we also ruled her out for PE
with a negative CTA which did show severe emphysema. We gave
prednisone burst x 5 days, albuterol and ipratropium nebulizers,
and azithromycin. Smoking cessation counseling was provided but
patient states she is not ready to quit and that she has already
significantly cut down her smoking from 3 packs to about half a
pack per day. We advise pt to use air filter at home and keep
windows closed to limit environmental allergens. We continue
home spiriva inhaler and was able to arrange for patient to get
a home nebulizer unit for at home albuterol nebulizer treatments
which the patient felt worked better than the MDI. On discharge
patient was still short of breath given her severe COPD but her
breathing was back at baseline.
# RUE pain and weakness: Pt presented with pain and weakness in
her right arm and hand which she states has been present for a
long time although it was now more painful. This increased pain
was likely related to cough and dyspnea, as patient pointed out
since when she coughs her right arm and shoulder shake when she
violently coughs. Pt does have chronic tremor and chronic R
sided pain/weakness, which may be from cervical spinal
dysfunction or peripheral nervous issues. An x-ray of her
shoulder was negative for fracture or dislocation.
# Fall: Pt had a recent mechanical fall at home, likely
secondary to neuropathy. ___ and OT were consulted which she
demonstrates decreased strength, decreased ROM, decreased
sensation, decreased safety awareness, and decreased functional
mobility affecting her ability to perform ADLs independently so
it was recommended that patient have home OT and ___
rehabilitation.
Chronic Issues:
# Hypertension: Pt was generally normotensive throughout
admission so we continue home HCTZ, Valsartan, and nifedipine.
# Depression: Stable without signs of worsening depression so we
continued home Amitriptyline.
# GERD: Asymptomatic so we continued pantoprazole BID
# Iron deficiency anemia: At baseline, if not a bit better so we
continued home Ferrous Sulfate.
Transitional Issues:
1. Pt will need continued encouragement for smoking cessation.
She has severe COPD and should stop smoking immediately.
2. Pt had elevated lactate level which is likely from her COPD
with no other evidence of end organ ischemia. This may need to
be followed up if there is concern for other etiologies other
than COPD.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Nitroglycerin SL 0.4 mg SL PRN chest pain
2. Loratadine *NF* 10 mg Oral DAILY:PRN allergies
3. HydrOXYzine 25 mg PO BID:PRN itching
4. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral Daily
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. Amitriptyline 50 mg PO HS
7. Aspirin 81 mg PO DAILY
8. Docusate Sodium 100 mg PO DAILY:PRN constipation
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Valsartan 320 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. Thiamine 50 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Pantoprazole 80 mg PO BID
16. NIFEdipine CR 60 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Hydrochlorothiazide 25 mg PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. Biotene Oralbalance *NF* (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) 0 pack MUCOUS MEMBRANE
TID: PRN dry mouth
21. Gabapentin 300 mg PO BID
Discharge Medications:
1. Amitriptyline 50 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Loratadine *NF* 10 mg Oral DAILY:PRN allergies
9. Multivitamins 1 TAB PO DAILY
10. NIFEdipine CR 60 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Simvastatin 20 mg PO DAILY
13. Thiamine 50 mg PO DAILY
14. Valsartan 320 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
16. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral Daily
17. Biotene Oralbalance *NF* (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) 0 pack MUCOUS MEMBRANE
TID: PRN dry mouth
18. Docusate Sodium 100 mg PO DAILY:PRN constipation
19. HydrOXYzine 25 mg PO BID:PRN itching
20. Nitroglycerin SL 0.4 mg SL PRN chest pain
21. Tiotropium Bromide 1 CAP IH DAILY
22. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea, wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Neb IH Q6H: PRN
wheezing/SOB Disp #*30 Cartridge Refills:*0
23. Nebulizer unit
One nebulizer unit.
24. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
25. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you on your recent hospitalization
at ___. You came to the hospital because you were having
difficulty breathing, cough, and pain in your right shoulder and
arm. Reassuringly we found that you did not have a blood clot in
your lungs. We found that you have a COPD exacerbation for which
we treated you with antibiotics and steroids and you got better.
Reassuringly an x-ray of your shoulder did not reveal any
fracture or dislocation.
The following changes were made to your medications:
Added:
1. PredniSONE 40 mg DAILY for total of 5 days
2. Azithromycin 250 mg Q24H for total of 5 days
3. Albuterol nebulizer 1 nebulizer tx every 4 hours as needed
for SOB/ wheezing. Do not use albuterol nebulizer and albuterol
inhaler together, please use only one or the other per 4 hour
period.
Changes:
1. Pantoprazole 40 mg twice per day
Followup Instructions:
___
|
19644467-DS-25
| 19,644,467 | 28,136,918 |
DS
| 25 |
2197-05-23 00:00:00
|
2197-05-23 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with history of COPD (no PFTs) who presents
with left chest and flank pain. She was in her usual state of
health until ~ 3 days ago, when she noted increasing DOE,
initially controlled by albuterol inhaler, but increasingly non
responsive to albuterol, to point where pt felt unable to breath
last night. EMS was called, and she received nebulizer
treatments en route, with some improvement in respiratory
status. Of note, she was admitted most recently in ___ for
COPD exacerbation, which was treated with nebulizers, prednisone
burst, and azithromycin; home nebulizer machine was arranged and
smoking cessation encouraged. (Currently smoking ___ pack a
day)
In the ED, initial vital signs were as follows: 98.7 ___
36 100%. Exam was notable for absence of adventitious breath
sounds and left CVA tenderness. Admission labs were notable for
bicarbonate of 19, initial VBG of 7.52/___,subsequent ABG
of ___, lactate of 3.7 to 2.6 to 1.9, and negative
urine hCG. UA included 82 Wbc and 182 Rbc. Serum toxicology
screen was negative. EKG revealed sinus tachycardia without
acute ischemic changes. CTA was negative for pulmonary embolus
while CT abdomen/pelvis without contrast was negative for
nephrolithiasis, though study limited by presence of contrast
from CTA. BCx were obtained, and she was swabbed for influenza.
She received ciprofloxacin 400mg IV for presumed UTI, as well as
IV Ativan and PO Klonopin for anxiety, tachypnea with
respiratory alkalosis, and concern for benzodiazepine withdrawal
(despite negative toxicology screen). She also received
nebulizers and 125mg IV methylprednisolone. Vital signs prior to
transfer were as follows: 97.8 78 153/82 18 100%.
On arrival to the floor, pt is 98% on RA with stable VS.
Past Medical History:
COPD (never formally dx by spirometry, bullous emphysema on CT
imaging ___
Hepatitis C (stage ___ fibrosis per liver bx ___
HTN (poorly controlled at b/l, non compliant with meds; P-MIBI
negative in ___, stress-Echo ___ EF 60%, trivial MR, no
inducible ischemia)
HLD
Peripheral neuropathy
PVD (L subclavian stenosis seen on CTA ___ and MRA ___
and RE arterial insufficiency; ABI showing minimal disease below
the knee at the tibial level on ___
Depression, requiring hospitalization in past
h/o polysubstance abuse, including cocaine and iv drug use, and
on-going alcohol and tobacco use
Hiatal hernia, s/p nissen fundoplication
GERD
esophageal stricture (Schatzkis ring)
Fe def anemia
Fibromyalgia
Cervical spondylosis
Stress incontinence
Osteoarthritis
Social History:
___
Family History:
Mother: CAD, deceased. 9 siblings, one deceased (cause unknown).
Four children, all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
HYSICAL EXAM:
VS: Tc: 98.3 HR: 84 BP: 146/82 RR:18 96% RA
GENERAL: chronically ill-appearing in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/ quiet breath sounds, no wheeze, resp
unlabored, no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
ADMISSION LABS:
___ 11:23PM PO2-75* PCO2-33* PH-7.44 TOTAL CO2-23 BASE
XS-0
___ 11:23PM LACTATE-1.9
___ 09:35PM URINE UCG-NEGATIVE
___ 08:51PM ___ PO2-127* PCO2-17* PH-7.59* TOTAL
CO2-17* BASE XS--1 COMMENTS-GREEN TOP
___ 08:51PM LACTATE-2.6*
___ 08:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 08:50PM URINE RBC->182* WBC-82* BACTERIA-FEW
YEAST-NONE EPI-1
___ 07:39PM ___ PO2-46* PCO2-25* PH-7.52* TOTAL
CO2-21 BASE XS-0 COMMENTS-GREEN TOP
___ 07:39PM LACTATE-3.7*
___ 07:35PM GLUCOSE-99 UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-19* ANION GAP-21*
___ 07:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:35PM WBC-6.7 RBC-4.70 HGB-15.4 HCT-46.7 MCV-99*
MCH-32.6* MCHC-32.9 RDW-12.9
___ 07:35PM NEUTS-63 BANDS-0 ___ MONOS-3 EOS-1
BASOS-0 ATYPS-3* ___ MYELOS-0
___ 07:35PM PLT SMR-NORMAL PLT COUNT-249
___ 07:35PM ___ PTT-30.5 ___
MICRO:
___ URINE URINE CULTURE-FINAL <10, 000
organisms
___ Influenza A/B by ___- NEGATIVE
___ Influenza A/B by ___- INSUFFICIENT
QUANTITY
___ BLOOD CULTURE-PENDING
___ BLOOD CULTURE-PENDING
IMAGES:
CT ABDOMEN, PELVIS
FINDINGS: The lung bases are clear. The visualized portions of
the heart and
pericardium are unremarkable. Evaluation of the liver is
limited in the
absence of intravenous contrast with no focal liver lesion
identified.
Cholecystectomy clips are noted in the gallbladder fossa. The
spleen,
pancreas, and adrenal are normal. Excreted contrast from CTA
chest opacifies
the proximal ureters. There is no hydronephrosis. However,
tiny renal
calculi cannot be excluded. Right-sided perinephric fat
stranding is
decreased when compared to prior CT abdomen and pelvis. The
stomach and small
bowel are unremarkable. There is no portacaval, mesenteric, or
retroperitoneal lymphadenopathy. There is no free air or free
fluid.
CT PELVIS: The appendix is normal. There are no secondary
signs of
inflammation. Sigmoid diverticulosis is noted without evidence
of
diverticulitis. Visualization of the uterus and adnexa is
somewhat limited by
streak artifact from excreted contrast within the urinary
bladder, but no
gross abnormality is seen. There is no pelvic lymphadenopathy
or free fluid.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for
malignancy.
IMPRESSION: No hydronephrosis. Evaluation for a
non-obstructing stone is
limited due to excreted contrast from CTA chest.
CTA CHEST: ___
FINDINGS: There is no pulmonary embolism. The heart and great
vessels are
unremarkable. The airways are centrally patent. There is no
axillary,
mediastinal, or hilar lymphadenopathy noted. Heart size and
shape is normal.
There is no pleural or pericardial effusion.
The lungs are clear, though note is made of upper lobe
predominant
centrilobular emphysema and large paraseptal blebs. There is no
focal
consolidation or worrisome nodule/mass. There is minimal lower
lobe bronchial
impaction.
Thin articular for subdiaphragmatic evaluation included portion
of the abdomen
and pelvis are remarkable only for a Nissen fundoplication.
Osseous structures: There is no lytic or blastic lesion
worrisome for
malignancy.
IMPRESSION:
1. No pulmonary embolism.
2. Emphysema.
3. Trace mucus plugging in small lower lobe bronchi.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Ms. ___ is a ___ with history of COPD (no PFTs) who presented
with left chest and flank pain concerning for COPD exacerbation
and UTI, respectively.
# COPD exacerbation: Her current presentation was most
consistent with recurrent COPD exacerbation, with most recent
exacerbation in ___. CXR/CTA negative for focal infiltrate,
and CTA negative for pulmonary embolus. Influenza test was
negative. She was treated with nebulizers, advair, prednisone
40mg daily for planned ___nd azithromycin for 5 day
course with improvement.
.
# Positive UA: Concerning for UTI in the setting of flank pain.
She has a history of nearly pansensitive E. coli UTI
(ampicillin/Bactrim-resistant, ciprofloxacin-sensitive) in ___.
CT abdomen/pelvis negative for nephrolithiasis, though study
limited by IV contrast administration for CTA. Urine Cx showed
<10,000 organisms. She was treated empirically with azithromycin
for UTI .
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 50 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Loratadine *NF* 10 mg Oral DAILY:PRN allergies
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
11. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral Daily
12. Biotene Oralbalance *NF* (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) 0 pack MUCOUS MEMBRANE
TID: PRN dry mouth
13. Docusate Sodium 100 mg PO DAILY:PRN constipation
14. HydrOXYzine 25 mg PO BID:PRN itching
15. Tiotropium Bromide 1 CAP IH DAILY
16. Ferrous Sulfate 325 mg PO TID
17. Pantoprazole 80 mg PO Q12H
18. Thiamine 100 mg PO DAILY
19. NIFEdipine CR 30 mg PO DAILY
20. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Amitriptyline 50 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Gabapentin 300 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. NIFEdipine CR 30 mg PO DAILY
9. Pantoprazole 80 mg PO Q12H
10. Simvastatin 20 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Azithromycin 500 mg PO Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth every day Disp #*2
Tablet Refills:*0
14. Cepacol (Menthol) 1 LOZ PO PRN sore throat
15. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
16. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp
#*10 Tablet Refills:*0
18. Biotene Oralbalance *NF* (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) 0 pack MUCOUS MEMBRANE
TID: PRN dry mouth
19. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral Daily
20. Ferrous Sulfate 325 mg PO TID
21. FoLIC Acid 1 mg PO DAILY
22. Hydrochlorothiazide 25 mg PO DAILY
23. HydrOXYzine 25 mg PO BID:PRN itching
24. Loratadine *NF* 10 mg Oral DAILY:PRN allergies
25. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
COPD exacerbation
Urinary Tract Infection
.
Secondary
Peripheral Neuropathy
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you had shortness of
breath and coughing with pain. You had imaging of your chest and
abdomen which was unremarkable. Your symptoms were due to a COPD
exacerbation. You are encouraged to stop smoking as this
contributes to your COPD flares.
Influenza swab was negative. You were treated with steroids,
nebulizers and azithromycin. The steroids and azithromycin will
continue for 2 more days.
Followup Instructions:
___
|
19644467-DS-27
| 19,644,467 | 29,911,117 |
DS
| 27 |
2200-01-23 00:00:00
|
2200-01-24 11:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril / mango / papaya
Attending: ___
Chief Complaint:
Acute arm, neck, and chest pain
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
___ year old female with history of HCV genotype 1a, cirrhosis
with history of ascites, alcohol abuse, depression, CAD,
hypertension, and hyperlipidemia presenting with weakness, chest
pain, and anemia with bright red blood per rectum.
In the ED, initial VS were 98.5 85 168/90 18 100% RA.
Exam notable for
Labs notable for WBC 5.5, H/H 8.2/27.8 from baseline 11.3/35.0,
plt 72, troponin negative x 2, negative D-dimer, ALT/AST 51/75,
AP 151, tbili 0.7, lipase 52, and lactate 3.1, INR 1.3
UA WNL
CXR demonstrated no acute intrathoracic processes
Received Oxycodone and Tylenol
Transfer VS were 98.1 92 150/57 20 100% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports...
The patient states that she was standing in her kitchen and her
arms hurt and then her legs gave out. She says she "blanked for
a moment" and partially remembers falling down. She then felt a
stabbing chest pain that did not improve with sl nitro. She has
had the chest pain for several days and the pain in her arms for
several weeks. She has chronic ___ neuropathy and her leg pain
prevents her from walking more than 10 ft.
She also has had neck stiffness for the past several days and
chronic photosensitivity for the past year that is not currently
worsened. She also endorses a HA that is bilateral and very
painful. She endorses palpitations and dizziness as well as
lightheadedness. She also states that her hips lock up, such
that she was not able to sit on the toilet yesterday and
urinated on herself.
The patient also notes that she has had red stools for the past
week (the actual color of the stools) with minimal other blood.
Had a lot of blood x 2 2 days ago. Blood is always bright red.
She has noted pain with defecation and blood with wiping. She
also endorses AM and ___ nausea, and last vomited 5 days ago.
She also endorses ___ years of short-term memory loss where she
can't remember activities she's doing (ie cooking).
She also complains of SOB and an partially-productive cough for
the last ___ mo.
REVIEW OF SYSTEMS:
Negative except as noted in HPI.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Hepatitis C cirrhosis- genotype 1a decompensated with h/o
ascites; liver biopsy in ___ showed stage ___ fibrosis
COPD
Depression
Hypertension
Hyperlipidemia
Alcohol abuse
Cocaine abuse
Tobacco abuse
Atypical chest pain
Breast pain
Abdominal pain
Cervical spondylosis
L subclavian stenosis
Peripheral vascular disease
GERD s/p lap fundoplication and hiatal hernia repair ___
s/p cholecystectomy
Social History:
___
Family History:
Mom had DM, CAD, and was in a wheelchair for neuropathy
(deceased). Father had alcoholism and rectal CA. Sister has
mental illness, also hx of falls.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.3 152/62 75 18 99%RA
GENERAL: Overweight, NAD
HEENT: AT/NC, EOMI, anicteric sclera, MMM, OP clear. Head
tender to palp diffusely.
NECK: supple neck, no LAD, tender to palp bilaterally.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: Tender to palpation diffusely.
LUNG: Crackles in Lower Lobes b/l. Breathing comfortably without
use of accessory muscles.
BACK: Diffusely tender to spine, paraspine, sacrum, and CVA
palpation.
ABDOMEN: mild distended, soft, diffusely tender especially in
the RUQ. + Rebound, no guarding.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Onychomycosis of toes. Warm.
NEURO: Face symmetric. EOMI. Tremor of R>>L hand, no asterixis.
Motor: ___ shoulder shrug b/l, ___ elbow
flexion, ___ hand strength, slowed rapid-alternating-movements.
Finger-to-nose minimally impaired. ___ R leg flexion, ___ L leg
flexion, back and leg pain ipsilaterally with leg raise b/l, ___
ankle flexion. Decreased fine touch sensation of distal lower
extremities b/l.
RECTAL: No blood in vault.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISHCARGE EXAM:
VS 98.4-99.1 98-105/36-60 ___ 18 94-96%RA
Wt: 62.1 <- 61.8 <- 60.1 <- 60.4 <- 59.3 <- 60.7 <- 59.9 <- 53.8
GENERAL: Overweight, appears uncomfortable
HEENT: AT/NC, anicteric sclera, supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: Notably tender to palpation diffusely.
LUNG: Coarse breath sounds at bases
ABDOMEN: moderately distended, soft, notably tender in RUQ and
LLQ. no guarding.
EXTREMITIES: moving all 4 extremities with purpose. No ___ edema.
R hand tremor, no asterixis.
NEURO: Face symmetric. A&Ox3.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 10:20AM BLOOD WBC-5.5 RBC-3.48* Hgb-8.2*# Hct-27.8*#
MCV-80*# MCH-23.6*# MCHC-29.5* RDW-19.5* RDWSD-55.5* Plt Ct-72*
___ 10:20AM BLOOD Neuts-71.4* Lymphs-17.3* Monos-10.0
Eos-0.7* Baso-0.4 Im ___ AbsNeut-3.93 AbsLymp-0.95*
AbsMono-0.55 AbsEos-0.04 AbsBaso-0.02
___ 10:20AM BLOOD ___ PTT-35.6 ___
___ 09:22PM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 10:20AM BLOOD Glucose-167* UreaN-14 Creat-0.8 Na-139
K-3.6 Cl-102 HCO3-22 AnGap-19
___ 10:20AM BLOOD ALT-51* AST-75* AlkPhos-151* TotBili-0.7
___ 10:20AM BLOOD Lipase-52
___ 10:20AM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD cTropnT-<0.01
___ 10:20AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-1.8
___ 10:20AM BLOOD D-Dimer-<150
___ 09:22PM BLOOD calTIBC-451 ___ Ferritn-15 TRF-347
___ 10:32AM BLOOD Lactate-3.1*
DISCHARGE LABS:
___ 05:54AM BLOOD WBC-5.3 RBC-3.27* Hgb-8.2* Hct-27.1*
MCV-83 MCH-25.1* MCHC-30.3* RDW-19.4* RDWSD-57.6* Plt Ct-91*
___ 06:05AM BLOOD ___ PTT-35.7 ___
___ 05:54AM BLOOD Glucose-78 UreaN-9 Creat-0.9 Na-133 K-4.6
Cl-98 HCO3-24 AnGap-16
___ 06:25AM BLOOD ALT-62* AST-99* LD(___)-199 AlkPhos-158*
TotBili-0.8
___ 03:37PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:54AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:54AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
___ 06:40AM BLOOD AFP-8.2
___ 09:12AM BLOOD Lactate-1.2
IMAGING:
Colonoscopy ___:
Impression: Diverticulosis of the sigmoid colon
Exam limited by poor prep proximally, but no bleeding or source
of bleeding was identified. Otherwise normal colonoscopy to
cecum
EGD ___:
Varices at the distal esophagus
Congestion, mosaic appearance and erythema in the stomach
compatible with portal hypertensive gastropathy
Erythema in the duodenum compatible with duodenitis
Nissen wrap seen
Otherwise normal EGD to third part of the duodenum
Liver US: ___:
IMPRESSION:
1. Cirrhotic liver. Questionable 0.7 cm lesion within the right
hepatic lobe only seen in a single image. This may be secondary
to artifact. If there is no elevation of AFP, then suggest that
MRI be performed as the next screening study. However, if there
is elevated AFP then consider obtaining MRI earlier for further
characterization.
2. Splenomegaly measuring 14.2 cm.
RECOMMENDATION(S): If there is no elevation of AFP, then
suggest that MRI be performed as the next screening study in 6
months. However, if there is elevated AFP then consider
obtaining MRI earlier for further characterization.
CXR ___
IMPRESSION:
No acute intrathoracic findings.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of HCV genotype
1a, cirrhosis with history of ascites, alcohol abuse,
depression, CAD, hypertension, and hyperlipidemia who presented
with weakness and musculoskeletal chest pain.
#Anemia: Pt notes BRBPR. Lower GI bleed vs hemorrhoids. Upper
endoscopy showed no active bleeds but having blood in stool.
Colonoscopy showed no site of bleeding. Her hemoglobin was
stable s/p 1U PRBC on ___. Her home ASA was held given her
bleeding.
#Acute urinary retention: The patient developed acute urinary
retention of unclear etiology, possibly secondary to
medications. Her loratadine was discontinued and narcotics were
avoided. She was acutely managed with a foley and succeeded with
her voiding trial ___.
#Chest pain: Pt has been having persistent intermittent chest
pain with MSK component. Her chest has been stably tender to
palpation. However, her EKG ___ showed nonspecific j-point
elevation different from baseline 1 week ago. Chest pain
resolved after taking her home inhaler and troponins were
negative.
#Thrombocytopenia: Likely ___ liver disease. She was given
vitamin K.
#Cirrhosis: Patient has a history of cirrhosis from HCV and EtOH
abuse. She had no ascites on ultrasound. Her AFP was within
normal limits. She should have an MRI as next screening
modality. Etoh abstinence was encourage. Hepatology was
consulted.
#Generalized pain: Unclear etiology. No clear neurophysiologic
cause. Troponins were negative & pain was reproducible with
palpation. Opioids were avoided.
#COPD: Pt has nonproductive cough. Minimal SOB. No fevers. Home
meds were continued.
#HTN: home meds were held
#Generalize weakness: Unclear etiology, not consistent with
radiculopathy.
#Peripheral neuropathy: Pt has minimal feeling in feet,
neuropathic pain, and pain limiting her walking. She was started
on gabapentin 300 BID, which was titrated to 400 BID. In
addition, she was started on tramadol PRN.
#GERD: s/p lap fundoplication and hiatal hernia repair ___. She
was not complaining of symptoms.
CODE: Full (confirmed)
EMERGENCY CONTACT HCP: ___ (boyfriend) ___
====================================================
TRANISTIONAL ISSUES:
[] Pt's home Lasix was held after she developed hyponatremia and
___
[] Pt's home nadolol was stopped per hepatology recommendations
[] Pt's home ASA was held at discharge given thrombocytopenia
and bleeding
[] Loratadine was held given concern for urinary retention.
[] Pt will follow up with hepatology and PCP after discharge
[] Pt was screened by ___ who suggested rehab however pt refused
and was discharged with skilled nursing, home health aid, and
___
[] Pt was discharged home with a walker per ___ recommendations
[] Pt's RUQ ultrasound demonstrated a questionable 0.7 cm lesion
within the right hepatic lobe only seen in a single image, which
may have been an artifact. AFP was not elevated. Radiology
recommends MRI for next ___ screening imaging.
[] Pt started on gabapentin for neuropathic pain
[] Per ___ recs, pt discharged home with walker, SN, ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY:PRN Allergies
2. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500
mg)-800 unit oral BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Valsartan 320 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Pantoprazole 40 mg PO Q12H
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
9. Aspirin 81 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Wheezing
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Furosemide 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. HydrOXYzine 25 mg PO BID:PRN Itch
15. Docusate Sodium 100 mg PO BID
16. Nadolol 20 mg PO DAILY
Discharge Medications:
1. Equipment
Rolling walker
ICD 9 781.2
Good prognosis
Needs for 13 months
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Wheezing
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Pantoprazole 40 mg PO Q12H
7. Tiotropium Bromide 1 CAP IH DAILY
8. Valsartan 320 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Loratadine 10 mg PO DAILY:PRN Allergies
11. HydrOXYzine 25 mg PO BID:PRN Itch
12. Ferrous Sulfate 325 mg PO DAILY
13. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
15. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*56 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lower GI Bleed
HCV and alcoholic Cirrhosis
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 seen at ___ for your anemia. You anemia was primarily
due to bleeding in your GI tract. However, neither endoscopy nor
colonoscopy revealed a site of bleeding. You were treated with a
blood transfusion and your blood levels remained stable
afterward.
You also had an ultrasound of your liver that showed progression
of cirrhosis. Please abstain from using alcohol and follow up
with your outpatient appointments.
You also developed an inability to urinate due to an inability
to void your bladder. You were treated with a short-term foley
catheter and your symptoms then resolved.
You also had some chest pain during your stay. Our tests
indicated it was unlikely to be due to your heart. Please
continue to take your inhalers as prescribed.
Please call your physician if you notice more blood in your
stools and come to the emergency room if you experience acute
worsening of shortness of breath or dizziness.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19644467-DS-29
| 19,644,467 | 23,611,765 |
DS
| 29 |
2201-12-03 00:00:00
|
2201-12-03 12:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril / mango / papaya
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Large volume paracentesis ___
History of Present Illness:
___ w/ HCV/ETOH cirrhosis (genotype 1a, child's class B with hx
ascites), polysubstance abuse, COPD, HTN, HLD, RA, p/w few month
hx of worsening abd pain, distention, and difficulty taking a
deep breath. Patient follows at ___ clinic. Her
last
visit in ___ was notable for increased ascites for which her
Lasix dose was increased from 20mg PO QD to 40mg PO QD. She was
previously on HCTZ that has since been discontinued. Patient has
had paracentesis in the past for volume management of her
ascites. This has been a slowly progressive process leading to
worsening diffuse waxing and waning abdominal pain. Patient
denies cough but reports SOB due to significant abdominal
distension. She denies fevers/chills. No chest pain. No
nausea/vomiting/hematemesis. She reports feeling like she needs
to have a bowel movement but not being able to move her bowels
regularly. Still passing gas. Reports urine appearance has
changed color and decreased in output. Positive difficulty
sleeping but no confusion or cloudiness.
In the ED, initial VS were: T 97.7 HR 104 BP 184/71 RR 18 100%
ra
Exam notable for: Diffuse abd distension, TTP, diminished BS b/l
Labs showed: wbc 4.4, hgb 9 (higher than recent values in ___,
plt 86, HCO3 20, Cr 0.6, INR 1.5, AST/ALT 41/13, AP 141, tbili
1.3, alb 3.3, UA unremarkable, urine cocaine positive, negative
serum tox.
Imaging showed: RUQUS pending.
Received: Fentanyl 50 mg IV x3, cipro 400 mg qd
Hepatology was consulted and recommended RUQUS w/ Doppler and
diagnostic paracentesis. Paracentesis w/ 1.4 protein, 131 glc,
303 WBC (74% macrophages and 9% PMNs), gram stain w/ no
microorganisms.
Transfer VS were: T 98.6 HR 95 BP 128/80 RR 18 99% ra
On arrival to the floor, patient reports the above history. She
continues to have ___ abdominal pain and ___ SOB due to
abdominal distension.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Hepatitis C cirrhosis- genotype 1a decompensated with h/o
ascites; liver biopsy in ___ showed stage ___ fibrosis
Hypertension
Hyperlipidemia
COPD
Alcohol abuse
Depression
Cocaine abuse
Tobacco abuse
Atypical chest pain
Breast pain
Abdominal pain
Cervical spondylosis
L subclavian stenosis
Peripheral vascular disease
GERD s/p lap fundoplication and hiatal hernia repair ___
s/p cholecystectomy
s/p R inguinal hernia repair
Social History:
___
Family History:
Mom had DM, CAD (COD), and was in a wheelchair for neuropathy.
Father had alcoholism and rectal CA (COD).
Sister has mental illness, also hx of falls.
Siblings: 1 brother neonatal death, 1 brother death at 3 months,
1 brother sudden death in ___.
Physical Exam:
ADMISSION EXAM
==============
VS: 98.1 155/73 95 22 98%Ra
GENERAL: Middle aged female, appears uncomfortable in bed.
breathing shallowly.
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: CTAB, no wheezes, rales, rhonchi
ABDOMEN: +BS, significant abdominal distension with diffuse
tenderness to palpation, greatest in RUQ. +fluid wave
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis.
SKIN: scattered spider angiomata
DISCHARGE EXAM
==============
VS: 98.0, HR 85, 123/68, RR 18, 96% RA
GENERAL: Middle aged female, appears well, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheeze
ABDOMEN: +BS, mild abdominal distension, minimal tenderness,
reducible umbilical hernia noted
EXTREMITIES: No cyanosis, clubbing, or edema
NEURO: Alert, oriented to person, place, time. Moving all 4
extremities with purpose. No asterixis. Ambulating around the
halls without difficulty
Pertinent Results:
ADMISSION LABS
==============
___ 10:55AM BLOOD WBC-4.4 RBC-3.62* Hgb-9.0* Hct-30.2*
MCV-83 MCH-24.9* MCHC-29.8* RDW-21.2* RDWSD-63.7* Plt Ct-86*
___ 10:55AM BLOOD Neuts-70.6 Lymphs-17.0* Monos-10.8
Eos-0.9* Baso-0.5 Im ___ AbsNeut-3.07 AbsLymp-0.74*
AbsMono-0.47 AbsEos-0.04 AbsBaso-0.02
___ 10:55AM BLOOD ___ PTT-34.2 ___
___ 10:55AM BLOOD Glucose-117* UreaN-5* Creat-0.6 Na-136
K-3.6 Cl-101 HCO3-20* AnGap-15
___ 10:55AM BLOOD ALT-13 AST-41* AlkPhos-141* TotBili-1.3
DirBili-0.4* IndBili-0.9
___ 10:55AM BLOOD Albumin-3.3*
NOTABLE LABS
============
___ 10:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:27AM BLOOD HCV VL-6.0*
MICRO
=====
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
IMAGING
=======
___ ABDOMINAL XR
IMPRESSION:
Cirrhosis with sequela of portal hypertension. Moderate ascites
is increased from most recent prior.
___ ABD XR
IMPRESSION:
No definite radiographic evidence of bowel obstruction; mildly
prominent loops
of large bowel may represent colonic ileus.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is
little change and no evidence of acute cardiopulmonary disease.
No pneumonia, vascular
congestion, or pleural effusion.
Large left perihilar bleb is again seen, better demonstrated on
a prior CT
scan.
___ LIVER US
IMPRESSION:
Cirrhosis is of portal hypertension, including splenomegaly and
small volume
ascites. No focal hepatic lesion. Patent portal veins with
appropriate
directional flow.
___ CXR
Very small pleural effusions unchanged. No pneumothorax. Mild
left basal
atelectasis. Lungs otherwise clear. Normal cardiomediastinal
and hilar
silhouettes.
DISCHARGE LABS
==============
___ 04:35AM BLOOD WBC-2.7* RBC-2.79* Hgb-7.2* Hct-23.8*
MCV-85 MCH-25.8* MCHC-30.3* RDW-22.4* RDWSD-69.5* Plt Ct-76*
___ 04:35AM BLOOD ___
___ 04:35AM BLOOD Glucose-139* UreaN-7 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-23 AnGap-14
___ 04:35AM BLOOD ALT-14 AST-40 AlkPhos-79 TotBili-1.0
___ 04:35AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
Brief Hospital Course:
HOSPITAL COURSE
===============
___ w/ HCV/ETOH cirrhosis (genotype 1a, child's class B with hx
ascites), polysubstance abuse, COPD, HTN, HLD, RA, who p/w few
month hx of worsening abd pain, distention, and SOB due to large
volume ascites. She received a large volume paracentesis with
improvement in symptoms. She developed ___ in the setting of
diuresis, so her home Furosemide was decreased from 40mg to 20mg
daily. She developed asterixis and encephalopathy early in her
hospital course, and was thus started on lactulose and
rifaximin.
ACTIVE ISSUES
=============
# Abdominal pain: Has had distended abdomen and TTP for 3+
months. RUQUS showed moderate ascites, patent portal veins, and
evidence of cirrhosis. S/p 4L paracentesis on ___ with some
improvement. Peritoneal studies not suggestive of SBP. Likely
multifactorial from constipation, abdominal hernia, ascites. On
discharge, pain was well controlled. Received PO Dilaudid while
inpatient, as needed. She was given a 3 day prescription for
her home Tramadol on discharge, with further narcotic refills
needing to be done by her outpatient providers.
# ___: Cr up to 1.4 on ___, from baseline 0.6. Likely due to
diuresis and paracentesis. Trialed albumin challenge on ___,
___, with improvement in Cr back to baseline. She was
subsequently restarted on a lower dose diuretic, Lasix 20mg
daily (home dose was 40mg), and tolerated this with stable Cr on
day of discharge.
# Hepatic encephalopathy
# HCV/ETOH cirrhosis:
___ MELD-Na 15 on admission, w/ hx ascites on
diuretics. Last EGD (___) w/ 3 small varices. Planned
Harvoni therapy in future when medically able. No prior history
of SBP or Hepatic Encephalopathy. Current presentation appeared
to be slow decompensation of liver disease over time, as opposed
to acute process. HCV-VL: 6.0. Diagnostic/therapeutic
paracentesis showed no evidence of SBP. Beta blocker and
diuretics were held while patient had ___, and on discharge the
Nadolol was held, and the Furosemide was decreased to 20mg
(prior dose was 40mg). Started lactulose and rifaximin given
concern for HE with asterixis and confusion early in the
admission.
# Dyspnea: Likely secondary to ascites and abdominal distension.
Resolved after paracentesis. Afebrile, WBC stable, CXR without
pneumonia or significant fluid. Continued home COPD regimen
# Polysubstance abuse: Hx heroin abuse in the past. Current ETOH
use daily and intermittent cocaine. Positive for cocaine by tox
screen in ED. SW consulted. Did not require CIWA inpatient.
# HTN: Held home valsartan 320 mg qd and amlodipine 5 mg qd
given normal BP and ___. Not to be restarted until discussed
with PCP.
# Pancytopenia: Relatively stable, likely related to cirrhosis
- Recheck as outpatient
CHRONIC ISSUES
==============
# Anemia: Hgb 9 on admission. Recent baseline ___. Last
colonoscopy (___) and EGD (___) w/o source of bleeding.
Continued folate and iron supplementation
# Nutrition: Continue home folate, thiamine, MVI, ca/vitamin D,
iron.
# Primary prevention: Continued home aspirin
# Pain: Held home gabapentin 800 mg TID as ineffective. Resume
home Tramadol on discharge.
# Allergies: Continued home loratidine, hydroxyzine prn, and
Flonase.
# Insomnia: Continued home mirtazapine.
# HLD: Continued home simvastatin 20 mg qd
# GERD: Continued home pantoprazole 40 mg BID
TRANSITIONAL ISSUES
===================
[] Recommend outpatient lab recheck, including CBC to trend
pancytopenia
[] CHANGED MEDICATIONS: Lasix decreased from 40mg to 20mg daily
[] NEW MEDICATIONS: Lactulose, Rifaximin
[] MEDICATIONS STOPPED: Gabapentin (ineffective for her),
Valsartan (developed ___, and BP was normal), Nadolol (developed
___, varices were very small on last EGD, BP's were normal)
[] MEDICATIONS HELD: Amlodipine - told pt not to restart until
discussing with PCP
[] Re: hepatology, consider Harvoni as an outpatient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 800 mg PO TID
9. HydrOXYzine 25 mg PO BID:PRN itch
10. Loratadine 10 mg PO DAILY:PRN allergies
11. Pantoprazole 40 mg PO Q12H
12. Simvastatin 20 mg PO QPM
13. Thiamine 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
16. Valsartan 320 mg PO DAILY
17. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
18. Furosemide 40 mg PO DAILY
19. Nadolol 20 mg PO DAILY
20. FoLIC Acid 1 mg PO DAILY
21. Mirtazapine 30 mg PO QHS
22. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO Q8H:PRN constipation
take to ensure multiple bowel movements per day
RX *lactulose 20 gram/30 mL 30 ml by mouth every 8 hours Disp
#*1 Bottle Refills:*1
2. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. FoLIC Acid 1 mg PO DAILY
12. HydrOXYzine 25 mg PO BID:PRN itch
13. Loratadine 10 mg PO DAILY:PRN allergies
14. Mirtazapine 30 mg PO QHS
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q12H
17. Simvastatin 20 mg PO QPM
18. Thiamine 100 mg PO DAILY
19. Tiotropium Bromide 1 CAP IH DAILY
20. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*12
Tablet Refills:*0
21. HELD- Amlodipine 5 mg PO DAILY This medication was held. Do
not restart Amlodipine until discussing with your primary care
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis with ascites, 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 with abdominal pain. There
were likely multiple causes for this, including ascites (fluid),
and you improved somewhat after we drained out this fluid.
You were confused and had hand shaking (asterixis), which is a
marker of a condition called hepatic encephalopathy. We started
you medications called Lactulose and Rifaximin to treat this
condition.
Because a kidney injury developed, we decreased the dose of your
water pill (Lasix, aka Furosemide). The dose is now 20mg, it
used to be 40mg. We also stopped your Nadolol, Amlodipine, and
Gabapentin.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19644467-DS-33
| 19,644,467 | 25,183,928 |
DS
| 33 |
2202-06-13 00:00:00
|
2202-06-13 18:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril / mango / papaya
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Bedside Paracentesis ___
___ Paracentesis ___
History of Present Illness:
___ with HCV/EtOH cirrhosis and polysubstance misuse with
multiple admissions for volume overload and abdominal pain
presents with abdominal pain since a outpatient therapeutic
paracentisis on ___ which was uncomplicated and removed 2.5L.
On ___, the patient was seen in ___ clinic where she was
complaining of increasing abdominal girth, tenderness and pain
on
palpation by prior paracentesis site. She was referred to the
emergency department to rule out SBP.
The patient endorses a 1 week history of general malaise,
myalgia
and total body aches in addition to her abdominal pain. She has
occasional faint, chest pain and stable dyspnea. She is without
palpitations. She endorses mild dysuria which is her baseline
and
has ___ loose bowel movements daily.
In the emergency department a bedside paracentesis was attempted
which withdrew free air. Ascites fluid was negative for SBP.
Given free air on paracentesis and abdominal pain a CT
abd/pelvis
was obtained to rule out perforation which demonstrated no
perforation or acute process.
The patient continued to have abdominal pain requiring morphine
for symptomatic relief.
Her emergency department course was subsequently complicated by
hypotension requiring the administration of saline.
In the ED, initial VS were:
T 98 HR 88 BP 148/71 R 16 SpO2 100% RA
Exam notable for:
ABD: impressively distended, caput medusa, tympanic to
percussion
until lower flanks bilaterally, periubmilical hernia
ECG: Not performed
Labs showed:
137 97 23
----------<
3.5 21 0.9
9.4
6.8>---<125
30.2
___: 15.4 PTT: 37.7 INR: 1.4
ALT: 83 AP: 226 Tbili: 1.6 Alb: 3.4
AST: 112
TSH:4.1
Ascites WBC 268 RBC 1365 13% Poly
Lactate:1.8
Imaging showed:
___ CT Abd & Pelvis W/O Contrast
1. Enteric contrast is seen diffusely throughout the loops of
small bowel without evidence of extraluminal contrast
extravasation. There is no free air.
2. Cirrhosis with moderate to large volume ascites.
3. Ill-defined hypodensity within the spleen is incompletely
characterized on the current study, similar in appearance to the
prior study.
___ US Abd Limit, Single Organ
1. Moderate volume ascites, decreased compared to ___.
2. The largest pocket is current located in the midline pelvis,
just below the umbilicus. A slightly smaller pocket of fluid
also
seen in the right lower quadrant.
Consults: Hepatology agreed with admission to the hepatology
service
Patient received:
___ 19:03 IV Morphine Sulfate 4 mg
___ 19:03 IV Ondansetron 4 mg
___ 20:31 IV Morphine Sulfate 4 mg
___ 23:57 IVF NS
___ 00:00 PO Pantoprazole 40 mg
___ 02:45 IV Morphine Sulfate 2 mg
___ 02:54 PO/NG Lactulose 30 mL
___ 05:39 PO/NG Lactulose 30 mL
___ 06:06 IV Ondansetron 4 mg
___ 07:43 PO/NG Lactulose 30 mL
___ 07:58 PO Pantoprazole 40 mg
___ 07:58 PO/NG amLODIPine 5 mg
___ 07:58 PO/NG Aspirin 81 mg
___ 07:58 PO/NG FoLIC Acid 1 mg
___ 07:58 PO/NG Furosemide 20 mg
___ 08:34 PO/NG Pregabalin 75 mg
___ 11:14 IH Fluticasone-Salmeterol Diskus (500/50) 1 INH
___ 11:14 PO/NG Valsartan 320 mg
___ 11:14 PO/NG Rifaximin 550 mg
___ 12:59 IVF NS
___ 13:13 IV Ondansetron 4 mg
___ 14:43 IV Morphine Sulfate 2 mg
___ 16:54 IV Morphine Sulfate 2 mg
___ 21:41 PO/NG Mirtazapine 30 mg
___ 21:41 PO/NG Pregabalin 75 mg
___ 21:42 PO/NG Lactulose 30 mL
On arrival to the floor, patient reports continued abdominal
pain
Past Medical History:
Hepatitis C cirrhosis- genotype 1a decompensated with h/o
ascites; liver biopsy in ___ showed stage ___ fibrosis
Hypertension
Hyperlipidemia
COPD
Alcohol abuse
Depression
Cocaine abuse
Tobacco abuse
Atypical chest pain
Breast pain
Abdominal pain
Cervical spondylosis
L subclavian stenosis
Peripheral vascular disease
GERD s/p lap fundoplication and hiatal hernia repair ___
s/p cholecystectomy
s/p R inguinal hernia repair
Social History:
___
Family History:
Mom had DM, CAD (COD), and was in a wheelchair for neuropathy.
Father had alcoholism and rectal CA (COD).
Sister has mental illness, also hx of falls.
Siblings: 1 brother neonatal death, 1 brother death at 3 months,
1 brother sudden death in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 PO BP 105/65 HR 95 R 18 SpO2 95 RA
GEN: Chronically ill and fatigued. Noted sarcopenia and temporal
wasting
HEENT: Sclerae anicteric, no tongue asterixis. Dry mucous
membranes
___: RRR II/IV SEM. JVP to angle of jaw at 45 degrees
RESP: No increased WOB, bibasilar crackles without wheezing or
rhonchi
ABD: Tense, distended with caput medusa. L sided ecchymosis with
clean, dry bandage on right abdominal wall. +rebound
EXT: warm, no edema
NEURO: CN II-XII intact. +asterixis
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 855)
Temp: 98.6 (Tm 98.6), BP: 115/65 (113-144/49-78), HR: 90
(82-98), RR: 18, O2 sat: 98% (93-100), O2 delivery: Ra, Wt:
128.31 lb/58.2 kg
Fluid Balance (last updated ___ @ 854)
Last 8 hours Total cumulative -600ml
IN: Total 0ml
OUT: Total 600ml, Urine Amt 600ml
Last 24 hours Total cumulative -855ml
IN: Total 420ml, PO Amt 420ml
OUT: Total 1275ml, Urine Amt 1275ml
GEN: Chronically ill and fatigued. Noted sarcopenia and temporal
wasting.
HEENT: Sclerae anicteric, no tongue asterixis. Dry mucous
membranes
CV: NR,RR. II/VI SEM.
RESP: No increased WOB, bibasilar crackles without wheezing or
rhonchi
ABD: Tense, distended. Tender to mild palpation. L sided
ecchymosis with clean, dry bandage on right abdominal wall.
+rebound
EXT: warm, no edema.
NEURO: CN II-XII intact. +asterixis. Gross tremor of BUE.
Finger-to-nose intact bilaterally. 2+ Patellar reflexes. ___
Strength BLE.
Pertinent Results:
ADMISSION LABS
==============
___ 11:42AM BLOOD WBC-6.8 RBC-3.46* Hgb-9.4* Hct-30.2*
MCV-87 MCH-27.2 MCHC-31.1* RDW-19.8* RDWSD-62.1* Plt ___
___ 11:42AM BLOOD ___ PTT-37.7* ___
___ 11:42AM BLOOD UreaN-23* Creat-0.9 Na-137 K-3.5 Cl-97
HCO3-21* AnGap-19*
___ 11:42AM BLOOD ALT-83* AST-112* AlkPhos-226*
TotBili-1.6*
___ 01:45AM BLOOD Albumin-3.1* Calcium-8.5 Phos-4.6* Mg-2.2
___ 11:42AM BLOOD %HbA1c-6.3* eAG-134*
___ 11:42AM BLOOD TSH-4.1
___ 11:42AM BLOOD AFP-7.4
___ 11:42AM BLOOD HCV VL-5.9*
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-4.5 RBC-2.91* Hgb-8.1* Hct-25.9*
MCV-89 MCH-27.8 MCHC-31.3* RDW-21.4* RDWSD-65.5* Plt Ct-61*
___ 06:45AM BLOOD ___
___ 06:45AM BLOOD Glucose-170* UreaN-16 Creat-0.9 Na-138
K-4.6 Cl-103 HCO3-20* AnGap-15
___ 06:45AM BLOOD ALT-34 AST-48* LD(LDH)-212 AlkPhos-156*
TotBili-0.7
___ 06:45AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.4
URINE
=====
___ 10:45PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:45PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 10:45PM URINE RBC-3* WBC-9* Bacteri-MOD* Yeast-NONE
Epi-26 TransE-<1
___ 10:26AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:26AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 10:26AM URINE RBC-118* WBC-153* Bacteri-MOD* Yeast-NONE
Epi-0
___ 10:26AM URINE CastHy-42*
STUDIES
=======
___ US ABD
1. Moderate volume ascites, decreased compared to ___.
2. The largest pocket is currently located in the midline
pelvis, just below the umbilicus. A slightly smaller pocket of
fluid also seen in the right lower quadrant.
___ CT A/P
1. Enteric contrast is seen diffusely throughout the loops of
small bowel
without evidence of extraluminal contrast extravasation. There
is no free
air.
2. Cirrhosis with moderate to large volume ascites.
3. Ill-defined hypodensity within the spleen is incompletely
characterized on the current study, similar in appearance to the
prior study and likely an infarct.
___ KUB
No free intraperitoneal air. No radiographic evidence of bowel
obstruction or ileus.
___ US Paracentesis
1. Technically successful ultrasound guided therapeutic
paracentesis.
2. 3.4 L of fluid were removed.
___ ABI
1. Mild right lower extremity (SFA) and tibia arterial
insufficiency at rest.
2. Moderate aorto-left iliac and left tibial arterial
insufficiency at rest.
___ Hip XR
Mild degenerative changes in the bilateral hip joints.
___ MRI Thoracic/Lumbar
1. There is no high-grade spinal canal or neural foraminal
narrowing of the thoracic or lumbar spine. No compression of
the cord or cauda equina.
2. Degenerative changes are most prominent at L5-S1 where a
right eccentric disc bulge crowds the right greater than left
subarticular zone contacting but not posteriorly displacing the
traversing right S1 nerve root.
3. There is 9 mm long segment of T2 hyperintense central cord
signal at the T1 level on sagittal sequences, not seen on prior
examinations and not confirmed on motion degraded axial
sequences. This could represent syringohydromyelia or prominent
central canal of uncertain clinical significance. This could be
further evaluated with contrast enhanced study.
4. Additional findings described above including sequela of
known cirrhosis.
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with HCV/EtOH cirrhosis
who presented with abdominal pain after elective paracentesis,
developed transient urinary retention, and continued to have
chronic pain.
# Decompensated HCV/EtOH Cirrhosis
# Hepatic encephalopathy
Known history of grade 1 varices, ascites and hepatic
encephalopathy. No h/o SBP or GIB. Sent from Liver clinic to ED
after c/o abdominal pain 1 week after therapeutic paracentesis.
Mild asterixis and volume overload noted. Flu negative. Reported
last alcohol 1 month ago. Liver U/S with patent vasculature.
Diagnostic bedside paracentesis performed, negative for SBP.
Continued on rifaximin, lactulose. Therapeutic paracentesis
performed with 3L removed. Given albumin 25g x1, then 50g x2.
Attempted repeat paracentesis, but insufficient fluid to
successfully drain. Held home furosemide/spironolactone.
# Abdominal Pain
# Chronic Pain
# Polysubstance misuse disorder
History of chronic pain. On tramadol, pregabalin, and APAP at
home. Last underwent paracentesis ___ and complained of
abdominal pain afterwards. Multiple similar admission. Over the
course of the admission, with further discussion it seems the
pain is severe, but longstanding. Notes "bone pain" throughout,
R hip locking, mandible pain, and abdominal pain. Also notes
pain/odd sensation with urination and defection which she
reports has been present since before the admission. Consulted
dental and obtained panorex which showed no infection. Consulted
chronic pain and trialed cyclobenzaprine and baclofen, however
both were discontinued due to urinary retention. Continued on
tramadol, tylenol, pregabalin, and lidocaine patch. At time of
discharge, pain at baseline from prior to admission.
# Urinary Retention
Noted new inability to urinate with high bladder scans. Foley
catheter placed after several straight cath attempts. Also
complained of new fecal incontinence to RN and thigh numbness.
Sensation intact on exam and rectal tone present, but obtained
MRI spine which showed no signs of cord compression. Stopped
cyclobenzaprine, Dilaudid, loratidine, baclofen. Urology
consulted and recommended home w/ foley for ___ days, but then
she briefly was able to void on her own. Retention presumed ___
med effect from cyclobenzaprine and/or baclofen but also may be
a component of neurogenic bladder given neuropathy elsewhere.
Repeat retention on day of discharge. ___ placed to remain in
with urology follow-up.
# Acute Kidney Injury
Baseline Cr 0.7-0.8. Admission Cr 1.1 likely representing
significant decrease in GFR due to patient's size and lack of
muscle mass. No hyponatremia or hydronephrosis. Cr peaked at
1.4, then improved s/p 2 day of 1mg/kg albumin. Held home
furosemide.
# T2 Hyperintense Signal
9mm segment of T2 hyperintensity noted in the central cord at
the T1 level on Thoracic MRI, not seen on previous exams and not
confirmed on axial sequences. Could be syringohydromyelia or
prominent central canal; unclear clinical significance. No
notable dermatomal sensory or strength deficits. Deferred
further evaluation, which could be done with a contrast-enhanced
MRI.
CHRONIC ISSUES
==============
# Severe Protein Malnutrition
Patient with temporal wasting and sarcopenia on exam with
reported decreased PO intake. Nutrition consulted. Provided
supplements with meals.
# Anemia
Stable, without signs of active bleeding.
# Thrombocytopenia
# Coagulopathy
Due to underlying cirrhosis. At baseline.
# h/o HTN
Losartan and amlodipine held on last admission for soft blood
pressures. BPs not elevated. Held antihypertensives
# COPD
Stable. Continued home inhalers.
# GERD
Continued home PPI.
TRANSITIONAL ISSUES
===================
[ ] Consider MRI T Spine with contrast to evaluate signal
abnormality of unclear clinical significance noted on MRI.
[ ] Should follow up with urology given persistent urinary
retention.
[ ] Developed acute urinary retention in setting of
cyclobenzaprine and baclofen use. Should avoid using these
medications in the future.
[ ] If persistent mandibular pain, consider dental appointment
and adjustment of dentures.
[ ] Volume overloaded, but unable to perform paracentesis
inpatient. Likely will need short-interval paracentesis.
[ ] Held diuretics on discharge due to rising creatinine every
time attempted to restart diuretics. Assess at f/u appointment
and restart if indicated.
[ ] Discharged with foley in place and urology follow-up for
retention. Foley placed ___.
#CODE: Full
#CONTACT: Fiance, ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. HydrOXYzine 25 mg PO BID:PRN itch
6. Loratadine 10 mg PO DAILY allergies
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Ondansetron ODT 4 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY
11. Rifaximin 550 mg PO BID
12. Simethicone 40-80 mg PO QID
13. Simvastatin 20 mg PO QPM
14. Thiamine 100 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraMADOL (Ultram) 50 mg PO TID:PRN pain
17. Ferrous GLUCONATE 324 mg PO DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
20. Pregabalin 75 mg PO BID
21. FoLIC Acid 1 mg PO DAILY
22. Zinc Sulfate 220 mg PO DAILY
23. Lactulose 30 mL PO TID
24. Nystatin Oral Suspension 5 mL PO QID
25. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Zinc Sulfate 220 mg PO DAILY
3. Pregabalin 150 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
7. Ferrous GLUCONATE 324 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. HydrOXYzine 25 mg PO BID:PRN itch
12. Lactulose 30 mL PO TID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Nystatin Oral Suspension 5 mL PO QID
15. Pantoprazole 40 mg PO Q12H
16. Polyethylene Glycol 17 g PO DAILY
17. Rifaximin 550 mg PO BID
18. Simethicone 40-80 mg PO QID
19. Simvastatin 20 mg PO QPM
20. Thiamine 100 mg PO DAILY
21. Tiotropium Bromide 1 CAP IH DAILY
22. TraMADOL (Ultram) 50 mg PO TID:PRN pain
23. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Decompensated Hepatitis C/Alcohol Cirrhosis
Volume Overload
Hepatic Encephalopathy
SECONDARY DIAGNOSES
===================
Claudication
Urinary Retention
Chronic Pain
Acute Kidney Injury
Severe Protein Malnutrition
Anemia
Thrombocytopenia
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having increased abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We looked at the fluid in your abdomen and saw that you did
not have an infection.
- We drained some fluid, but were unable to drain it a second
time.
- We got x-rays of your hips which showed arthritis.
- We got x-rays of your jaw and had the dentist see you and they
said there was no infection.
- We got an MRI of your back because you were having difficulty
peeing and it showed no compression of your spinal cord.
- We had to place a urinary drainage catheter as you were unable
to reliably empty your bladder, if you should start having any
new symptoms or if the catheter is not functioning please
contact urology or come to the emergency room.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19644467-DS-35
| 19,644,467 | 23,290,728 |
DS
| 35 |
2202-07-02 00:00:00
|
2202-07-03 08:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Morphine /
Lisinopril / mango / papaya
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms ___ is a ___ female with HCV (genotype 1a) and
EtOH cirrhosis (child's class B) c/b ascites, esophageal
varices, and hepatic encephalopathy, hx polysubstance abuse,
COPD, HTN, and HLD presenting with complaint of abdominal
distention, abnormal labs.
Over the past several days to weeks she has had ongoing
worsening diffuse abdominal pain, distention. Yesterday she had
an outpatient paracentesis in which 2.45 L fluid was removed,
also had surveillance labs that were notable for an elevated
creatinine of 1.4 (baseline 0.7). She was contacted by phone and
advised to present to the emergency department for admission.
Of note, recent admissions to ___ ___ with abdominal
pain, urinary retention, ___. Discharged off of diuretics given
recurrent ___ with diuretic challenge. Additional admission
___ with abdominal distention secondary to re-accumulating
ascites, underwent therapeutic paracentesis with 6L fluid
removed. Diuretics not
Past Medical History:
Hepatitis C cirrhosis- genotype 1a decompensated with h/o
ascites; liver biopsy in ___ showed stage ___ fibrosis
Hypertension
Hyperlipidemia
COPD
Alcohol abuse
Depression
Cocaine abuse
Tobacco abuse
Atypical chest pain
Breast pain
Abdominal pain
Cervical spondylosis
L subclavian stenosis
Peripheral vascular disease
GERD s/p lap fundoplication and hiatal hernia repair ___
s/p cholecystectomy
s/p R inguinal hernia repair
Social History:
___
Family History:
Mom had DM, CAD (COD), and was in a wheelchair for neuropathy.
Father had alcoholism and rectal CA (COD).
Sister has mental illness, also hx of falls.
Siblings: 1 brother neonatal death, 1 brother death at 3 months,
1 brother sudden death in ___.
Physical Exam:
Admission Physical Exams:
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
LUNGS: Decreased breath sounds in both bases b/l
ABDOMEN: NABS, distended, periumbilical hernia present, pain
with palpation of the hernia and pain with palpation of the R
flank, no rebound or guarding. Hernia reducible.
EXTREMITIES: Warm, well perfused. No ___ edema.
NEUROLOGIC: Mild asterixis
Discharge Exam:
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
LUNGS: Decreased breath sounds in both bases b/l
ABDOMEN: NABS, distended, periumbilical hernia present, pain
with palpation of the hernia and pain with palpation of the R
flank, no rebound or guarding. Hernia reducible.
EXTREMITIES: Warm, well perfused. No ___ edema.
NEUROLOGIC: Mild asterixis
Pertinent Results:
Admission Labs:
===============
___ 07:15AM BLOOD WBC-4.6 RBC-3.35* Hgb-9.4* Hct-30.9*
MCV-92 MCH-28.1 MCHC-30.4* RDW-20.6* RDWSD-69.1* Plt ___
___ 01:16PM BLOOD Neuts-73.9* Lymphs-14.5* Monos-9.6
Eos-1.1 Baso-0.4 Im ___ AbsNeut-4.18 AbsLymp-0.82*
AbsMono-0.54 AbsEos-0.06 AbsBaso-0.02
___ 07:15AM BLOOD ___ PTT-39.2* ___
___ 07:15AM BLOOD Glucose-231* UreaN-45* Creat-1.4* Na-140
K-5.2 Cl-108 HCO3-15* AnGap-17
___ 07:15AM BLOOD ALT-20 AST-45* AlkPhos-221* TotBili-1.0
DirBili-0.5* IndBili-0.5
___ 07:15AM BLOOD Albumin-3.2*
___ 11:33PM BLOOD Lactate-2.4*
Microbiology:
=============
___ 1:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:08 pm URINE
URINE CULTURE (Pending
Imaging:
========
CXR: ___
IMPRESSION:
No acute cardiopulmonary process.
Liver Gb US ___:
IMPRESSION:
1. Main portal vein is patent with hepatopetal flow.
2. Small volume ascites.
3. Splenomegaly measuring up to 17.3 cm.
4. Coarsened and nodular hepatic parenchyma consistent with
history of
cirrhosis. No evidence of focal liver mass.
Discharge Labs:
===============
___ 05:10AM BLOOD WBC-4.2 RBC-2.99* Hgb-8.7* Hct-27.6*
MCV-92 MCH-29.1 MCHC-31.5* RDW-20.2* RDWSD-67.7* Plt Ct-95*
___ 05:10AM BLOOD ___ PTT-39.3* ___
___ 05:10AM BLOOD Glucose-124* UreaN-28* Creat-0.8 Na-141
K-5.1 Cl-110* HCO3-20* AnGap-11
___ 05:10AM BLOOD ALT-22 AST-51* AlkPhos-216* TotBili-1.1
___ 05:10AM BLOOD Albumin-3.6 Calcium-8.7 Phos-3.0 Mg-2.5
Iron-44
Brief Hospital Course:
Ms. ___ is a ___ with HCV (genotype 1a) and EtOH cirrhosis
(child's class B) c/b ascites, varices, and hepatic
encephalopathy, hx polysubstance abuse, COPD, HTN, and HLD
referred to the ___ ED for ___ resolved without
intervention. Of note, the patient had not yet received her
sofosbuvir-velpatasvir (___), which will be started at her
next ___ visit.
ACUTE ISSUES:
=============
___
The patient ___ contacted to present to the ED after she was
found to have a creatinine of 1.7 after having a scheduled
therapeutic paracentesis. She received 25G albumin X 4 in ED. On
recheck creatinine down trended to 0.8 which is the patients
baseline. ___ may have been related to fluid removal given
paracentesis prior to abnormal labs. Of note the patient is not
maintained on diuretics due to recurrent ___ when trialed on
diuretics.
#ABDOMINAL DISTENTION
#ABDOMINAL PAIN
Patient notes chronic pain with history of hiatal hernia and R
inguinal hernia and now with periumbilical hernia. She notes
that periumbilical hernia is chronic. Her hernia was reducible.
Lactate was elevated but was likely due to fluid shifts from
paracentesis. She was seen by surgery in ___ and at
that time, it was asymptomatic and surgery was not offered.
Suspect that some of pain is also related to ascites. Lipase was
normal. Pain was treated with lidocaine patch, tramadol. Surgery
consultation was deferred given no concerns for worsening or
incarceration, but could consider referral as outpatient.
#HCV/ETOH CIRRHOSIS
Patient with Child Class B cirrhosis followed by hepatology at
___. MELD NA 13. She last saw liver service at the end of
___. Recurrent ascites with last paracentesis on ___.
Per last hepatology note she will continue to get weekly
paracentesis and have biweekly labs. There was no tapable pocket
of fluid on ED ultrasound to evaluate for SBP. She continued on
home lactulose, rifamixin folic acid, thiamine.
Of note, the patient was due to start antiviral
sofosbuvir-velpatasvir [___]. It has been confirmed that
this will be started at her next liver clinic appointment later
this month.
#Polypharmacy:
The patient is on 25 medications. Her home medications were
confirmed on filling history when speaking to pharmacy as well
as to the patient.
#Diuretics:
Patient last filed furosemide on ___. She has a history of
recurrent ___ on diuretics and on recent admission was
discontinue on diuretics with plan for weekly paracentesis. The
patient was last seen a the ___ on ___ with no
documented plan to resume diuretics. We will continue to hold
furosemide at discharge with plan for ___ check at ___ visit
next week.
CHRONIC ISSUES:
===============
#COPD: Continued home inhalers: albuterol, tiotropium,
fluticasone-salmeterol
Transitional Issues:
===================
[] Patient will start sofosbuvir-velpatasvir [___] following
next ___ appointment on ___.
[] Recommend repeat BMP at ___ appointment on ___
[] Did not trial diuretics on patient given recurrent ___ in
past
[] Evaluate periumbilical hernia as outpatient for consideration
of outpatient surgical referral for elective hernia repair
[] Continue paracentesis as needed, biweekly labs
[] Last EGD ___, 3 cords of small varices were seen in the
lower esophagus. No history of GI bleeding. Not on home
naldolol.
[] HE: History of HE in past. Continue home lactulose and
rifaxmin, titrate 3BMs per day
#CODE: Full
#CONTACT: Fiance, ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. HydrOXYzine 25 mg PO BID:PRN itch
7. Lactulose 30 mL PO TID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. Simvastatin 20 mg PO QPM
12. Thiamine 100 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
15. Nystatin Oral Suspension 5 mL PO QID
16. Simethicone 40-80 mg PO QID
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Ondansetron ODT 4 mg PO Q8H:PRN nausea
19. Pregabalin 150 mg PO BID
20. Valsartan 320 mg PO DAILY
21. amLODIPine 5 mg PO DAILY
22. Escitalopram Oxalate 10 mg PO DAILY
23. Zinc Sulfate 220 mg PO DAILY
24. ___ (sofosbuvir-velpatasvir) 400-100 mg oral Daily
25. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral BID
5. Escitalopram Oxalate 10 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. HydrOXYzine 25 mg PO BID:PRN itch
10. Lactulose 30 mL PO TID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Nystatin Oral Suspension 5 mL PO QID
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea
14. Pantoprazole 40 mg PO Q12H
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Pregabalin 150 mg PO BID
17. Rifaximin 550 mg PO BID
18. Simethicone 40-80 mg PO QID
19. Simvastatin 20 mg PO QPM
20. Thiamine 100 mg PO DAILY
21. Tiotropium Bromide 1 CAP IH DAILY
22. Valsartan 320 mg PO DAILY
23. Zinc Sulfate 220 mg PO DAILY
24. HELD- ___ (sofosbuvir-velpatasvir) 400-100 mg oral Daily
This medication was held. Do not restart ___ until you have
your liver clinic appointment.
25. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until you speak to your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
HCV/Alcoholic Cirrhosis
Abdominal Pain
Ascites
Chronic Issues:
Periumbilical Hernia
COPD
Hypertention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- Because your Creatinine, which looks at how well your
kidneys are working, was not normal
What did you receive in the hospital?
- We gave you albumin and your Creatinine improved
- We called your pharmacy to make sure that you get your
hepatitis C medication named ___. You can pick this up at
the ___ once you are discharged
What should you do once you leave the hospital?
- Please pick up your Hepatitis C medication named ___ at
the ___
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19644467-DS-41
| 19,644,467 | 24,899,124 |
DS
| 41 |
2203-01-03 00:00:00
|
2203-01-04 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Valium / Penicillins / Omeprazole Sodium / Lisinopril
/ mango / papaya / morphine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis (___)
History of Present Illness:
___ woman with past medical history of hep C and
alcoholic cirrhosis complicated by ascites, esophageal varices,
rectal varices, hepatic encephalopathy, polysubstance use
disorder, hyperlipidemia, COPD, peripheral vascular disease,
GERD status post lap fundoplication and hiatal hernia repair who
presents with worsening abdominal pain, back pain, and bilateral
inguinal pain. Patient fell off her uncles couch about 2 weeks
ago and broke her ribs. She was evaluated by her PCP after the
fall. Reports that it may have been because she forgot that she
was on the edge of the couch and rolled over after taking her
morphine. Since that time, she has had worsening abdominal pain
and believes is from her inguinal/abdominal hernias. She states
that all of her hernias are easily reducible and she has no
overlying skin issues but notes that therapeutic paracentesis
(8L on ___ did not make her abdominal pain better. Patient
otherwise denies chest pain, palpitations, cough, URI symptoms,
urinary symptoms, vaginal bleeding, vaginal discharge. Does note
subjective chills and/or fevers.
In the ED initial vitals:
98.1, 88, 128/70, 16, 100% RA
- Labs notable for:
3.8 > 8.0/26.3 < 65
137 | 111 | 16 AGap=12
-------------< 244
4.5 | 14 | 0.8
ALT: 35 AP: 173 Tbili: 1.2 Alb: 3.2
AST: 51 LDH: Dbili: 0.5
AFP 4.4
___: 15.8 PTT: 31.8 INR: 1.5
Ascitic Studies:
WBC 285, RBC 884
Poly 4
Lymph 23
Mono 47
Bands: ___
Mesothe: ___
Macroph: 18
Protein 1.3
Glucose 193
pH 7.33
pCO2 40
- Trauma Consult:
Rib fractures are not acute, no other surgical or traumatic
injuries
- Patient was given:
SC Insulin 8 UNIT
Docusate Sodium 100 mg
Pregabalin 75 mg
Polyethylene Glycol 17 g
Pantoprazole 40 mg
Aspirin 81 mg
Escitalopram Oxalate 10 mg
FoLIC Acid 1 mg
HydrOXYzine 25 mg
Lactulose 30 mL
Thiamine 100 mg
Tizanidine 2 mg
Fluticasone-Salmeterol Diskus (500/50) 1 INH
Rifaximin 550 mg
Pregabalin 75 mg
SC Insulin 4 Units
Tizanidine 2 mg
Docusate Sodium 100 mg
Rifaximin 550 mg
HydrOXYzine 25 mg
Tizanidine 2 mg
Pregabalin 150 mg
Morphine Sulfate 4 mg
SC Insulin 22 UNIT
SC Insulin 8 Units
- Transfer vitals;
98.5, 69, 130/63, 16, 98% RA
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
HCV - genotype 1a decompensated with h/o ascites; liver biopsy
in ___ showed stage ___ fibrosis
EtOH cirrhosis (Child's Class B) c/b ascites, esophageal
varices, HE
Hypertension
Hyperlipidemia
COPD
Alcohol use disorder
Depression
Cocaine use disorder
Tobacco use disorder
Cervical spondylosis
L subclavian stenosis
Peripheral vascular disease
GERD s/p lap fundoplication and hiatal hernia repair ___
s/p cholecystectomy
s/p R inguinal hernia repair
Social History:
___
Family History:
Mother: DM, CAD (COD), and was in a wheelchair for neuropathy.
Father: ___, rectal CA (COD)
Sister: mental illness
___: 1 brother neonatal death, 1 brother death at 3 months,
1 brother sudden death in ___.
Physical Exam:
ADMISSION EXAM
==============
VS:97.6PO, 113/60, 65, 16, 98% 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: Bibasilar crackles
ABDOMEN: significantly distended abdomen, tender to palpation
diffusely, +caput medusa, no rebound/guarding, para site c/d/i
EXTREMITIES: no cyanosis, clubbing, or edema , TTP in right
inguinal area with reducible hernia
NEURO: A&Ox3, moving all 4 extremities with purpose, CN ___
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
================
VITALS: Temp: 98.1 PO BP: 109/57 HR: 75 RR: 18 O2 sat: 97% O2 RA
GENERAL: NAD, lying comfortably in bed. Jaundiced.
HEENT: AT/NC. MMM. Sclera icterus.
CV: RRR with normal S1 and S2. No murmur, rubs or gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Significantly distended abdomen, multiple reducible
hernias, baseline tenderness throughout. Mild guarding, no
rebound. Normoactive BS.
EXTREMITIES: Warm, 1+ ___ edema, no erythema. Tenderness over
BLE.
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis.
SKIN: Warm and well perfused
Pertinent Results:
ADMISSION LABS
==============
___ 08:30AM BLOOD WBC-5.8 RBC-3.21* Hgb-8.9* Hct-28.3*
MCV-88 MCH-27.7 MCHC-31.4* RDW-19.1* RDWSD-62.0* Plt Ct-85*
___ 08:30AM BLOOD ___ PTT-31.8 ___
___ 08:30AM BLOOD Plt Ct-85*
___ 08:30AM BLOOD Glucose-174* UreaN-20 Creat-0.7 Na-137
K-3.9 Cl-107 HCO3-18* AnGap-12
___ 08:30AM BLOOD ALT-35 AST-51* AlkPhos-173* TotBili-1.2
DirBili-0.5* IndBili-0.7
___ 11:02PM BLOOD Calcium-7.8* Phos-3.2 Mg-1.9
___ 08:30AM BLOOD Albumin-3.2*
PERTINENT LABS/MICRO:
====================
___ 06:35AM BLOOD Folate->20
___ 06:35AM BLOOD 25VitD-11*
___ 08:30AM BLOOD AFP-4.4
___ 06:20AM BLOOD Cortsol-0.4*
___ 06:43AM BLOOD Cortsol-0.5*
___ Stim Testing:
___ 05:42AM BLOOD Cortsol-0.3* - before
___ 06:30AM BLOOD Cortsol-3.2 - 30 min
___ 07:00AM BLOOD Cortsol-4.5 - 60 min
___ 09:30AM BLOOD Cortsol-1.4* - repeat AM cortisol
DISCHARGE LABS
=============
___ 07:35AM BLOOD WBC-4.7 RBC-2.47* Hgb-7.1* Hct-23.1*
MCV-94 MCH-28.7 MCHC-30.7* RDW-18.9* RDWSD-65.0* Plt Ct-55*
___ 07:35AM BLOOD Glucose-109* UreaN-33* Creat-0.9 Na-140
K-5.3 Cl-101 HCO3-22 AnGap-17
___ 07:35AM BLOOD ALT-20 AST-31 AlkPhos-130* TotBili-0.7
___ 07:35AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.6
PERTINENT IMAGING:
================
___ RUQUS
1. Cirrhotic liver, with sequela of portal hypertension,
including
splenomegaly and moderate volume ascites.
2. Patent main, right, and left portal veins, without evidence
of thrombosis.
___ CT ABD/PELVIS
1. Multiple nondisplaced rib fractures within the left
hemithorax, including
the anterolateral eighth through tenth ribs.
2. Bowel containing ventral hernia without evidence of
obstruction or
strangulation.
3. Stable mild prominence of the left intrahepatic biliary ducts
and
dilatation of the common bile duct status post cholecystectomy.
As with prior
studies, no evidence to suggest new biliary obstruction.
4. Cirrhosis with portal hypertensive sequelae, with the
exception of ascites,
appear grossly similar to prior.
5. Large volume ascites, increased from prior.
6. Right femoral hernia containing ascitic fluid.
7. Grossly unchanged 4 mm hyperenhancing focus in the right
hepatic lobe is
incompletely evaluated but may represent a perfusional anomaly.
Agree with
prior recommendations for nonurgent evaluation with MRI with
contrast, if
indicated.
Brief Hospital Course:
___ y/o woman with a history of HCV and alcoholic cirrhosis c/b
ascites requiring weekly paracentesis, esophageal/rectal
varices, and hepatic encephalopathy who presented with subacute
rib fractures and diffuse abdominal pain, hospital course c/b
odynophagia, anemia, and concern for adrenal insufficiency
ACUTE ISSUES:
=============
#Acute on Chronic Abdominal Pain
The patient has an extensive history of intermittent, diffuse
abdominal pain though particularly worse over her multiple
umbilical hernias. Her pain has previously had minimal
improvement following large volume paracentesis. She presented
with acute on chronic abdominal pain in the setting of a recent
traumatic fall resulting in possible rib fracture. CT abd/pelvis
showed no PVT and infectious work up was negative, including a
diagnostic paracentesis that showed no SBP. The etiology
remained unclear, possible due to baseline distention and
umbilical hernias. Her morphine regimen was increased in
frequency and her pain slowly improved. She tolerate tube feeds
throughout this time. She was discharged on her home morphine
regimen.
# Decompensated HCV/EtOH Cirrhosis
She has a history of HCV/EtOH cirrhosis c/b ascites requiring
weekly LVP (did not tolerate diuretics), esophageal/rectal
varies and HE. Previously deemed to not be a transplant
candidate. On admission, found to have MELD-Na 14, Child's Class
B. Diagnostic paracentesis negative for SBP. Given last EGD on
___ showed grade II varices in distal esophagus, she was trialed
on nadolol 20mg QD beginning ___, but d/ced in setting of
worsening Cr and Na. She continued to receive weekly LVP, last
on ___ ___s lactulose and rifaxamin. She will need q6
month HCC screening.
#Adrenal insufficiency
Given persistent hyperkalemia, morning cortisol was checked and
found to be ~0.5 x2. Cosyntropin stimulation test then showed an
inappropriate response concerning for adrenal insufficiency.
Endocrine was consulted, recommended sending 21-hydroxylase Ab,
pending at time of discharge, and holding off on imaging. She
was discharged on hydrocortisone 10 mg am and 5 mg at 3 pm with
plan to follow up in the ___ for further
management, including possible repetition of the cosyntropin
stimulation test and with aldosterone.
# Odynophagia
Patient presented with white plaques on tongue and pain with
swallowing, concern for ___ esophagitis. The symptoms also
corresponded to two Dobhoff placements, so mechanical trauma to
esophagus was also considered. She had only mild improvement
with Nystatin/Fluconazole x 14 days. GI was consulted and
recommended starting carafate and PPI for possible variceal
irritation by ___. Overall her symptoms improved/remained
stable. She should follow up with her PCP and GI as an
outpatient to consider repeat EGD.
# HCV, Genotype 1a
HCV VL undetectable earlier in ___. She was previously started
on a 24 week course of sofosbuvir-velpatasvir (Epclusa) that was
to end in late ___, but the patient had missed
significant portion of the doses during serial admissions. She
was asked to bring in the Epclusa but she had recently ran out.
She will need to continue Epclusa as an outpatient, like for an
extended period. She planned to refill her outpatient script
upon discharge.
# Normocytic anemia
# BRBPR
Patient has a history of chronic anemia in setting of cirrhosis,
compounded by occasional blood loss from rectal varices. She had
received 4 units of pRBCs in ___ prior to admission. On ___,
the patient developed blood-streaked stool and Hb dropped to
6.8. She had no UGI symptoms or vital sign changes. She was
transfused 1 unit on ___ and her Hgb remained stable around
___. She will need a repeat CBC as an outpatient.
#Malnutrition
Noted to have very poor oral intake associated with significant
weight loss in last month. ___ was placed this admission and
tube feeds were started per nutrition recs. She should continue
on tube feeds and tolerated her goal rate. Discharged with plan
to continue them at home.
#Disposition
Physical therapy evaluated the patient and recommended rehab.
The patient refused and wished to be discharged home. Risks were
reviewed, including concern for falls and serious harm. She
understood the risks and still wished to go home. She was
ultimately discharged home with home services with plan for
close follow up.
CHRONIC ISSUES
==============
# Diabetes Mellitus
Presented with elevated blood glucose values after missing
several doses of insulin. She was placed back on her home
regimen of glargine, NPH and SSI with good blood glucose
control. She will need outpatient monitoring of her blood sugars
and up titration of her insulin following initiation of
steroids.
# COPD
- Continued Albuterol nebs PRN
# GERD
- Continued home PPI
# Depression
- Continued home SSRI
# Polysubstance use disorder
- Continued MVI, folate, thiamine
# Vitamin D deficiency
- Vitamin D level low at 11. She was started on repletion on
___. Consider further repletion as an outpatient.
TRANSITIONAL ISSUES
==================
[ ] Please check her MELD labs (electrolytes, CBC, INR, LFTs) at
her next appointment
[ ] CT showing 4 mm hyperenhancing focus in the right hepatic
lobe is, incompletely evaluated but may represent a perfusional
anomaly. Agree with prior recommendations for nonurgent
evaluation with MRI with contrast, if indicated
[ ] Needs refill of Epclusa as outpatient and discussion with
Hepatology regarding extending her time course
[ ] Seen by palliative care in the hospital with plan to
continue to see them as an outpatient for pain control and GOC
discussions
[ ] Needs follow up with Endocrine for further management of
adrenal insufficiency, will be arranged by Endocrinology
[ ] Follow up 21-hydroxylase Ab, pending at time of discharge
[ ] Consider outpatient repetition of cosyntropin stimulation
test and add aldosterone per Endocrine Recs
[ ] Started on hydrocortisone 10 mg am, 5 mg pm, will need
monitoring of blood glucose levels and titration of insulin
regimen
[ ] Next paracentesis due on ___
[ ] Consider outpatient EGD if odynophagia does not improve
# CONTACT: ___ (fiance) p: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Ondansetron ODT 4 mg PO Q8H:PRN nausea
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Pregabalin 150 mg PO BID
11. Rifaximin 550 mg PO BID
12. Thiamine 100 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Zinc Sulfate 220 mg PO DAILY
15. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN shortness of
breath, wheezing
16. Albuterol Inhaler 2 PUFF IH Q4H-Q6H PRN shortness of breath,
wheezing
17. Epclusa (sofosbuvir-velpatasvir) 400-100 mg oral Daily
18. Lidocaine 5% Patch 2 PTCH TD QAM
19. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q2-4H:PRN
Pain - Moderate
20. Tizanidine 2 mg PO DAILY:PRN muscle spasm
21. Glargine 8 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Hydrocortisone 10 mg PO DAILY
RX *hydrocortisone 5 mg 1 tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*0
2. Hydrocortisone 5 mg PO AFTERNOON
3. Pantoprazole 40 mg PO Q12H pill esophagitis
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram/10 mL 1 suspension(s) by mouth
four times a day Refills:*0
5. Glargine 8 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lactulose 30 mL PO QID
7. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN shortness of
breath, wheezing
8. Albuterol Inhaler 2 PUFF IH Q4H-Q6H PRN shortness of breath,
wheezing
9. Aspirin 81 mg PO DAILY
10. Epclusa (sofosbuvir-velpatasvir) 400-100 mg oral Daily
11. Escitalopram Oxalate 20 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. FoLIC Acid 1 mg PO DAILY
15. Lidocaine 5% Patch 2 PTCH TD QAM
16. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q2-4H:PRN
Pain - Moderate
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Ondansetron ODT 4 mg PO Q8H:PRN nausea
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Pregabalin 150 mg PO BID
21. Rifaximin 550 mg PO BID
22. Thiamine 100 mg PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
24. Tizanidine 2 mg PO DAILY:PRN muscle spasm
25. Zinc Sulfate 220 mg PO DAILY
26.Tube feeds
- Osmolite 1.5 Cal; Full strength
- 100ml/hr, cycled over 12 hours daily
- 1 months supply, 2 refills
- ICD10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary diagnosis
- Abdominal pain, acute on chronic
#Secondary diagnoses
- Decompensated cirrhosis ___ alcoholic and hepatitis C
- Odynophagia
- Normocytic anemia
- Malnutrition
- Hepatitis C infection
- Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain and chest
pain. The cause of this was from rib fractures and from the
chronic abdominal pain related to your cirrhosis.
Your labs were stable in the hospital, and we continued to treat
the symptoms and conditions related to your cirrhosis.
You developed pain in your throat while hospitalized. We felt
this may be related to the feeding tube which was placed to
provide extra nutrition. It could also be caused by a fungus
called ___, and we started an anti-fungal medication to
treat this. If this pain does not resolve, you may need an
endoscopy to take a look at the esophagus.
We discussed your prognosis; unfortunately, with your liver
disease, we can treat the symptoms but not the primary cause. As
some point you will get an infection or bleed which we cannot
treat. We don't think this will be tomorrow or next week, but it
could be in a year or less. The palliative care team helped and
will continue to help you make the best choices and support you
in this difficult time.
You will need a repeat paracentesis on ___. Additionally,
please start taking the new medications as described below.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19644643-DS-19
| 19,644,643 | 23,638,822 |
DS
| 19 |
2133-02-07 00:00:00
|
2133-02-07 11:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left femoral neck fracture
Major Surgical or Invasive Procedure:
___ - left hip hemiarthroplasty
History of Present Illness:
L femoral neck fracture
___ sp unwitnessed mechanical fall at rehab sustaining L
femoral neck fracture. Patient has hx of prior R TFN and was on
coumadin for dvt ppx post op. Her INR on arrival is 3.9.
ROS negative other than stated in HPI
Past Medical History:
dementia
depression
hx R TFN ___ w coumadin post op.
Social History:
___
Family History:
NC
Physical Exam:
Easy work of breathing
LLE
No laceration, deformity, skin intact
Firest ___
SILT dp/sp/t
wwp
Pertinent Results:
___ 04:30AM BLOOD WBC-11.2* RBC-3.17* Hgb-9.9* Hct-30.3*
MCV-95 MCH-31.2 MCHC-32.7 RDW-14.2 Plt ___
___ 04:30AM BLOOD Glucose-157* UreaN-27* Creat-0.5 Na-139
K-3.2* Cl-104 HCO3-23 AnGap-15
___ 07:05AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.6* Hct-26.4*
MCV-95 MCH-30.8 MCHC-32.4 RDW-14.8 Plt ___
___ 07:05AM BLOOD ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a left hip hemiarthroplasty, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient was admitted on coumadin, which had
been started following her recent fracture of the RIGHT hip.
The need for coumadin therapy was discussed with the patient's
PCP and it was determined that there was no ongoing need for
coumadin. Therefore, she was discharged on lovenox for DVT
prophylaxis to be started on ___. The patient will follow up
in two weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Medications on Admission:
Citalopram 10 mg PO DAILY
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Coumadin
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Citalopram 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H Disp #*50 Tablet
Refills:*0
6. Senna 17.2 mg PO HS
7. Enoxaparin Sodium 30 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 30 mg/0.3 mL 30 mg sc Daily Disp #*30 Syringe
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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 1 month
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
Danger Signs:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
WBAT BLEs
Treatments Frequency:
Daily dressing changes if wound drainage. ___ leave open to air
if dry.
Followup Instructions:
___
|
19644952-DS-15
| 19,644,952 | 28,804,598 |
DS
| 15 |
2174-02-02 00:00:00
|
2174-02-03 19:45:00
|
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:
___: Suturing of pyloric channel ulcer and omental patch,
ulcer biopsy, Prevena VAC placement
History of Present Illness:
___ with history of hypertension, hyperlipidemia,
non-insulin-dependent diabetes, gout, history of inguinal hernia
repair on the left side ×2 and umbilical hernia repair ×1,
presenting with ?gastric perforation as a transfer from ___
___ as there were no ICU beds. Patient states that for ___
days he has not been eating well. He states at 6 ___ last night,
he developed diffuse, severe abdominal epigastric pain. He
presented to the outside hospital where they performed a CAT
scan which showed free air and free fluid consistent with bowel
perforation, as well as proximal small bowel wall thickening,
raising concern for ischemia. Patient was given 2 L of fluid and
Zosyn. Patient reportedly had hypotension with fentanyl. He had
blood pressures in the ___ and was started on levophed. In the
ED, the patient continues to be on Levophed. Surgery was called
emergently to bedside to evaluate the patient is a patient was
hypotensive and his exam was reportedly peritonitic. Of note,
patient reports feeling unwell and fatigued for about 2 weeks
prior to this event.
Past Medical History:
Past Medical History:
Hypertension, hyperlipidemia, diabetes, gout, ?fatty liver
Past Surgical History:
lap umbilical hernia repair, left inguinal hernia repair ×2
Social History:
___
Family History:
Family History:
breast ca in mother at age ___
Physical Exam:
Discharge Physical Exam:
VS: 99.4, 135/75, 73, 18, 98 Ra
Gen: A&O x3, slightly jaundiced
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND. Midline incision with staples CDI no erythema
or drainage
Ext: WWP no edema
Pertinent Results:
___ 06:00AM BLOOD WBC-16.5* RBC-2.26* Hgb-7.9* Hct-24.9*
MCV-110* MCH-35.0* MCHC-31.7* RDW-18.8* RDWSD-74.9* Plt ___
___ 06:10AM BLOOD WBC-14.2* RBC-2.29* Hgb-8.0* Hct-25.6*
MCV-112* MCH-34.9* MCHC-31.3* RDW-19.1* RDWSD-76.2* Plt ___
___ 06:10AM BLOOD ___ PTT-26.7 ___
___ 06:10AM BLOOD Glucose-110* UreaN-16 Creat-0.7 Na-142
K-3.8 Cl-102 HCO3-24 AnGap-16
___ 06:10AM BLOOD ALT-69* AST-64* LD(LDH)-204 AlkPhos-242*
TotBili-3.1*
___ 10:28AM BLOOD ALT-203* AST-381* AlkPhos-407*
TotBili-5.2* DirBili-4.3* IndBili-0.9
___ 05:02AM BLOOD ALT-226* AST-453* AlkPhos-500*
TotBili-5.9*
___ 06:10AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.6 Mg-1.8
___ 02:12AM BLOOD IgG-368* IgA-183 IgM-47
Brief Hospital Course:
The patient presented to the ER at OSH with abdominal pain where
he underwent CT scan showing free air and free fluid in the
abdomen, as well as concern for possible ischemic bowel. He was
transferred to the ___ ER where he became hypotensive and was
started on pressors. He was evaluated by the surgery service and
taken emergently to the OR for exploratory laparotomy. 1.5L of
succus was encountered and he was found to have a perforated
pre-pyloric gastric ulcer, which was primarily oversewn followed
by an omental patch. An NGT was placed intraoperatively. He was
brought to the ___ post-operatively still requiring pressors
and continued undergoing IVF rescusitation with gradual weaning
of his pressors. He was noted to have significant LFT elevations
and concern for cirrhotic liver intra-operatively; his MELD was
calculated at 20 so a hepatology consult was obtained. He was
started on phenobarb CIWA given concern for a significant
alcohol history. He was stabilized and transferred to the floor
for further monitoring. His diet was advanced to a regular diet
and his medications were transitioned to oral formulations. He
was evaluated by ___ who recommended discharge to home with a
walker. He was evaluated by the Gastroenterology team due to his
cirrhosis. They are recommending outpatient follow-up. He was
prescribed a PPI prior to discharge. At the time of discharge on
___, he was tolerating a regular diet, his pain was well
controlled, he was ambulating with a walker and he understood
and agreed with the discharge plan for home with services. He
will follow-up in clinic in ___ weeks.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
4. Furosemide 40 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6.Outpatient Physical Therapy
Dx: Gait instability
Prognosis: Good
___: 6 weeks
7.Rolling Walker
Dx: Gait instability
Prognosis: Good
___: 13 months
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Perforated intra-abdominal viscus, shock bowel perforated
pyloric channel ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with abdominal pain and were found to have a
perforated gastric ulcer. You were taken urgently to the
operating room for surgical repair of the perforation. You
tolerated this procedure well. You are now tolerating a regular
diet and your pain is well controlled. You are ambulating with a
walker and the Physical Therapists have cleared you for
discharge home with home ___.
The Gastroenterology team saw you during this admission due to
your cirrhosis. They are recommending outpatient follow-up. You
will need to establish a new GI doctor, which your PCP can help
you with.
Due to your gastric perforation you will need to take an acid
suppressing drug. You are being prescribed for protonix
(pantoprazole). Your PCP can continue prescribing this.
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
Followup Instructions:
___
|
19645295-DS-5
| 19,645,295 | 21,641,527 |
DS
| 5 |
2135-04-27 00:00:00
|
2135-04-27 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
Ms. ___ is a ___ woman with history of CAD, HTN,
DMII, CKD, esophageal cancer presenting with cough and shortness
of breath.
Per review of the chart, the patient was recently admitted from
___ to ___ for shortness of breath, found to have acute
hypoxic respiratory failure requiring intubation due to
obstruction of the left mainstem bronchus by the esophageal
mass. Interventional pulmonology placed a left mainstem bronchus
stent and Y stent.
The patient's daughter, who is at the bedside, reports that her
mother has not been doing well since discharge. She has been
weak. She developed a cough that has progressively worsened. The
cough is productive of sputum. The patient coughs so much that
she is unable to sleep and has decreased appetite. This is
associated with shortness of breath. She denies any fevers or
chills. The patient has lost about 10 pounds due to poor
appetite. Given her cough and shortness of breath, she presented
to the ED for further management.
In the ED, vitals: 97.6 116 114/60 24 95% 3L NC Exam notable
for: Diffuse rhonchi without rales or wheezing, anterior and
posteriorly, breathing comfortably when asleep without
respiratory distress, appearing somewhat tachypneic when awake
and talking and/or coughing Labs notable for: WBC 13.6, Hb 8.2,
plt 561; Na 134, K 5.5, BUN/Cr ___ Ca ___ lactate 3.9->3.1
Imaging: CXR Patient given: 1L NS, Zosyn 4.5 g
On arrival to the floor, the patient reports that her breathing
is improved. She continues to have a cough productive of sputum.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative
Past Medical History:
- CAD
- HTN
- DMII
- CKD
- Esophageal cancer
- Atrial fibrillation
- Anemia
- Glaucoma
Social History:
___
Family History:
- Sister died of metastatic "vaginal" cancer
- 2 brothers and 7 sisters.
- Has 1 sister w/ CABG aged ___.
Physical Exam:
ADMISSION:
=========
VITALS: 97.9 118/48 100 18 99 4L NC->2L NC
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: Respirations are shallow but breathing is non-labored.
Lungs with diffuse rhonchi and intermittent productive cough
during exam.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 02:45PM BLOOD WBC-13.6* RBC-3.10* Hgb-8.2* Hct-26.6*
MCV-86 MCH-26.5 MCHC-30.8* RDW-16.8* RDWSD-51.3* Plt ___
___ 02:45PM BLOOD UreaN-26* Creat-1.1 Na-134* K-5.5* Cl-101
HCO3-22 AnGap-11
___ 02:45PM BLOOD ALT-38 AST-66* AlkPhos-123* TotBili-0.4
___ 06:28PM BLOOD Lactate-3.9* K-5.6*
MICRO:
======
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
IMAGING/OTHER STUDIES:
====================
CXR (___):
Right-sided PICC line projects over the cavoatrial junction,
unchanged. The stent within the esophagus is also unchanged.
There is an additional stent within the left mainstem bronchus.
Lungs are low volume with bibasilar atelectasis.
Cardiomediastinal silhouette is stable. Small bilateral
effusions left greater than right are unchanged. No
pneumothorax.
KUB (___):
1. Nonobstructive bowel gas pattern.
2. Moderate stool burden.
CXR (___):
Comparison to ___. The pre-existing pleural effusions
are resolved. Parenchymal opacities at both the right and the
left lung bases persist. There also is a stable retrocardiac
atelectasis. Stable borderline size of the cardiac silhouette.
Stable position of the esophageal stent and of the right PICC
line.
CXR (___):
In comparison with the study of ___, the monitoring and
support devices are unchanged, as is the cardiomediastinal
silhouette. Continued evidence of pulmonary vascular congestion
with bilateral pleural effusions and compressive atelectasis at
the bases.
TTE (___):
EF 30%. Extensive apical hypokinesis/akinesis involving both
ventricle. Moderate-to-severe TR.
CT chest w/cont (___):
1. Slight interval increase in mediastinal and hilar
lymphadenopathy since ___.
2. Re-demonstrated is circumferential esophageal wall thickening
involving the mid to distal esophagus consistent with known
esophageal malignancy. Interval placement of an esophageal
stent, which contains moderate debris, but is otherwise patent.
3. Patchy consolidation in the left lower lobe, compatible with
pneumonia. Additional peribronchovascular nodules and
consolidative opacities in the right lower lobe and lingula,
concerning for additional areas of infection/aspiration.
4. Interval increase in size in moderate bilateral,
nonhemorrhagic pleural effusions.
5. Millimetric pulmonary nodules in the left upper lobe are
unchanged.
6. Patent Y-stent in unchanged position within the trachea and
mainstem bronchi. Increased secretions in the bilateral
mainstem
bronchi.
PET (___):
1. Intensely FDG avid esophageal mass in keeping with known
malignancy. FDG avid right upper esophageal node is likely
metastatic. Previously described subcarinal lymphadenopathy is
difficult to discern given intense FDG avidity from the adjacent
esophageal mass.
2. Bilateral FDG avid lower lobe opacities, left greater right,
likely represent aspiration/pneumonia.
3. Mild FDG avidity of pre-vascular lymph nodes may be reactive
to infectious/inflammatory changes.
4. Trace bilateral pleural effusions, left greater right.
5. Redemonstration of punctate right nonobstructing
nephrolithiasis. Known left renal nephrolithiasis is not seen
on
this nondiagnostic CT.
6. 1.7 cm non FDG left adnexal cyst is probably benign. If
not previously known, this can be followed up when appropriate.
Brief Hospital Course:
Ms. ___ is an ___ woman with history of CAD, HTN,
DMII, SC esophageal cancer s/p L mainstem/Y stenting (not on
treatment) presenting with cough and shortness of breath, found
to have MRSA pneumonia, with course complicated by acute
hypoxemic/hypercarbic respiratory failure, likely due to
aspiration.
# Respiratory Failure:
# Dysphagia with risk of aspiration:
# Esophageal Cancer:
Recent diagnosis of locally advanced squamous cell esophageal
cancer s/p stent to the L mainstem and a Y stent during recent
admission (___). At clinic visit ___ with Dr. ___
had been for medical optimization prior to possible chemo/XRT,
but in the interval she presented with cough and shortness of
breath and wound to have multifocal PNA treated with
vanc/ceftaz. Was in the ICU and intubated/ventilated briefly.
After extubation, patient/family decided to transition to
DNR/DNI, ok for BiPAP. Per SLP she was at continued risk of
aspiration but
patient wanted to accept risk and eat modified diet. Feeding
tube not within her GOC. Although the original goal was to try
to discharge to rehab in case she could gain strength and
potentially be a candidate for cancer treatment, in the hospital
her condition continued to decline. Family decided on ___ to
transition to comfort care given her inability to receive future
cancer therapy, ongoing aspiration, and declining functional
status. She was placed on morphine drip ___. Frequently
communication and emotional support offered to the family.
Family sought hospice near ___ where most of the family
lives. At discharge morphine drip basal was 0 mg/hr with 0.5mg
boluses PRN respiratory distress/pain.
# Acute systolic HFrEF:
# Elevated troponin:
# CAD:
TTE ___ w/ LVEF 30%, bilateral apical hypokinesis/akinesis,
mod-severe TR, and PA pressure 29mm Hg. No prior TTE available
for comparison but may be longstanding based on cath ___ at
___ showing 3-vessel disease involving LAD (70-90%), Cx
(90%), RCA/PDA. Alternatively, may be acute, stress-induced CM
from underlying infection. No prior history of MI or Q-waves on
ECG. Serial troponins slightly elevated but plateaued, and EKG
with TWI in anterolateral leads. Evaluated by cardiology, who
recommended against cardiac catheterization in the absence of
chest pain and given her malignancy and goals of care.
Recommended anticoagulation for apical akinesis, which
patient/family declined in setting of c/f bleeding and overall
goals of care. She was intermittently diuresed for pulmonary
edema as above, but did not require maintenance diuretic in the
setting of poor p.o. intake. Home losartan and metoprolol were
continued, as was fractionated isosorbide, ASA, and statin. All
medications and monitoring eventually held per above.
# HTN:
Home metoprolol and Isordil were continued, fractionated to
allow for crushing in purées. Home losartan was continued. Home
chlorthalidone was held in the setting of poor PO intake. All
medications eventually held per above.
# pAF:
Developed during prior hospitalization in ___. CHADS2VASC 6.
During prior hospitalization, decision was made to defer
anticoagulation until after further discussion of malignancy
treatment - particularly given normocytic anemia and concern for
potential slow GIB. Fractionated metoprolol continued as was
aspirin. All medications eventually held per above.
# Anemia of chronic disease:
Hgb has been largely stable at ___, likely in setting of anemia
of inflammation based on ferritin 341. No evidence of bleeding
or hemolysis. All monitoring eventually held per above.
# Hypercalcemia
Corrected Ca ___ on ___. Likely malignancy related, with PTH
10, vit D 66. In discussion with outpatient oncologist, she was
given pamidronate 60 mg IV, with improvement in her
hypercalcemia (low suspicion for osteonecrosis of jaw). All
monitoring and meds eventually held per above.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. MetFORMIN (Glucophage) 850 mg PO BID
8. Chlorthalidone 25 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. GuaiFENesin ER 1200 mg PO Q12H
12. GuaiFENesin 10 mL PO Q6H:PRN cough
13. Albuterol 0.083% Neb Soln 1 NEB IH BID
14. Acetylcysteine 20% ___ mL NEB BID
15. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Discharge Medications:
1. Morphine Infusion Comfort Care Guidelines ___ mg/hr IV
DRIP INFUSION
Start w/basal of 0mg/hr and 0.5mg bolus PRN respiratory
distress/pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA pneumonia
Acute systolic heart failure
Atrial fibrillation
Esophageal cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Very lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with cough and shortness of
breath due to a serious lung infection. In addition, you were
found to have a condition called congestive heart failure. You
were treated with antibiotics and with medicines to remove fluid
from your lungs. Unfortunately, due to your esophageal cancer
much of what you eat and drink continues to go down into your
lungs, putting you at high risk for recurrent infection. In
discussion with you, your family, and your cancer doctor the
decision was made to pursue hospice.
It was a privilege to care for you and to get to know you and
your family.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19645331-DS-11
| 19,645,331 | 27,731,318 |
DS
| 11 |
2124-07-13 00:00:00
|
2124-07-14 07:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Aphasia with CTH revealing left frontal SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old female with pmhx of CVA in ___ for
which she has residual left sided hemiparesis, who presented to
OSH with concerns of aphasia. Patient states that she woke up
early this AM and called her aids to help her with the restroom,
patient states shortly after that time she was unable to speak
or
move but she was fully aware of everything around her. Patient
states this episode finally resolved however she was brought to
OSH for workup. CTH at OSH was notable for a 13mm left sided
frontal SDH. Of note patient is on Coumadin and INR at OSH was
4.1, she was given Feiba and transferred to ___ ED for
escalation of care and neurosurgical evaluation. On arrival to
ED
repeat INR was 1.7. Per ED patient's RLE was notably weak and
she
was taken for a STAT CTH which revealed stable to slightly
larger
SDH. Patient denies recent trauma or falls. Patient does state
she had a fall back in ___ on ___ where she hit
the left side of her face, however has not had any traumatic
events since.
On exam in ED patient brought back to room from ___. Patient
appears comfortable in stretcher in NAD. Patient denies pain,
headache, visual changes, nausea, numbness or tingling. Patients
states that she fells completely back to her baseline.
Past Medical History:
CVA ___ with left sided residual hemiparesis and slowed speech
Social History:
Lives at ___.
Physical Exam:
-----------
on admission
-----------
PHYSICAL EXAM:
T: 98.3 BP: 152/81 HR: 60 R: 18 O2Sats:96% room air
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-2mm bilaterally
EOMs: Intact
Neck: Supple.
Extrem: Warm and well-perfused. Pitting edema noted to LLE,
patient states this is baseline
Date and Time of evaluation: ___ ___
___ Coma Scale:
[ ]Intubated [X]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[X]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[X]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[X]6 Obeys commands
__15__ Total
ICH Score:
GCS
[ ]2 GCS ___
[ ]1 GCS ___
[X]0 GCS ___
ICH Volume
[ ]1 30 mL or Greater
[X]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[X]0 Absent
Infratentorial ICH
[ ___ Yes
[X]0 No
Age
[X]1 ___ years old or greater
[ ]0 Less than ___ years old
Total Score: ___1___
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
however slowed and slightly slurred due to prior CVA in ___.
Naming intact. No paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Frail elderly woman. No abnormal movements or tremors.
Strength full power ___nd RLE except right
IP/Q ___. LUE/LLE hemiparetic due to prior CVA in ___.
Unable to test pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing LLE, unequivocal RLE.
Coordination: Right side only tested. Normal on
finger-nose-finger, rapid alternating movements, heel to shin
Handedness: Right
----------
at discharge
----------
EXAM:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Bilaterally 2mm, cataracts
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: baseline left-sided plegia, no right drift
Speech Fluent: Speech thick, dysarthric
Comprehension intact: [x]Yes [ ]No
Motor:
Deltoid BicepTricepGrip
LeftBaseline plegia------------>
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Pertinent Results:
see OMR
Brief Hospital Course:
Ms. ___ was admitted to neurosurgery with acute SDH.
#SDH
Repeat CT in the ED was stable to prior. Coumadin was held and
she had received FEIBA at OSH. INR was 1.7 in ED, and 2.0 on
arrival to ___. Exam remained stable. She was given Vitamin k x
3 days and 2 units FFP. Patient had transfusion reaction with
diffuse hives following FFP administration, product was
immediately stopped and she was given 25mg IV Benadryl with
improvement. INR was rechecked, still elevated 1.7. She was
given 1 unit at decreased rate and well tolerated. INR level
normalized. She was also started on keppra x7 days on admission.
Patient exam remained stable with some lethargy but arousable
with slower speech, but otherwise close to baseline. Surgical
options were discussed, with decision to hold off on any
intervention and observe patient over time largely in part due
to patients age and lack of focal symptoms. Plan to follow up in
2 weeks with head CT (or sooner if any change). Patient remained
stable and was transferred to the floor on ___. She continued to
do well and was planned to be discharged on ___. In the
afternoon of ___, patient triggered for another episode of
aphasia and HTN up to 190s. Both self resolved and merit was
consulted for workup evaluation. On ___ patient appeared SOB
with increased respirations. She was maintaining O2 sats without
supplemental oxygen. CXR and CTA chest negative. On the way back
from CT, patient triggered again for aphasia as well as desats
to the ___. Again both resolved. Given patient's h/o stroke and
TIAs, differential for aphasia episodes included TIA vs. seizure
activity. Patient received an extra dose of Keppra (on 500mg BID
since ___ and EEG was started. EEG showed Focal slowing
bilateral temporal regions, rare discharges, no seizures.
Neurology was consulted, imaging negative for acute stroke in
___ and no hemorrhage at that time. Likely, decreased
seizure threshold or cortical irritability due to SDH, less
likely to be TIA/stroke.
#Dysphagia
SLP was consulted to evaluate and put the patient on a diet of
pureed solids and nectar thick liquids. Video swallow was
completed and she was continued on pureed solids and nectar
thick liquids. Patient will require ongoing SLP involvement at
next level of care for pharyngeal strengthening.
#Hypoxia
The patient had an oxygen desaturation to the ___ while sleeping
overnight ___, and once again while awake ___. A CTA was done
on ___, and was negative for PE. CXR ___ with little overall
change compared to prior CXR . No evidence of acute focal
consolidation.
#Hypertension:
New since admission; Medicine consulted and per recommendation
Chlorthalidone 12.5mg daily started but this was discontinued
due to hypotension. The patient was eventually able to
self-regulate blood pressures.
#Sacral pressure ulcer
Wound nursing was consulted for a pressure ulcer on the
patient's sacrum, who recommend topical therapy and Mepiplex
dressings to be changed every 3 days.
Medications on Admission:
Multivitamin daily
Omeprazole 20mg daily
Preservision W/areds 7160/113 daily
Refresh liquigel 1%, one gtt each eye TID
Refresh tears 0.5% one gtt each eye BID
Lidocaine 4% patch daily
Senna 8.6mg daily
Simvastatin 20mg QHS
Tizanidine 4mg QHS
Acetaminophen 650mg Q6hrs PRN pain
Warfarin 3mg daily
Nystatin/Triamcin 0.1% ointment, apply daily
Nystatin powder, apply daily PRN
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 vial IH every 6
hours as needed Disp #*28 Vial Refills:*0
2. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 100 mg by mouth twice a day
Refills:*0
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
4. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hours
as needed Disp #*56 Capsule Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
7. Simvastatin 20 mg PO QPM
RX *simvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*7 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Hypertension
Intermittent aphasia
Dysphagia
Hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by your Neurosurgeon.
- You may use Acetaminophen(Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptom after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
19645420-DS-10
| 19,645,420 | 28,277,913 |
DS
| 10 |
2133-09-24 00:00:00
|
2133-09-24 18:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
___ brain biopsy and EVD placement, Dr. ___
___ VP shunt placement, Dr ___
___ of Present Illness:
Patient presents to ED with 2 wks of headaches with nausea and
vomiting. Also unsteady gait and persistent double vision.
Companion states that she has
also been forgetful and not herself.
Past Medical History:
depression
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
: T:98.1 BP:130/87 HR:82 R:18 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm and minimally reactive EOMs: intact b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place and year, but not month.
Cranial Nerves:
I: Not tested
II: Pupils equally round and minimally reactive to light. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: finger-nose-finger revealed some delay
bilaterally,
rapid alternating movements normal
ON DISCHARGE:
Gen: NAD
HEENT: no OP lesions, R frontal/parietal incision, with dried
blood otherwise well healed sutures intact w/ drainage,
partially shaved head. EOMI
PULM: CTAB
CV: rrr no m/r/g
Abd: Soft, nontender, nondistended.
___: no asterixis, no ___ edema or rash
Neuro: Oriented, drowsy but arouses to voice, EOMI, ___, bilat
horiz 2 beat nystagmus, face symmetric, no tongue deviation,
strength ___, sensation intact to light touch, visual fields
full to confrontation, FTN remains delayed but no dysmetria,
gait slow but steady w/ walker
Pertinent Results:
___ CTA HEAD ___ C & RECONS:
1. Interval placement of right frontal approach ventriculostomy
catheter with minimal interval decrease in the size of the
ventricles. Stable
transependymal flow of CSF.
2. Ill-defined heterogeneous pineal gland mass. Possible
differential
diagnosis includes germinoma versus pineoblastoma.
3. Prominent venous structures are identified from the mass
extending to
adjacent venous sinuses. No enlarged arterial structures are
seen.
___ CT STEREOTAXIS W/ CONTRAST:
1. Unchanged positioning of the ventriculostomy catheter, with
interval
decrease in the size of the lateral and third ventricles.
2. Large irregularly enhancing mass within the region of pineal
gland, causing effacement of the quadrigeminal plate cistern.
___ CT HEAD W/O CONTRAST:
1. Marked decreased size of the lateral ventricles as well as
decreased
effacement of the quadrigeminal plate cistern compared to the
prior
examination. Transependymal flow of CSF has also greatly
improved.
2. New small hyperdensity in third ventricle suggestive of small
intraventricular hemorrhage.
3. No evidence of acute infarction.
4. Ill-defined heterogeneous pineal gland mass is stable in
size.
___ MR ___ W/O CONTRAST; MR ___ &W/O
CONTRAST; MR ___ & W/O CONTRAST:
1. Heterogeneous high signal on axial T1 postcontrast imaging
within the
cervical and thoracic spine with more focal nodular high signal
at the C2-C3 and T8 levels, as described. These areas of high
signal are not seen on the sagittal T1 post-contrast sequence or
precontrast sequences. Given history of pineal mass, these
findings could represent subarachnoid seeding. Recommend
correlation with CSF analysis.
2. Mild degenerative changes of the cervical spine.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
4:17 ___
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
___ CXR
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
___ CT HEAD W/O CONTRAST
1. Hypodensity in the region of previously seen tumor as well as
in the
midline involving the genu and anterior portion of corpus
callosum could be
related to ischemic changes . Further evaluation with MRI of
the brain is
recommended.
2. The ventricular size is decreased compared to the prior
study.
3. There is redistribution of blood products in the third
ventricle but no
definite new hemorrhage seen.
___ MRI BRAIN
IMPRESSION:
1. The ventricles appear slit-like, similar to the most recent
CT from ___, but decreased compared to ___. VP
shunt catheter position is stable.
2. The large peripherally enhancing midline mass centered in the
pineal region demonstrates marked enlargement of its central
nonenhancing portion compared to the preoperative MRI from ___. The mass is now overall larger, extending
further anteriorly. The expanded central nonenhancing portion
appears heterogeneous, with complex fluid and small amount of
blood. The enlargement is most likely secondary to decreased
intracranial pressure and
associated fluid shifts after relief of hydrocephalus.
3. Unchanged mild contrast enhancement along the right superior
cerebellar
folia compared to the preoperative MRI, suggesting tumor
infiltration.
4. Linear blood products and contrast enhancement along the
biopsy track
through the right parietal and occipital parenchyma. The
contrast enhancement
is presumably reactive, but should be reassessed on follow up.
5. No evidence for an acute infarction.
Brief Hospital Course:
___ is a ___ yr old female who presented to ___ with
complaints of headache and vision changes accompanied by
nausea/vomiting and unsteady gait and intermittent confusion.
MRI revealed pineal mass with significant hydrocephalus. Patient
was brought to the OR for EVD placement and post-operative
admitted to the ICU for close neuro monitoring. Post-operative,
patient remained neurologically intact with intermittent double
vision.
#Glioblastoma - pineal mass found on brain MRI on admission as
above. Brain biopsy ___ consistent with glioblastoma. mass was
unresectable, she initiated brain XRT, ___ of ___ started ___,
she will return on ___ to resume treatments in ___
clinic. Sutures will be removed in ___ clinic this
week. She will also f/u with Dr ___ in ___ clinic w/ plan
to initiate avastin and temodar. Port will be placed as
outpatient in anticipation of ongoing chemotherapy in near
future. Ongoing neurologic deficits include intermittent
diplopia due to compression of tectum and word finding
difficulty. She is ambulatory with a walker. She declined home
___ and will start outpatient ___.
#Cerebral edema - ___ above, was started on dexamethasone, will
cont 8mg BID on discharge to be adjusted by rad onc or
neuro-onc. Also to be determined need for PCP ___ by ___
providers, if able to wean steroids quickly will not start
Bactrim.
#Hydrocephalus - Noted on admission head CT and brain MRI.
Patient underwent placement of EVD at time of brain biopsy by Dr
___ on ___, converted to VP shunt on ___ after decision made
that primary mass was not resectable. Delta Valve 1.5 placed the
procedure was well tolerated. She is no longer having
headaches. Follow-up with Dr ___ is being arranged.
# Hyponatremia - new finding on ___. Was started on salt tabs
per neurosurgery but had also been receiving IVF. she was also
started on Bactrim and steroids which can cause hyponatremia. No
acute changes in neuro symptoms, no headaches. salt tabs stopped
and Na remained stable, likely med related vs SIADH. Na remains
130 at time of discharge no further intervention indicated.
# Proteus UTI - received 3 days CTX. Also then initiated
Bactrim ___ after pt reported urgency however UA normal at that
time and repeat Cx negative. Bactrim stopped.
# Leukocytosis - likely due to steroids pt afebrile and no signs
systemic infxn
Medications on Admission:
prozac
Discharge Medications:
1. Rolling Walker
Please dispense one rolling walker
Diagnosis: Gait unsteadiness secondary to brain mass
Prognosis: Poor
___: ___ weeks
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Dexamethasone 8 mg PO Q12H
take at 8am and again at 2 or 4pm
RX *dexamethasone 4 mg 2 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*1
4. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
take first
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID prn Disp
#*30 Tablet Refills:*1
6. Senna 17.2 mg PO BID:PRN constipation
take second
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*20 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Glioblastoma
Hydrocephalus
Diplopia
Cerebral edema
Discharge Condition:
Mental Status: Confused sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ it was a pleasure caring for you during your stay at
___. You were admitted with change in vision, balance and
headaches. You were found to have a mass near the pineal region
on brain MRI and underwent brain biopsy. Result was consistent
with a type of brain tumor called glioblastoma. You also
underwent placement of a VP (ventriculoperitoneal) shunt to
treat elevated pressures caused by the tumor. You started brain
radiation and will continue as scheduled. Please also continue
taking dexamethasone for swelling in the brain. This will be
adjusted either by Dr ___ your radiation doctors.
Your shunt is a ___ Delta Valve 1.5 which is NOT
programmable. It is MRI safe and needs no adjustment after a
MRI.
Your incision should be kept dry until sutures or staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19645464-DS-6
| 19,645,464 | 22,528,140 |
DS
| 6 |
2122-07-20 00:00:00
|
2122-07-21 08:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Iodinated Contrast Media - IV Dye / Quinolones
Attending: ___.
Chief Complaint:
neck swelling/pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH COPD (not on home o2), anxiety/depression, poorly
controlled HTN, p/w R sided neck swelling/pain for past ___
days. Patient has had many cavities repaired in lifetime, broke
off a piece of a R lower molar about 1 week ago while eating
something but didn't see a dentist. Noted swelling on ___,
called dentist but she couldn't get off work yesterday. Having
worsening pain and difficulty opening mouth but drinking
fluids/breathing without problems. No history of similar. No
fevers, chills. Today went to dentist and then referred to ___.
___ ED. WBC 14.5, chem7 unremarkable. Had CT scan of neck
there which showed no discrete fluid collections but significant
diffuse stranding of the R submandibular space, given
decadron/toradol/clindamycin at noon, transferred for ___ eval
at ___.
In the ED, initial VS 98, 70, 170/115, 18, 96% on RA. No labs
ordered. Patient was redosed with clindamycin 600 mg, decadron
10 mg, and received toradol 30 mg for pain. Patient was
evaluated by ___ who will plan for likely dental extraction
tomorrow am--no need for I/D of submandibular abscess.
Upon arrival to the floor, initial VS 97.9, 87, 198/98, 91% on
RA. Pt denied any headache, vision changes, SOB or chest pain.
Reports that her HTN has been poorly controlled and that she
already took all of her home medications.
Past Medical History:
HTN
Anxiety
Depression
Herpes Simplex infection
COPD
Asthma
Social History:
___
___ History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - VS 97.9, 87, 198/98, 91% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition with decayed molar and missing teeth, R
mandible mildly tender to palpation. No trismus.
NECK: nontender supple neck, no LAD, no JVD. R-sided
submandibular edema TTP
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
.
DISCHARGE PHYSICAL EXAM
=======================
Vitals - VS 98.1 160/90 74 20 96RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, poor dentition with decayed molar and missing teeth, R
mandible w/ very mild swelling, no sig. erythema, no tenderness.
No trismus.
NECK: nontender supple neck, no LAD, no JVD. R-sided
submandibular edema TTP
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact
Pertinent Results:
___ 06:44AM BLOOD WBC-14.1* RBC-4.16* Hgb-13.2 Hct-38.2
MCV-92 MCH-31.8 MCHC-34.6 RDW-13.1 Plt ___
___ 06:44AM BLOOD ___ PTT-27.8 ___
___ 06:44AM BLOOD Glucose-149* UreaN-13 Creat-0.4 Na-136
K-4.4 Cl-102 HCO3-21* AnGap-17
___ 06:44AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.1
IMAGING
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS)
INDICATION: ___ year old woman with submandibular swelling.
Evaluate for
abscess
TECHNIQUE: MDCT images of the neck were obtained at an outside
hospital
without intravenous contrast. Images were uploaded to PACs for
second opinion
reading.
COMPARISON: None
FINDINGS:
Subtle periapical lucency is noted around the right second
mandibular molar
with 4 mm thick soft tissue density tracking adjacent on the
lingual surface
of the mandible (03:33), measuring 1.5 cm in AP dimension.
Without IV contrast
an abscess cannot be excluded. Soft tissue stranding inferior
and to the right
of the mandibular body and in the submental region with
thickening of the
platysma is also noted. Reactive cervical lymphadenopathy is
also appreciated.
Partially imaged maxillary and sphenoid sinuses are clear. The
mastoid air
cells and middle ear cavities are also clear.
The aerodigestive tract is clear without exophytic mucosal mass
or area of
focal mass effect.
The left lobe of the thyroid gland is enlarged with a hypodense
nodule
measuring 9 x 9 mm. Inferiorly in the left lobe, there is an
indistinct
hypodensity, not clearly a nodule. Within the right lobe, there
is a 6 mm
hypodense nodule. The submandibular and parotid glands are
normal
bilaterally.
The visualized lung apices are clear.
The cervical spine demonstrates mild degenerative changes
characterized by
endplate osteophyte formation at C5-6 and C6-7.
IMPRESSION:
1. Subtle periapical lucency around the right second mandibular
molar with
soft tissue density along the lingual surface of the mandible.
Without
intravenous contrast, an abscess cannot be excluded. Reactive
soft tissue
stranding inferior to the mandibular body and submental region.
2. Multi nodular thyroid can be further evaluated via a
nonemergent
ultrasound. Correlation with thyroid function tests is
recommended.
Brief Hospital Course:
___ PMHx HTN, depression, anxiety, asthma, COPD, p/w R
submandibular space cellulitis ___ dental infection, found to be
in hypertensive urgency
# Submandibular space cellulitis/dental infection - pt presented
with neck swelling/pain. CT neck showed Reactive soft tissue
stranding inferior to the mandibular body and submental region.
Pt received IV clindamycin and Dexamethasone 10 mg IV ONCE.
Swelling and pain resolved the following morning. Pt was
evaluated by ___, who deemed that there was no drainable fluid
collection. Pt was discharged with PO clindamycin for a total
of 7 day course. She has follow up on ___ for extraction of
tooth #31.
# Hypertensive urgency - patient presented with systolic blood
pressure > 190. no signs of endorgan damange. Pt was previously
on hctz, but non-compliant due to c/o frequent urination. Pt
was started on amldopine 5mg daily. Discharge BP was 160/90.
F/u BP check and further titration of medication is recommended.
# Asthma - stable on home symbicort 60 mcg
# Depression - stable on citalopram 60 mg daily and alprazolam
bid prn
# Allergies - stalbe on Zyrtec 10 daily prn
## TRANSITIONAL ISSUE
- please check BP and consider uptitrating anti-htn medication
as needed
- pt will need teeth extraction on ___
- Multi nodular thyroid noted on CT scan. Recommend outpatietn
evaluation via a nonemergent ultrasound. recommend thyroid
function test as well
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Citalopram 60 mg PO DAILY
3. ALPRAZolam 0.5 mg PO BID:PRN anxiety
4. ValGANCIclovir 900 mg PO Q24H
5. Cetirizine 10 mg PO DAILY:PRN allergies
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation daily SOB
Discharge Medications:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Cetirizine 10 mg PO DAILY:PRN allergies
3. Citalopram 60 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % rinse swish and spit twice a
day Refills:*0
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY SOB
8. ValGANCIclovir 900 mg PO Q24H
9. Clindamycin 300 mg PO Q6H Duration: 7 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours
Disp #*28 Capsule Refills:*0
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. OxycoDONE (Immediate Release) 5 mg PO Q12H:PRN breakthrough
pain
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Submandibular space cellulitis
Dental caries
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It has been our pleasure caring for you at ___. You were
admitted for a soft tissue infection around your jaw. You
received antibiotics and steroid, and we are glad to see that
you are feeling better. You were seen by our oral surgeon, who
recommended for you to have tooth extraction next week (please
see follow up appointment below). Please continue to take
antibiotics and make appointment to see your primary care doctor
next week for ___. We have also started you on
amplodipine for blood pressure control, please remember to take
it daily.
Followup Instructions:
___
|
19645563-DS-22
| 19,645,563 | 25,807,594 |
DS
| 22 |
2146-01-14 00:00:00
|
2146-01-15 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ speaking w/hx of chronic mild
asymptomatic hyponatremia ___ SIADH, IDDM, HTN, CAD (s/p LAD
stent
___ lesions in LMCA, ostial LCx), ischemic CHF (LVEF
___, prior GIB ___ gastric ulcers on EGD in ___, chronic
urinary retention ___ BPH p/w worsening SOB
Pt developed acute onset SOB earlier today while sitting in
chair, not associated with exertion. Denies concurrent chest
pain. Reports new cough for 2 days preceding this episode with
yellow sputum production. No F/C. Denies orthopnea. No ___ pain
or
edema. No dysuria. Patient denying missing med doses, including
Lasix. Pt was tachypnic to ___ on arrival of EMS, got dunoebs,
and by time of arrival to ED, breathing comfortably.
In the ED, initial VS were: T99.1 78 165/60 24 100% RA
-Exam notable for: AAOx3. JVP 1cm above clavicle. Diffuse
wheezing b/l, no crackles. s1/s2 RRR. No abdominal pain. Trace
___
edema.
-ECG: HR 76, LBBB, nonspecific ST changes from prior
-Labs showed: Hb 9.8, WBC 8.4, Plt 165, Trop x1 neg, Na 124, Cl
85, BUN/Cr ___, Lac 1.5, Urine Na 37, UOsm 463,
-Imaging showed: CXR w/unchanged mild-to-moderate cardiomegaly
with similar mild pulmonary vascular congestion and trace left
pleural effusion.
-Patient received: Duoneb x1, IV Methylpred 125mg, Insulin 10U,
IV Mg 2g, IV Lasix 40mg
-Transfer VS were: T98.5 82 170/69 18 94% RA
On arrival to the floor, patient reports SOB/wheezing yesterday,
but wasn't too severe. This ___, suddenly worsened, needed EMS
and
couldn't wait for son to come home to bring to hospital.
+productive cough x3d, white-yellow sputum. +recent cough last
week as well that resolved. No DOE/orthopnea. No chest pain. No
LH/dizziness. +NBNB emesis yesterday, no abd pain, no D/C. No
dysuria. No falls or syncope. No GIB. Of note, Pt recently Rx'd
HCTZ 12.5 for HTN, but hasn't been filled yet. Losartan
increased
to 100mg from 50mg recently for proteinuria, took first higher
dose yesterday. Also recently filled Megace for poor appetite,
though hasn't taken yet. Per son, has had poor PO intake and wt
loss, thinks ___ poor diet from wife, doesn't know dry weight.
Past Medical History:
-Diabetes Mellitus
- HTN
- CAD s/p LAD stent placed in ___ in ___ lesions in
LMCA, ostial LCx.
- Ischemic CHF with EF ___, NYHA II
- syndrome of inappropriate antidiuretic hormone
- H/o GIB, found to have gastric ulcers on EGD in ___
- bilateral inguinal hernia
- Urinary retention
- BPH
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 PO 173 / 82 R Lying 76 20 96 Ra
GENERAL: NAD, pleasant, thin appearing
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: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, NDNT, no rebound/guarding
EXTREMITIES: no ___ edema b/l
PULSES: 2+ DP pulses bilaterally
NEURO: alert, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
___ 1752 Temp: 98.3 PO BP: 115/68 HR: 87 RR: 18 O2 sat: 97%
O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVP elevation
Lungs: improved scattered crackles, no wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, non-edematous, non-tender bilaterally
Neuro: alert, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS
=============
___ 08:10PM BLOOD WBC-8.4 RBC-4.55* Hgb-9.8* Hct-29.9*
MCV-66* MCH 21.5* MCHC-32.8 RDW-15.5 RDWSD-35.8 Plt ___
___ 08:10PM BLOOD Neuts-84.1* Lymphs-8.2* Monos-6.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.04* AbsLymp-0.69*
AbsMono-0.56 AbsEos-0.01* AbsBaso-0.02
___ 08:18PM BLOOD Glucose-245* UreaN-20 Creat-0.8 Na-124*
K-4.2 Cl-85* HCO3-23 AnGap-16
___ 08:18PM BLOOD cTropnT-<0.01 proBNP-5122*
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-7.2 RBC-5.26 Hgb-11.4* Hct-34.2*
MCV-65* MCH-21.7* MCHC-33.3 RDW-15.6* RDWSD-34.6* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-247* UreaN-34* Creat-0.9 Na-133*
K-4.7 Cl-96 HCO3-27 AnGap-10
___ 05:40AM BLOOD Calcium-9.9 Phos-3.2 Mg-2.1
IMAGING:
___ CXR:
Unchanged mild-to-moderate cardiomegaly with similar mild
pulmonary vascular congestion and trace left pleural effusion.
___ TTE:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal
cavity size. There is SEVERE regional left ventricular systolic
dysfunction with akinesis of the anterior
wall, inferior wall, and septum (see schematic) and mild
hypokinesis of the remaining segments. Global
left ventricular systolic function is normal. The visually
estimated left ventricular ejection fraction is
___. 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 normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is mild [1+] aortic
regurgitation. The mitral leaflets are mildly thickened with no
mitral valve prolapse. There is mild to
moderate [___] mitral regurgitation. The tricuspid valve is not
well seen. There is physiologic tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a small pericardial
effusion. There are no 2D or Doppler echocardiographic evidence
of tamponade.
IMPRESSION: Adequate image quality. Severe regional left
ventricular systolic dysfunction most
consistent with multivessel coronary artery disease. Normal
right ventricular cavity size and systolic
function. MIld to moderate mitral regurgitation. Small
pericardial effusion.
___ CXR:
No acute cardiopulmonary process.
___ CT c w/ con:
1. Bronchial wall thickening, likely reflective of mild
infectious bronchitis.
2. Marked coronary arterial calcifications and atherosclerotic
disease of the
thoracic aorta.
3. Improved left lung base atelectasis with residual opacities
along the
medial left lung base.
MICRO:
___ Blood Cx 2x: No growth
Brief Hospital Course:
SUMMARY STATEMENT
==================
Mr. ___ is a ___ ___ speaking w/hx of chronic mild
asymptomatic hyponatremia ___ SIADH, IDDM, HTN, CAD (s/p LAD
stent ___ lesions in LMCA, ostial LCx), ischemic CHF
(LVEF
___, prior GIB ___ gastric ulcers on EGD in ___, chronic
urinary retention ___ BPH p/w worsening SOB, found to have COPD
exacerbation and bronchitis, course complicated by hyperglycemia
in the setting of steroids.
ACUTE ISSUES
===========
# Shortness of breath
# COPD exacerbation
# Bronchitis
# HFrEF
Patient presented with acute onset shortness of breath, found to
have diffuse wheezing and hyperinflated lungs on CXR suggesting
COPD exacerbation. No history of smoking but may be due to
environmental exposures. Euvolemic to dry on exam so unlikely to
be due to CHF exacerbation although new TTE shows slightly worse
LVEF 30% to ___. Continued home metoprolol and losartan. Home
lasix 20 mg daily was held while patient appeared euvolemic and
restarted at discharge. Trop x2 negative. Received 125 mg IV
solumedrol in ED, and continued on prednisone 40 mg daily for 5
days. Since patient continued to complain of dyspnea despite
nebulizers and steroids, a CT chest was obtained, which showed
bronchial wall thickening suggestive of mild infectious
bronchitis. Treated with 5 days of azithromycin (___).
Prescribed ipratropium and albuterol nebs.
#IDDM
Held home Januvia, acarbose. Recommended to PCP that patient may
benefit from alternative to acarbose as it can cause
malabsorption. Confirmed with PCP that patient takes 70/30 10U
with dinner although son does not remember the switch from
lantus. Patient had labile blood glucose while inpatient likely
due to steroid administration. He required 7U NPH BID while on
prednisone, which he will be continued on. However, will need
close outpatient f/u for his glucose levels and potentially more
aggressive management.
# Hyponatremia
# History of SIADH
Baseline Na ranges from 129-135. Patient presented with
hyponatremia to 124, which corrected with free water
restriction. FeNa 0.5, UNa 37. Managed with fluid restriction to
1.5 L.
#Severe Malnutrition
Per nutrition, patient meets criteria for severe malnutrition
with 8.6% weight loss over 2 months. Added glucerna TID. Held
home megace as patient had not started taking it yet.
Recommended switching acarbose as above.
CHRONIC ISSUES
==============
#CAD: s/p LAD stent ___ lesions in LMCA, ostial LCx
Continued with home aspirin, atorvastatin and metoprolol.
#HTN
Continued with home lostartan and HCTZ.
#BPH
Continued with home finasteride.
TI:
[ ] Started on ipratropium/albuterol nebs for COPD
[ ] Please continue to monitor blood glucose, given new home
insulin regimen of NPH 7u BID, will need close outpatient f/u
for his glucose levels and potentially more aggressive
management. his last A1c was 8.7%. also consider quantifying his
protein in urine.
[ ] on TTE has MIld to moderate mitral regurgitation. Small
pericardial effusion. please follow up as needed,
[ ] on CT chest has Marked coronary arterial calcifications and
atherosclerotic. please consider aggressive cardiac risk
optimization.
[ ] Stopped acarbose, consider an alternative to acarbose due to
possible malabsorption as a side effect of the medication.
[ ] Consider outpatient pulmonary function tests to diagnose
COPD.
[ ] Please continue to monitor volume status given reduced
ejection fraction.
[ ] patient was found to have anemia with h/h on discharge of
11.4/34.2. please follow up with a CBC and investigate as
appropriate
[ ] on discharge his sodium was 133 and he was placed on a
___ fluid restriction. Please f/u Na level at next visit
[ ] please order LFTs at next fist and monitor ALT levels.
[ ] please titrate Lasix dose as needed. Discharge weight was 43
kg
[ ] we stopped his hydrochlorothiazide.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Acarbose 50 mg PO TID
3. Atorvastatin 40 mg PO QPM
4. Finasteride 5 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Januvia (SITagliptin) 100 mg oral DAILY
9. Furosemide 20 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Megestrol Acetate 20 mg PO BID
12. 70/30 10 Units Dinner
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
inhaled every 6 hours as needed Disp #*30 Ampule Refills:*0
2. Simethicone 80 mg PO QID:PRN bloating pain
RX *simethicone 80 mg 1 tablet by mouth up to four times a day
Disp #*120 Tablet Refills:*0
3. NPH 7 Units Breakfast
NPH 7 Units Dinner
RX *insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin]
100 unit/mL AS DIR 7 Units before BKFT; 7 Units before DINR;
Disp #*3 Vial Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Januvia (SITagliptin) 100 mg oral DAILY
9. Loratadine 10 mg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Megestrol Acetate 20 mg PO BID
12. Metoprolol Succinate XL 25 mg PO DAILY
13. HELD- Acarbose 50 mg PO TID This medication was held. Do
not restart Acarbose until told to do so by your doctor
14.Nebulizer
WHAT: Nebulizer for home use
WHY: Chronic obstructive pulmonary disease ICD-10: ___.1
WHEN: >99 days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bronchitis
COPD Exacerbation
Diabetes Mellitus
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for shortness of breath.
WHAT HAPPENED IN THE HOSPITAL?
-You were found to have COPD exacerbation and bronchitis.
-You were treated with steroids and antibiotics.
-You received additional insulin to reduce high blood glucose
levels.
WHAT SHOULD YOU DO AT HOME?
-You should continue to take medications as prescribed.
-You should follow-up with your doctors ___ as listed
below.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- we stopped your acarbos and hydrochlorothiazide
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19645563-DS-24
| 19,645,563 | 24,066,516 |
DS
| 24 |
2147-06-01 00:00:00
|
2147-06-02 07:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of CAD (s/p stent ___, HFrEF (EF30%), gastritis,
DM, HTN, SIADH p/w Nausea, vomiting and cough.
Mr. ___ via an interpreter reports anorexia and a productive
cough x ___ days. He also had 1 episode of vomiting ~10 days
ago
which was relieved by pepto bismol. On the day of admission he
began having frequent nausea and vomiting and was unable to keep
any solid food down. He also reports missing his insulin
injection this morning. The combination of vomiting and feeling
generally unwell led to presentation to the ED. He denies
shortness of breath. He denies abdominal pain. No hematemesis.
No
constipation/diarrhea. No hematochezia or melena. Last BM this
AM. No dysphagia. He has lost 10 lb in the past week.
He has had two prior admissions for productive cough ___ and
___. The admission in ___ was treated as a copd
exacerbation while ___ was treated as a CHF exacerbation.
He currently denies fever, diarrhea, abdominal pain, difficulty
swallowing, dysuria, shortness of breath or chest pain,
hematochezia, hematuria.
In the ED:
His ED course was notable for normal vitals, a normal CXR,
negative flu swab, but a K of 5.9, Cr of 1.4 up from 0.9-1,
glucose of 600 and a U/A with 1000 glucose, no ketones. He was
given insulin 10R, calcium gluconate and 1L of IVF in the ED.
Upon arrival to the floor, patient is without complaint.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- Diabetes Mellitus (insulin-dependent)
- Hypertension
- CAD: ___ lesions in LMCA, ostial LCx. s/p LAD stent placed
in ___ in ___.
- Ischemic CHF with EF 30%, NYHA II
- SIADH (baseline Na high 120s-135)
- H/o GIB, found to have gastric ulcers on EGD in ___ but
patient/family without recollection
- bilateral inguinal hernia
- Urinary retention
- BPH
-Beta thalassemia trait
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS: T 98.2, BP: 148/56, HR68 RR: 18 SpO2: 99
GENERAL: Cachectic appearing male. Alert and interactive. In no
acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD
Lymph: No cervical, supraclavicular, axillary adenopathy. 1
fixed
firm 1cm nodule palpated in left inguinal region.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Liver edge palpated just
inferior to ribs in mid clavicular line. No organomegaly.
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. Alert and conversational
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
============================
VITALS: 24 HR Data (last updated ___ @ 121)
Temp: 98.2 (Tm 98.2), BP: 148/56, HR: 68, RR: 18, O2 sat:
99%, O2 delivery: Ra, Wt: 95.46 lb/43.3 kg
GENERAL: Cachectic appearing male. Alert and interactive. In no
acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Very thin. Normal bowels sounds, non distended,
non-tender to deep palpation in all four quadrants. Liver edge
palpated just inferior to ribs in mid clavicular line. No
organomegaly. Hypopigmentation spots on the abdomen with some
telangiectasias
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC:grossly intact
Pertinent Results:
ADMISSION LABS
===================
___ 06:47PM BLOOD WBC-5.9 RBC-5.08 Hgb-10.6* Hct-34.2*
MCV-67* MCH-20.9* MCHC-31.0* RDW-16.5* RDWSD-38.5 Plt ___
___ 06:47PM BLOOD Neuts-75.2* Lymphs-16.7* Monos-5.4
Eos-1.9 Baso-0.5 Im ___ AbsNeut-4.46 AbsLymp-0.99*
AbsMono-0.32 AbsEos-0.11 AbsBaso-0.03
___ 06:47PM BLOOD Glucose-600* UreaN-40* Creat-1.4* Na-133*
K-5.9* Cl-93* HCO3-23 AnGap-17
___ 06:47PM BLOOD Albumin-4.1 Calcium-10.4* Phos-4.1 Mg-2.3
___ 06:47PM BLOOD %HbA1c-11.4* eAG-280*
___ 01:35PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* HAV
Ab-POS* IgM HAV-NEG
___ 01:35PM BLOOD HIV Ab-NEG
___ 08:43PM BLOOD ___ pO2-42* pCO2-47* pH-7.37
calTCO2-28 Base XS-0
___ 06:48PM BLOOD Lactate-1.4 K-5.3
DISCHARGE LABS
===================
___ 07:00AM BLOOD WBC-6.2 RBC-4.53* Hgb-9.6* Hct-30.7*
MCV-68* MCH-21.2* MCHC-31.3* RDW-16.4* RDWSD-38.5 Plt ___
___ 07:00AM BLOOD Glucose-104* UreaN-28* Creat-1.0 Na-138
K-4.7 Cl-101 HCO3-22 AnGap-15
IMAGING
====================
Barium Swallow ___
IMPRESSION:
The supine portion of this assessment was deferred due to
concerns he may
aspirate. There was no gross aspiration on upright images.
Dysmotility, as noted by moderate tertiary contractions. There
is no mucosal
abnormality or sign of obstruction, stricture or mass.
The stomach is elongated with the antrum residing in the pelvis.
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided. Stable mild
cardiac
enlargement. Low lungs are clear without consolidation, large
effusion or
pneumothorax. Mediastinal contour stable. Bony structures are
intact.
IMPRESSION:
Mild cardiomegaly. No signs of pneumonia.
Brief Hospital Course:
SUMMARY
=============
___ with hx of CAD (s/p stent ___, HFrEF (EF30%), gastritis,
DM, HTN, SIADH p/w a 1 week history of productive cough and
anorexia with nausea, vomiting x1 day and ___ iso
unintentional weight loss over several months.
TRANSITIONAL ISSUES
====================
[] At the time of discharge, the barium swallow only had a
preliminary report of no apparent mass or stricture causing the
symptoms. There did appear to be tertiary contractions. Full
report to follow.
[] Recommend CT Torso as outpatient to follow up on significant
cachexia and report of significant weight loss since ___.
[] Patient instructed to take 15u Lantus instead of NPH as
instructed to by ___. Patient provided with new prescription
at discharge.
ACUTE ISSUES
=================
#Nausea/Vomiting:
#Anorexia
Etiology of presentation unclear but most likely acute episode
of vomiting may have represented a gastroenteritis. It was
concerning however that he has had two of these episodes at
least in recent weeks, suggesting a possible esophageal
etiology. Barium swallow with tertiary contractions but no
evidence of mass or stricture. Patinet was evaluated by speech
and swallow who determined there was no oropharyngeal concern to
swallowing. Negative HIV, and negative hepatitis serologies
except for Hep B core Ab, but negative HepSAb (and LFTs WNL).
Hep A Ab positive, but Hep AIgM negative. Given resolution of
acute symptoms will refer patient for outpatient follow up with
PCP.
#Weight Loss:
#Severe Malnutrition in context of acute illness
He is down from 47kg in ___ to 43kg. His family reports that
he has lost about 10lbs in the past week prior to presentation,
and endorses that he has been losing weight in weeks prior to
this. He is quite cachectic
on exam raising concern for an occult malignancy. He had a CT
chest from ___ which only noted a stable nodule. He also had
a
colonoscopy and EGD last in ___ which showed H pylori infection
but no concern for malignancy. Recommend CT torso as outpatient
to rule out underlying mass, as well as age-appropriate cancer
screening if appropriate within the patient's GOCs (given age of
___).
#Productive Cough:
Likely ___ a viral process. CXR is clear without evidence of
pneumonia or aspiration. He is not wheezing on exam. He denies
any nasal congestion or sore throat to raise concern. Treated
with Tessalon pearls and dextromethorphan.
#Hyperglycemia
#IDDMII
On his last discharge he was on Novolog Mix 70/30 10 Units
Breakfast and Novolog Mix 70/30 4 Units Dinner. His son reports
he is taking 10 in the AM and 10 in the evening. He missed his
insulin injections on day of admission, and was found to have
hyperglycemia to 600 at admission. Of note he was seen at ___
in ___ with recommendations to change insulin to lantus 15
units. He was started on ___ u Lantus as an inpatient and
tolerated this dose well.
# ___ on Chronic Kidney Disease stage II
#Hyperkalemia (resolved)
Initially with Cr 1.4 with baseline Cr 1.0 on admission. Likely
prerenal from N/V and hyperglycemia while still taking
furosemide. Held losartan iso normotension and held furosemide
as patient appeared dry on exam.
CHRONIC ISSUES
=================
# Hypertension: Patient has been normotensive
-Held home losartan
-continued home metoprolol
# Hyponatremia
# Hx of SIADH
Admission Na (corrected) was 133, baseline Na ranges from
129-135.
# Coronary Artery Disease s/p LAD stent (___)
# Hyperlipidemia
Increased atorvastatin to 80mg. Continued home aspirin,
metoprolol, but held losartan. Restarted empagliflozin on
discharge.
# Beta thalassemia trait
# Microcytic Anemia (mild)
Chronic: MCV high ___, Hgb is usually ___. Hemoglobin
electrophoresis from ___ with PCP 94.3% HbA and 5.7% HgA2,
consistent with beta thalassemia minor. Iron studies
unremarkable.
# BPH
Continued home finasteride
###############
>30 minutes spent on discharge planning and care coordination on
the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. 70/30 10 Units Dinner
8. Jardiance (empagliflozin) 25 mg oral QAM
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Dextromethorphan Polistirex ___ mg PO Q12H:PRN cough
RX *dextromethorphan polistirex [Delsym 12 hour] 30 mg/5 mL 30
ml by mouth every twelve (12) hours Refills:*0
3. Glargine 15 Units Breakfast
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) 15 units IM 15 Units before BKFT; Disp #*4 Syringe
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Jardiance (empagliflozin) 25 mg oral QAM
8. Metoprolol Succinate XL 25 mg PO DAILY
9. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until instructed to by your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Severe Malnutrition in context of acute illness
Hyperglycemia
SECONDARY DIAGNOSIS
=====================
Nausea, NOS
Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
================================
- You were in the hospital because you had nausea and vomiting.
WHAT HAPPENED TO ME IN THE HOSPITAL?
=======================================
- We gave you fluids and you had a test to look at your
swallowing.
- We started you on insulin glargine to control your blood
sugar. It is important that you use the glargine (also known as
Lantus) instead of the insulin NPH. DO NOT TAKE BOTH THE OLD
INSULIN AND THE NEW INSULIN TOGETHER!
- We recommend that you do not restart your losartan (blood
pressure medicine) or furosemide (water pill) until you follow
up with your doctor.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
================================================
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19645833-DS-9
| 19,645,833 | 23,514,901 |
DS
| 9 |
2133-03-14 00:00:00
|
2133-03-14 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Vicodin / tramadol
Attending: ___.
Chief Complaint:
Leg pain, swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CAD s/p CABG, CHF, RA, DM, HTN, CKD (baseline Cr
1.5-1.7),hypothyroid presenting with weeks of left leg
pain/swelling. Patient previously evaluated for her left leg
pain and swelling. Underwent an ultrasound which was without
evidence of DVT and was started on a course of PO Keflex. Noted
improvement of her symptoms while on Keflex, but she finised the
course on the ___. This morning she noticed that when she
woke up her LLE was tight and she has a hard time moving it. She
thought it was a muscle cramp and tried to walk it off but
symptoms got worse to the point where she could not put pressure
on it and noticed that her leg was red. Pain and swelling
spreads from the foot to just distal to the knee. Has not noted
associated fevers. Pain is improved somewhat with elevation of
the leg.
Initial ED vitals: Pain 10 T98.0 P64 BP125/40 RR20 O2 sat 100%.
Labs were notable for WBC 8.2, HCT 33.8, Lactate 1.3. Blood cx
were obtained, ___ was negative for DVT. Patient was started on
vancomycin and ciprofloxacin IV and admitted to medicine for
further management.
On the floor, VS: T97.6 BP154/47 HR65 RR18 02 sat100% RA.
Patient appears comfortable and has no complaints. Corroborates
the above story.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 on
___, Diabetes Mellitus, Hypertension,
Hypercholesterolemia, Congestive Heart Failure, Diabetic
Retinopathy, Hypothyroidism, Carpal tunnel syndrome s/p
bilateral surgery, s/p Hysterectomy, Obesity, Recurrent Urinary
Tract Infections, s/p Appendectomy, s/p Tonsillectomy, s/p
bilateral cataract surgery, s/p Thyroidectomy
Social History:
___
Family History:
Mother with heart disease. Diabetes is prevalent in the family.
Physical Exam:
Admission Physical
====================
Vitals - T97.6 BP154/47 HR65 RR18 02 sat 100% RA
GENERAL: NAD, sitting up in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, JVP difficult to assess given body habitus
CARDIAC: distant heart sounds, but normal RRR, no appreciable
m/r/g
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, soft BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
___ edema 1+ L>R, with very mild erythema over LLE that is TTP.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical
======================
Vitals- Tm98.6 ___ 58-66 18 99% RA
GENERAL: NAD, sitting up in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, JVP difficult to assess given body habitus
CARDIAC: distant heart sounds, but normal RRR, no appreciable
m/r/g
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, soft BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
___ edema 1+ L>R, with very mild erythema over LLE but no TTP
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
================
___ 08:30PM BLOOD WBC-8.2 RBC-3.79* Hgb-10.2* Hct-33.8*
MCV-89 MCH-26.8* MCHC-30.1* RDW-14.7 Plt ___
___ 08:30PM BLOOD Neuts-51.1 ___ Monos-8.6 Eos-7.1*
Baso-0.7
___ 08:30PM BLOOD Glucose-144* UreaN-85* Creat-2.0* Na-144
K-4.8 Cl-107 HCO3-20* AnGap-22*
___ 08:22AM BLOOD Albumin-4.1 Calcium-6.7* Phos-5.7* Mg-2.4
___ 08:54AM BLOOD PTH-145*
___ 11:17AM BLOOD freeCa-0.84*
___ 08:53PM BLOOD Lactate-1.3
Discharge Labs
=================
___ 07:20AM BLOOD WBC-6.6 RBC-3.52* Hgb-9.4* Hct-30.8*
MCV-87 MCH-26.7* MCHC-30.5* RDW-14.5 Plt ___
___ 07:20AM BLOOD Glucose-67* UreaN-42* Creat-1.3* Na-144
K-5.1 Cl-111* HCO3-25 AnGap-13
___ 07:20AM BLOOD Calcium-8.7 Phos-3.8# Mg-2.2
Microbiology
=============
___ 7:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Imaging
===========
Lower extremity ultrasound ___
IMPRESSION:
No evidence of deep vein thrombosis in the left lower extremity.
Brief Hospital Course:
___ woman with CAD, CHF, DM, HTN, RA presenting LLE swelling
and redness after a ~10 day course of keflex for cellulitis,
concerning for cellulitis and antibiotic failure.
# Cellulitis/Superficial thrombophlebitis: Her symptoms were
concerning for a possibly incompletely treated cellulitis. She
had recently stopped Keflex and then represented with worsening
symptoms similar to what she had just been treated for. Her
pain, erythema, and swelling were on the same left leg. She had
another lower extremity ultrasound checked which was negative
for DVT. She had a CK checked which was negative. She was put on
broader spectrum antibiotics to cover for MRSA and for gram
negatives given her diabetes. She was markedly improved in her
erythema within 24 hours. However she continued to complain of
pain of leg pain along her left shin and felt that she could
feel a "band." Physical exam was not consistent with
thrombophlebitis but she improved with warm compresses to the
lower extremities. Her gabapentin, which was initially held on
admission also was restarted and was temporally correlated with
an improvement in her lower leg pain. She was planned to
complete a full course of antibiotics for cellulitis with
bactrim and augmentin.
# ___ on CKD: Her baseline Cr 1.5-1.7, and she initially
presented with a creatinine of 2.0 with potential etiologies
include pre-renal from overdiuresis or poor forward flow from
CHF. Her notably high BUN was also consistent with prerenal
etiology. Her furosemide and lisinopril were held and creatinine
and BUN quickly and markedly downtrended to a discharge
creatinine of 1.3. Her BUN was still downtrending on day of
discharge from admission of ___ to discharge of 42.
- Consider adjusting her diuresis and lisinopril given her
hypovolemia
- She should have electrolytes checked at her next PCP
___
# CHF: She was not decompensated during her hospital stay, as
she was on room air and satting well with clear lungs. In fact
her high creatinine was indicative of possibly overdiuresis and
hypovolemia. Her lasix and lisinopril were held and she was kept
on a low sodium diet with a mild fluid restriction. She did not
develop any worsening clinical signs of heart failure. These
medications were restarted on discharge.
# Hypocalcemia - She was initially initially found to have
profoundly low calcium to 6.9, which was likely in the setting
of acute on chronic renal failure. Her high PTH and high phos
were consistent with secondary hyperparathyroidism from her
renal failure. She was aggressively repleted and her calcium
normalized.
- Should continue on daily supplementation
# Hyperkalemia - Initially she had very mildly elevated
potassium, likely from kidney failure. Her lisinopril was held
and her kidney function improved and her potassium levels
normalized.
# Hyperphosphatemia - She initially presented with elevated
phosphate, likely from renal failure. She was treated as above
for her electrolyte disturbances and as her renal function
improved her phosphatemia trended downward.
- She should have electrolytes checked by her PCP
# HTN: Held Lisinopril and furosemide for given elevated
creatinine and her creatinine improved to 1.3 with her BUN still
downtrending on day of discharge.
# DM: Continued on home 38 Lantus QHS plus SSI. Glucose levels
were well controlled.
# RA: Continued on home leflunomide. She had no complaints.
# Hypothyroidism: Appeared euthyroid and was continued on home
levothyroxine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Furosemide 160 mg PO DAILY
4. Gabapentin 1200 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. leflunomide 20 mg oral daily
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
12. diclofenac sodium 3 % TOPICAL QID: PRN back pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. leflunomide 20 mg oral daily
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. diclofenac sodium 3 % TOPICAL QID: PRN back pain
8. Furosemide 160 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
14. Gabapentin 1200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
-Cellulitis
-Acute Kidney Injury
-Superficial Thrombophlebitis
Secondary Diagnosis
-Congestive Heart Failure
-Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___
It was our pleasure caring for you at ___
___. You were admitted for lower leg pain and concern
that you still had an infection. You were started on
antibiotics. It could be that the previous antibiotics had not
completely cleared up your infection.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19646006-DS-19
| 19,646,006 | 25,580,067 |
DS
| 19 |
2207-03-02 00:00:00
|
2207-03-02 19:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Reglan
Attending: ___.
Chief Complaint:
symptomatic bradycardia
Major Surgical or Invasive Procedure:
Dual Chamber Permanent Pacemaker Placement via L cephalic vein
___
History of Present Illness:
___ with CAD s/p CABG and PCI, HTN, mild AS, and bradycardia
with multiple presentations in the past for symptomatic
bradycardia who p/w symptomatic bradycardia.
Pt has had multiple presentations for symptomatic bradycardia
with HR in ___. He was previously on atenolol which has been on
hold since ___. More recently, he was seen in ___ on
___ for fatigue and dyspnea. He was found to have HR in
___. ECG showed RBBB with AV delay. At that time it was felt to
be unclear whether his symptoms were related to bradycardia or
worsening AS. He was therefore scheduled for a stress echo on
___. He returned home but symptoms persisted and he presented to
the ED.
In the ED,
- Initial vitals: T 97.3 HR 35, BP 140/58, RR 16, SpO2 100% RA
- EKG: Sinus with RBBB, HR ___
- Labs/studies notable for:
CBC: WBC 8.9, Hgb 12.6, plt 159
Chem: BUN 58, Cr 2.1 (bl 1.7-2.0 in last ___ yrs), bicarb 21
Coags: INR 1.1
Trop 0.02 -> <0.01, CK: 55 MB: 3
Consults-
Cards- It was recommended that he have a stress echo to evaluate
for worsening conduction disease and valvular pathology which
was ordered but not yet completed. The patient now presents with
similar symptoms compared to prior. Given the nature of the
patients symptoms and multiple presentations for the same
complaint, would agree with admission to ___ service for
inpatient work up of his bradycardia with stress echo. Would
hold all nodal blocking agents and atenolol as previously noted
per ___ note on ___.
- Patient was given: Nothing
On the floor, he denies any chest pain, shortness of breath or
abdominal pain. He does endorse feeling gassy. Denies any
nausea, vomiting or diarrhea. He is feeling more tired and
feels like he has very little energy. He has stopped taking
atenolol for a little while. He notices that when he was in
___ he was able to go up and down the stairs without any
problem. He left ___ oh ___ and has been having some
shortness of breath with exertion. Endorses that he has had
chronic lower extremity
edema for a couple of years. Says it is 170 pounds is a good
weight for him.
REVIEW OF SYSTEMS:
Per HPI
Past Medical History:
# Hypertension
# Hyperlipidemia
# CAD s/p CABG in ___ at ___ (LIMA to LAD, SVG to PDA, SVG to
RI/ OM). S/p multiple angioplasties and rotablations to the RCA,
stents x 3 to RCA in ___ complicated by ISR, followed by
multiple angioplasties and rotablations as well as one
additional stent to RCA in ___, multiple angioplasties to the
PLV, stent to SVG-ramus-OM graft in ___ which is now occluded,
stents to LCx and LAD at ___ in ___, ___ ___ to ostial
LCx and mid LCx, and most recently DES to ___ ___.
# CKD
# Spinal stenosis
# Lower back pain s/p epidural injections
# Osteoarthritis, s/p left knee replacement ___ needs right
knee replacement in the future
# Erectile dysfunction s/p penile prosthesis
# GERD
# BPH
# s/p Right cataract surgery
Social History:
___
Family History:
Dad died from MI at age ___. Mother with heart condition in
her ___ and died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS 24 HR Data (last updated ___ @ 533)Temp: 97.8 (Tm 97.9),
BP:
172/82 (170-173/72-82), HR: 70 (70-74), RR: 18 (___), O2 sat:
97% (97-99), O2 delivery: Ra, Wt: 165.78 lb/75.2 kg
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP not elevated
CARDIAC: RRR, normal S1, S2. Crescendo decrescendo murmur
appreciated through the precordium, radiating to the carotids.
No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pitting edema to the mid shins bilaterally.
No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.8 ___ 96%Ra
GEN: NAD, sitting up on edge of bed
HEENT: Clear OP, moist mmm
___: NSR, III/VI crescendo-decrescendo murmur with radiation to
carotids, dressing over left anterior chest wall
RESP: CTAB, No wheezing, rhonchi or crackles
ABD: soft abdomen, NTND No HSM
EXT: Warm to touch, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 04:13PM ___ PTT-28.1 ___
___ 04:13PM NEUTS-67.9 ___ MONOS-7.7 EOS-3.1
BASOS-0.3 IM ___ AbsNeut-6.01 AbsLymp-1.83 AbsMono-0.68
AbsEos-0.27 AbsBaso-0.03
___ 04:13PM WBC-8.9 RBC-3.99* HGB-12.6* HCT-38.7* MCV-97
MCH-31.6 MCHC-32.6 RDW-14.5 RDWSD-51.6*
___ 04:13PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.7
___ 04:13PM CK-MB-3
___ 04:13PM cTropnT-0.02*
___ 04:13PM GLUCOSE-100 UREA N-58* CREAT-2.1* SODIUM-140
POTASSIUM-5.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13
___ 09:38PM cTropnT-0.01
DISCHARGE LABS
==============
___ 07:50AM BLOOD WBC-7.7 RBC-4.13* Hgb-12.9* Hct-39.9*
MCV-97 MCH-31.2 MCHC-32.3 RDW-14.7 RDWSD-51.3* Plt ___
___ 07:50AM BLOOD Glucose-96 UreaN-35* Creat-1.5* Na-141
K-4.6 Cl-106 HCO3-23 AnGap-12
___ 07:50AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
OTHER LABS
==========
___ 06:18AM BLOOD TSH-5.9*
OTHER IMAGING
=============
___ TTE
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA size. No atrial septal defect by 2D/color Doppler.
Normal IVC diameter with normal inspiratory collapse==>RA
pressure ___ mmHg.
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity
size. Mild focal systolic dysfunction. The visually estimated
left ventricular ejection fraction is 45-50%. No resting outflow
tract
gradient.
RIGHT VENTRICLE (RV): Normal cavity size. Moderate global free
wall hypokinesis.
AORTA: Normal sinus diameter for gender. Mildly increased
ascending diameter. Focal calcifications in aortic sinus.
AORTIC VALVE (AV): Severely thickened leaflets. Moderate
stenosis (area 1.0-1.5 cm2). Peak gradient from apical 5 chamber
orientation. Mild [1+] regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Mild MAC. Trivial regurgitation.
PULMONIC VALVE (PV): Normal leaflets. Mild regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Mild [1+] regurgitation.
Undertermined pulmonary artery systolic pressure.
PERICARDIUM: Trivial effusion.
ADDITIONAL FINDINGS: Sinus bradycardia.
___ CXR
Left-sided pacemaker leads project to the right atrium and right
ventricle. Lungs are low volume. There is bibasilar
atelectasis. Cardiomediastinal silhouette is stable. No
pneumothorax is seen.
Brief Hospital Course:
___ year old man with CAD s/p CABG and PCI, HTN, moderate AS, and
bradycardia with multiple prior presentations in the past who
was admitted to ___ for expedited workup of symptomatic
bradycardia now s/p permanent dual chamber pacemaker placement
on ___.
# Symptomatic Bradycardia
# Mobitz II with 2:1 block
Patient admitted with bradycardia (HR ___ with varying
block. He was previously on atenolol, but this was held due to
the above. His last dose was over weeks ago. EKG on admission
showed Mobitz II with 2:1 block. He was also noted to have
strips in Mobitz I on telemetry. Patient endorsed fatigue while
in this rhythm but otherwise was asymptomatic. He underwent
uncomplicated device placement via the L cephalic vein. CXR
confirmed that pacemaker leads project to the right atrium and
right ventricle. The pacer was evaluated by EP and showed normal
pacer function with acceptable lead measurements and battery
status. Patient will follow up in device clinic in 1 week.
# CAD s/p CABG(___-LAD) and multiple PCI (most recent ___
DES to ___ LAD).
Chronic and stable. No ischemic changes on EKG. TTE ___ was
notable for mild regional left ventricular systolic dysfunction
with hypokinesis of the inferoseptum and inferior walls in the
RCA distribution. Though the hypokinesis did not appear apparent
on our review of images, patient should have an exercise nuclear
stress test in the outpatient setting to further work up.
Patient was continued on home ASA 81mg and atorvastatin 80mg.
Following pacemaker placement, low dose metoprolol succinate XL
25mg was started for cardioprotective effects.
# HTN: Home hydrochlorothiazide and amlodipine were held on
arrival to prevent hypotension and possible nodal blockade
respectively. Losartan was uptitrated from 50 to 100mg daily
with better control in blood pressure. Due to well-controlled
pressures, HCTZ and amlodipine were not restarted.
# CKD: Baseline Cr ~1.6-1.8. Creatinine was trended as losartan
was uptitrated. Cr on discharge 1.5.
# GERD: Continued on omeprazole
# BPH: Continued on home finasteride
# Gout: Continued on home allopurinol
TRANSITIONAL ISSUES
===================
[] TTE with regional wall motion abnormalities in RCA
distribution. Patient will need an exercise stress test with
nuclear perfusion in two weeks to further evaluate. He was
started on a low dose beta blocker for cardioprotective effects
now that pacer is preventing bradycardia.
[] Home hydrochlorothiazide and amlodipine were held on
admission. Losaratan was uptitrated to 100mg daily with adequate
control of blood pressure. Patient may require further titration
of medications in the outpatient setting.
[] Patient is awaiting follow-up in device clinic with Dr.
___ in one week. He will be called when an appointment
is made.
[] TSH 5.9. Consider rechecking and further evaluating in
outpatient setting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Omeprazole 20 mg PO QHS
3. Losartan Potassium 50 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. amLODIPine 5 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
10. Ezetimibe 10 mg PO DAILY
11. Ranolazine ER 500 mg PO BID
12. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
13. Pilocarpine 1% 1 DROP LEFT EYE Q8H
14. Ranitidine 150 mg PO QAM
15. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Allopurinol ___ mg PO DAILY
4. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
9. Ezetimibe 10 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
12. Omeprazole 20 mg PO QHS
13. Pilocarpine 1% 1 DROP LEFT EYE Q8H
14. Ranitidine 150 mg PO QAM
15. Ranolazine ER 500 mg PO BID
16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your PCP tells you to do so
17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until your PCP
tells you to do so
Discharge Disposition:
Home
Discharge Diagnosis:
# Symptomatic Bradycardia
# Mobitz II with 2:1 block: s/p PPM ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with a slow heart rate. To treat this
you underwent placement of a permanent pacemaker on ___. You
tolerated the procedure well and your heart rates are now paced
by this new device.
A few changes have also been made in your medications:
- please START taking metoprolol succinate xl 25mg daily
(prescription provided)
- please STOP taking amlodipine and hydrochlorothiazide until a
provider instructs you otherwise
- your losartan was INCREASED to 100mg daily
An exercise stress test has been scheduled for you on ___.
Specific instructions have been sent to your home.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19646104-DS-20
| 19,646,104 | 22,142,361 |
DS
| 20 |
2140-11-12 00:00:00
|
2140-11-17 21:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Vancomycin / Imipenem / Ciprofloxacin / Linezolid
/ Cefpodoxime
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ male with hx of pancreatitis, initially
from gallstone pancreatitis, complicated by pancreatic
necrosis/ARDS and pseudocysts s/p CCY ___, former alcohol
abuse, and hepatitis C presenting with abdominal pain and
nausea. Pt reports mid-epigastric abdominal pain that began on
morning of admission. Associated with nausea, no vomiting, and
anorexia. Abdominal pain is ___, constant. No change in BMs,
last BM this morning that was normal. Reports no sick contacts
or recent alcohol use.
.
In the ED, initial VS 97.2 73 132/72 16 100% RA. Labs notable
for Lipase 1394, BUN 35, Hct 36, AST 241, ALT 375, WBC 8.2,
lactate 1.3. He received Morphine 4mg x3 with no relief of pain.
He then received dilaudid 1mg x2 which did improve pain. Most
recent set of vitals: 97.8 149/75 89 14 98% RA.
.
Upon arrival to the floor, pt appears comfortable though
complaining of mid-epigastric pain and nausea. He has been
better controlled on IV dilaudid.
.
ROS: Denies fever, chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Severe pancreatitis ___ c/b necrosis/ARDS/prolonged ICU
stay. s/p open CCY ___. Pancreatic abscess drained in
___ s/p ERCP drainage of 6.4x6.2 pseudocyst by ___ in
___
2. Periumbilical hernia
3. Mild COPD
4. Hypertension.
5. Hepatitis C.
6. History of colon polyps.
7. Hx of VRE/MRSA
8. Diabetes mellitus, type 2
Social History:
___
Family History:
Father with history of hypertension, coronary disease, and
passed away from a CVA. Mother also with history of coronary
disease, CVA, and hypertension. There is no history of colon
cancer or prostate cancer.
Physical Exam:
Admission Vitals:
VS - 98.7 130/80 89 16 100% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, mildly diffusely tender worse in
mid-epigastrium, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
On Discharge:
VS- 98.3 110/58 78 20 96% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
On admission:
___ 01:30PM BLOOD WBC-8.2 RBC-4.97 Hgb-16.7 Hct-46.1 MCV-93
MCH-33.7* MCHC-36.3* RDW-12.9 Plt ___
___ 01:30PM BLOOD ___ PTT-28.5 ___
___ 01:30PM BLOOD Glucose-84 UreaN-35* Creat-1.1 Na-134
K-4.7 Cl-100 HCO3-22 AnGap-17
___ 01:30PM BLOOD ALT-375* AST-241* AlkPhos-70 TotBili-0.7
___ 01:30PM BLOOD Albumin-4.6
___ 01:28PM BLOOD Lactate-1.3
___ 07:44AM BLOOD Calcium-7.2* Phos-1.9*# Mg-1.6
Imaging:
___ ___ ultrasound
FINDINGS: The liver is normal in echogenicity and contour
without focal liver lesion identified. The portal vein is patent
with hepatopetal flow. No intrahepatic biliary dilation is seen.
The extrahepatic CBD is distended
measuring up to 13 mm. The pancreas is not visualized due to
overlying bowel gas. The patient is status post cholecystectomy.
No free fluid is seen.
IMPRESSION: Dilated CBD in this patient with history of
cholecystectomy. The CBD has been previously seen to be dilated,
though comparison with CT is limited.
On discharge:
___ 07:15AM BLOOD WBC-5.9 RBC-4.19* Hgb-14.3 Hct-40.0
MCV-96 MCH-34.2* MCHC-35.8* RDW-12.7 Plt ___
___ 07:15AM BLOOD Glucose-115* UreaN-13 Creat-0.8 Na-135
K-4.6 Cl-102 HCO3-26 AnGap-12
___ 07:15AM BLOOD ALT-220* AST-103* AlkPhos-51 TotBili-1.1
___ 07:15AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.9
Lipase:
___ 01:30PM BLOOD Lipase-1394*
___ 07:44AM BLOOD Lipase-509*
___ 07:15AM BLOOD Lipase-265*
.
HCV VL
___ 7:44 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
20,200,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
Roche COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory (___) so that results can be confirmed
by an
alternate methodology.
Brief Hospital Course:
___ male with history of pancreatitis, initially from
gallstone pancreatitis, complicated by pancreatic necrosis/ARDS
and pseudocysts s/p CCY ___, former alcohol abuse, and
hepatitis C presenting with abdominal pain and nausea.
.
# acute pancreatitis: Pt presenting with mid-epigastric pain,
nausea, anorexia, and elevated lipase consistent with acute
pancreatitis. The patient was made NPO, started on aggressive
IV fluids, given standard anti-emetics and pain control.
Lisinopril was discontinued given that it might contribute/cause
pancreatitis. A RUQ ultrasound was performed which demonstrated
a CBD that had been seen previously. The patient reported that
IV morphine was ineffective and was switched to IV dilaudid on
HD#1. He required IV dilaudid 1mg IV q2-3 hours (placed in 50cc
bags) from ___, then on ___ required no more pain
control. His diet was advanced from clears to solids, and in
fact against medical advance, ate a cheese burger without
difficulty and was discharged home. His lipase was elevated to
1394 at the time of admission and decreased daily until the day
of discharge and was 265. The patient was instructed to follow
up with his gastroenterologist within 2 weeks for evaluation of
chronic pancreatitis. The patient reports having increasing
fatty stools and might benefit from pancreatic enzymatic
replacement.
.
# Elevated LFTs: The patient has a history of hepatitis C and
baseline LFTs elevation. The patient presented with an evidence
of hepatocellular damage (ALT-375 and AST-241) without evidence
of synthetic dysfunction (normal INR and albumen) or cholestasis
(normal bilirum and alk phos). A RUQ ultrasound demonstrated
patent hepatopetal flow, and a liver that was normal in
echogenicity and contour without focal liver lesions. The LFT
downtrended daily, and the patient was discharge with follow up
with his gastroenterologist within 2 weeks of discharge for
further evaluation and management of these LFT abnormalities.
His HCV viral load, which was pending at the time of discharge,
was 20.2 million IU/mL.
.
# Type 2 DM: The patient home medication of glyburide 5 mg
daily was held at the time of admission and restarted at the
time of discharge. He was placed on a HISS sliding scale while
inpatient.
.
# HTN: The patients lisinopril 40mg daily was discontinued
given that he reported both a chronic cough and the possibility
of it contribution/causing pancreatitis. He was started on
losartan for BP control (and nephro-protection) and continued on
his home dose of nifedipine.
.
#Transitional Issues:
-the patient should follow up with his PCP for further blood
pressure medication titration
-the patient should also follow up with a GI physician fo
further ___ of his acute on chronic pancreatitis and HCV
Medications on Admission:
GLYBURIDE - 5 mg Tablet - 1 Tablet(s) by mouth once daily
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day
NIFEDIPINE [ADALAT CC] - 30 mg Tablet Extended Release - take 1
Tablet(s) by mouth qam
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - daily as needed for rash
avoid face, axillae and groin
BLOOD SUGAR DIAGNOSTIC ___ AVIVA] - Strip - use as
directed three times a day and as needed to monitor blood
glucose
IBUPROFEN [ADVIL] - (OTC) - 200 mg Tablet - 2 Tablet(s) by mouth
___ daily prn for pain
Discharge Medications:
1. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
2. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical
once a day as needed for RASH.
5. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
acute pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for
abdominal pain. We believe your pain is due to acute
pancreatitis and you were treated with pain medications and
bowel rest. Your pain improved and you were able to eat food
without your pain worsening. ___ you go home, we recommend that
you continue to eat a bland diet of bananas, rice and toast for
the next 5 days. Please make an appointment to follow up with
your gastroenterologist within 2 weeks. Please discuss the
possibility that you may now have chronic pancreatitis and if
enzyme supplementation would be beneficial.
Medication Changes:
STOP taking lisinopril
START taking losartan 50mg daily
Continue all other medications
Followup Instructions:
___
|
19646107-DS-20
| 19,646,107 | 21,848,458 |
DS
| 20 |
2143-05-29 00:00:00
|
2143-05-31 23:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Ibuprofen
Attending: ___
Chief Complaint:
R rib fractures, L orbital floor blowout fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an intoxicated ___ YO M who was in a MVC this
evening. He cannot provide reliable details due to his
intoxicated status. Admits to drinking tonight.
Past Medical History:
Anxiety
Social History:
___
Family History:
Non contributory
Physical Exam:
Upon Discharge:
Vitals: stable
General: AAOx3, NAD
HEENT: Left eye hematoma, PEERLA, MOM, ___
Heart: ___
Chest: CTAx2. tenderness on right sided of chest
Abdomen: Soft/Depressible, non-tender, non-distended
Extremities: No cyanosis, no edema
Pertinent Results:
___ 04:15PM BLOOD WBC-9.0 RBC-4.52* Hgb-14.9 Hct-42.3
MCV-94 MCH-33.0* MCHC-35.2 RDW-12.2 RDWSD-41.8 Plt ___
___ 04:15PM BLOOD ___ PTT-27.5 ___
___ 04:15PM BLOOD ___ 04:15PM BLOOD UreaN-14 Creat-0.9
___ 04:15PM BLOOD Lipase-554*
___ 04:15PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:20PM BLOOD pO2-43* pCO2-39 pH-7.40 calTCO2-25 Base
XS-0
___ 04:20PM BLOOD Glucose-125* Lactate-3.2* Na-139 K-3.5
Cl-101
___ 04:20PM BLOOD Hgb-15.7 calcHCT-47
___ 04:20PM BLOOD freeCa-1.08*
Brief Hospital Course:
The patient presented to Emergency Department on ___ . Pt
was evaluated upon arrival to ED as a basic trauma activation,
primary and secondary survey's were performed which were
unremarkable. Given findings, the patient was taken to the CT
scan for further evaluation of his injuries. Patient was found
to have a left orbital floor blow out fracture which was
evaluated by ophthalmology and was found to have no entrapment
of the eye and cleared from their standpoint. Patient was
admitted to the hospital for management of his rib fractures and
detox. Patient hospital course is described below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed oral oxycodone once
tolerating a 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 advanced sequentially to a Regular
diet, which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Other: Patient was evaluated by ___ and was cleared to go home.
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 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.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Ibuprofen 400 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
-Minimally displaced, comminuted left nasal bone fracture,
septal fracture, left lamina papyracea fracture, and left
orbital floor fracture
-Multiple acute nondisplaced anterior right (3, 4, 6, 7, 8) and
left (3, 4, 5, 6) rib fractures.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a motor vehicle collision. Your
injuries include multiple left sided facial fractures and
multiple bilateral rib fractures. You were admitted for pain
control and observation. Plastic Surgery evaluated you and would
like to see you in 1 week to discuss repair of the facial
fractures. Opthalmology saw you and determined there was no
injury to the left eye, and you can follow-up as needed with an
ophthalmologist if you develop any vision problems.
Your pain is well controlled on ibuprofen alone and you are
ambulating and tolerating a regular diet. Your vital signs are
all stable. You are ready to be discharged home to continue your
recovery.
Please note the following discharge instructions:
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
SINUS PRECAUTIONS:
- Do not forcefully spit for several days.
- Do not smoke for several days.
- Do not use straws for several days.
- Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
- Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
- Eat only soft foods for several days, always trying to chew on
the opposite side of your mouth.
Followup Instructions:
___
|
19646403-DS-7
| 19,646,403 | 20,167,591 |
DS
| 7 |
2117-02-18 00:00:00
|
2117-02-18 14:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
Culture of left foot blister
History of Present Illness:
Mr ___ is a ___ with hx of obesity who p/w LLE pain,
erythema, and chills.
Tht pt states that ___ night he felt febrile with chills,
was exhausted and slept for 12h. ___ am he noticed his LLE
was a little sore and had some difficult walking, but did not
notice any erythema. By 4pm walking was seriously limited by
pain and he noticed some erythema, and at midnight he spiked a
temp of 102. He took ibuprofen without relief, and notes he felt
a little delirious.
Of note the patient states that he is not aware of any skin
breakdown on his leg, denies bugbites, scratches, foot fungus or
itching. He denies recent immersion of his legs in bodies of
water or a hottub. He denies recent travel, animal bites, or
diabetes. He does state he was on the roof of his home last week
sweeping up the leaves and mold, but denies scratching his legs.
He does note that ___ ago he developed similar symptoms of
fatigue, chills, and erythema/tenderness of the left thigh, but
that spontaneously resolved after 24h.
Per his wife's suggestion, the patient presented to the ED,
where he was found to have initial vs 98.7 82 140/93 20 98%. He
received Vancomcyin 1 gram IV x2, and Unasyn 3g IV x3. He also
had a CT non con LLE with did not show any e/o abscess. He was
obsed in the ED but it was felt that the cellulitis had extended
slightly beyond the borders of demarcation and so he was
admitted for further management.
.
On arrival to the floor the pt VS: 100.1 120/70 73 18 97%RA. He
patient reports improvement of pain, decreased warmth, and some
recession of the erythema. He also feels he has more energy.
Past Medical History:
L inguinal hernia repair in ___
Bilateral shoulder surgery in college
Skin infection following flu-like illness resovled spontaneously
___ yrs ago
Social History:
___
Family History:
No contributing family history
Physical Exam:
ADMISSION PE
VS 100.1 120/70 73 18 97%RA
GEN Obese man, Alert, oriented, no acute distress, pleasant
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT LLE with dark erythema and non-purulent blistering on the
anterior shin from ankle to ___ up, larger blister on the
posterior ankle, no pain over the achilles tender, negative
___ sign. three discrete areas of light erythema, mildly
ttp, no blistering on the medial left thigh. Mildly, tender
inguinal LAD.
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions, no intertriginous maceration
LABS: reviewed, see below
DISCHARGE PE
VS 97.6 128/84 68 18 97%RA
GEN Obese man, Alert, oriented, no acute distress, pleasant
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT LLE with erythema and non-purulent blistering on the
anterior shin from ankle to ___ up significanly receded within
the marked borders, larger blister on the posterior ankle, no
pain over the achilles tender, negative ___ sign. three
discrete areas of light erythema, mildly ttp, no erythema or
blistering on the medial left thigh.
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions, no intertriginous maceration
LABS: reviewed, see below
Pertinent Results:
ADMISSION
___ 03:21AM BLOOD WBC-15.2* RBC-4.83 Hgb-15.1 Hct-42.3
MCV-88 MCH-31.2 MCHC-35.6* RDW-12.9 Plt ___
___ 03:21AM BLOOD Neuts-83.6* Lymphs-7.7* Monos-7.2 Eos-1.0
Baso-0.5
___ 03:21AM BLOOD Plt ___
___ 03:21AM BLOOD Glucose-107* UreaN-10 Creat-0.9 Na-134
K-3.8 Cl-97 HCO3-26 AnGap-15
___ 03:44AM BLOOD Lactate-1.5
IMAGING
___ w/o Contrast ___
Subcutaneous soft tissue stranding and edema involving the
medial
left lower extremity. There is no soft tissue air or abscess.
Several mildly prominent inguinal lymph nodes with mild
surrounding stranding, likely reactive.
DISCHARGE
___ 06:00AM BLOOD WBC-7.0 RBC-4.72 Hgb-14.7 Hct-42.2 MCV-89
MCH-31.2 MCHC-34.9 RDW-12.9 Plt ___
Brief Hospital Course:
HOSPITAL COURSE
___ y.o male w/ no Pmhx presenting with 1 day of worsening LLE
erythema and swelling with fevers/chills. In ED treated with
Vanc/unasyn in ED and transferred to floor for slow response to
abx. Clinical improvement on this regimen. Given blistering and
lymphanggitic spread this was considered a likely strep species
and patient was changed to Keflex on ___. Being sent out
with plans to complete 7 day course total antibiotics with and
followup with PCP to assess for resolution on ___. If it does
not resolve, should consider changing treatment to Bactrim for
MRSA coverage. Also complained of eye irritation which was
treated with erythromycin eyedrops.
ACTIVE ISSUES
# Cellultis: Pt presents with complaints ___ pain, erythema,
swelling, and chills, found to have cellulitis without e/o
abscess or nec. fasc. on CT imaging. Given the apparent
lymphangitic spread up the leg and blistery appearances without
purulent focus, seems more likely associated with strep, however
cannot r/o staph. The patient was empirically treated on
vanc/unasyn in the ED, however given slow resolution was
admitted for further IV abx management. On exam there are no
signs of joint involevement, no creptitus. No calf pain or
swelling to suggest DVT. Cellulitis was demarcated with marker
and decreased in size with abx.
# Eye pain/conjunctivitis: On day two of admission developed eye
erythema, irritation in left eye. Was given Erythromycin and
Naphazoline-Pheniramine eyedrops with decrease in symptoms.
TRANSITIONAL ISSUES
f/u resolution of cellulitis. If not resolving consider changing
from Keflex to Bactrim to cover MRSA. If significantly worsened,
may need to be covered again with IV vanc.
Medications on Admission:
None
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*11 Capsule Refills:*0
2. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID
RX *erythromycin 5 mg/gram (0.5 %) 1 drop(s) left eye four times
a day Disp #*1 Unit Refills:*0
3. Naphazoline-Pheniramine Ophth. Solution 1 DROP LEFT EYE
QID:PRN itching, redness
RX *naphazoline-pheniramine [Visine-A] 0.025 %-0.3 % 1 drop both
eyes four times a day Disp #*1 Unit Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Streptococcal Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing us for your care. You were admitted
because you had a skin infection of the skin. Based on the
appearance and pattern of spread, we treated you initially with
IV antibiotics but switched you to the oral antibiotic Keflex.
Please continue to take this medicine through ___ to complete
a 7 day course.
We also gave you drops for eye irritation. You can take these as
directed until your eyes feel better.
Please START
Cephalexin (Keflex) 500mg every six hours to treat your skin
infection. Please take this through ___
Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE four times a day
for one week
Naphazoline-Pheniramine Ophth. Solution 1 DROP LEFT EYE four
times a day as needed for itching, redness
Followup Instructions:
___
|
19646753-DS-5
| 19,646,753 | 23,300,830 |
DS
| 5 |
2169-03-09 00:00:00
|
2169-03-11 10:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
___ Laparascopic Cholecystectomy
History of Present Illness:
___ year old female who presents with complaint of right upper
quadrant abdominal pain that has been intermittent x6 days.
According to the patient she has had a few similar episodes of
this pain in the past - approx ___ times a year - all of which
occured at night and would self resolve within a short amount of
time. However, approx 6 days ago she experienced another episode
of right upper quadrant abdominal pain that was associated with
a fatty meal, and did not resolve immediately. This led her to
present to an outside hospital where a right upper quadrant
ultrasound was performed and demonstrated evidence of
cholelithiasis. Her pain resolved while in the ED, and after
passing a PO challenge without recurrence of pain, she was
subsequently discharged home.
Approx 2 days later the pain recurred after eating a
cheeseburger, and yet again another day afterwards after eating
a sandwich. Most recently, a third episode of this pain awakened
her from sleep around 11pm this last evening, and was more
severe in intensity than prior. The patient states that between
these episodes, she was pain-free and able to tolerate bland
foods such as soup. She denies any fevers, but does endorse one
episode of sweat and chills last night. The pain is associated
with nausea, but no emesis. Bowel movements have been normal and
the patient is passing flatus.
The pain continues to persist at this time (now approx 5 hours
in duration) and ACS has been consulted regarding further
management
Of note, the patient discovered three days ago that she is
pregnant. At this time she is not interested in carring the
fetus to term
Past Medical History:
PMH:
Hydradinitis
PSH:
-Excision of axillary hydradinitis
-___: I&D of left thigh abscess secondary to hydradinitis
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam upon admission:
Vitals: Temp: 97.8 HR: 76 BP: 150/83 RR: 16 SaO2: 100%
General: No acute distress; alert and fully oriented
Cardiac: Regular rate and rhythm; normal S1 and S2; no
appreciable murmurs
Pulmonary: Lungs clear to auscultation bilaterally
Abdomen: Soft, obese, non-tender in the bilateral lower
quadrants; non-tender in the left upper quadrant; acutely tender
in the right upper quadrant and epigastrium; palpable
gallbladder; no rebound or gaurding
Extremities: Warm and well perfused
Physical Exam upon discharge:
VS: 98.1, 110/63, HR 81, RR 16, 99/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM.
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB No W/R/R
Abdomen: Soft/nondistended/mildly tender at lap site incisions
Ext: + pedal pulses. No CCE
Neruo: AAOx4, normal mentation
Pertinent Results:
___ 02:28AM BLOOD WBC-12.2* RBC-4.35 Hgb-11.8* Hct-37.3
MCV-86 MCH-27.1 MCHC-31.7 RDW-14.7 Plt ___
___ 02:28AM BLOOD Neuts-59.3 ___ Monos-5.4 Eos-2.0
Baso-1.0
___ 07:16AM BLOOD ___ PTT-29.9 ___
___ 02:28AM BLOOD Plt ___
___ 02:28AM BLOOD ALT-34 AST-36 AlkPhos-103 TotBili-0.1
___ 02:28AM BLOOD Albumin-3.8
___ 02:28AM BLOOD HCG-1648
___ Radiology EARLY OB US <14WEEKS
IMPRESSION:
Findings confirm the given history of pregnancy with a small
gestational sac, thickened endometrium and left-sided corpus
luteum cyst. Per measurement, the gestational age is
approximately 5 weeks.
___ Radiology LIVER OR GALLBLADDER US
Cholelithiasis with multiple gallstones filling the gallbladder.
The anterior wall appears to be within normal limits. Shadowing
obscures the posterior gallbladder wall, limiting its
evaluation, although no definite evidence of cholecystitis is
identified.
Brief Hospital Course:
Ms. ___ was admitted on ___ under the acute care surgery
service for management of her acute cholecystitis.
The patient learned that she was several weeks pregnant directly
prior to admission. An HCG level came back as positive. OBGYN
was consulted during the patient's hospitalization and the
patient underwent a tranvaginal ultrasound in order to visualize
the IUP for a possible D&C in the operating room.
The patient was was taken to the operating room and underwent a
laparoscopic cholecystectomy, however OBGYN was unable to be
present in the operatign room to perform the D&C procedure. Ms.
___ tolerated the procedure well and was extubated upon
completion. She was subsequently taken to the PACU for recovery.
The patient 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. Her diet was advanced
on the morning of ___ to regular, which she tolerated without
abdominal pain, nausea, 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 as well as in the ___ Clinic.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
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 to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19647041-DS-14
| 19,647,041 | 29,523,898 |
DS
| 14 |
2168-05-29 00:00:00
|
2168-05-31 14:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ diagnostic/therapeutic paracentesis
___ diagnostic/therapeutic paracentesis
___ diagnostic/therapeutic paracentesis
History of Present Illness:
Mr. ___ is a ___ with history of HTN, DM, with recently diagnosed
abdominal tumor s/p biopsy at ___ with results pending
who is presenting with worsening abdominal pain, distension, and
anorexia. As per the patient and his family, all this had
started about 3 weeks ago when he developed intermittent
abdominal pain. Reports feeling "odd." Reports feeling bloated
and having decreased appetite. He had been going to ___
where he had his ascites tapped, drained 2.5L on ___, and
he had a biopsy of his omentum on ___. As per the patient's
family, his ascites cytology was positive. He had CT
chest/abdominal/pelvis at ___ which was notable for
peritoneal carcinomatosis with liver mets, and moderate ascites;
there was suspicion for gastric cancer, as well as evidence
suggestive of colon or pancreatic cancer. Multiple hepatic
lesions, as well as a lung nodule was noted. The patient's
daughter also reports that he had EGD on ___ that was notable
for polyp in duodenum, but that was otherwise negative.
Of note, when the patient first presented to ___ of
___, he was noted to have a sodium 125, which the patient's
family said improved after getting normal saline fluids.
Over the last month, the patient's family reports that he has
lost 10 pounds. For the last two days, he reports that he has
not been eating, due to decreased appetite. Denies any
fevers/nausea. No chest pain or shortness of breath. No
changes in bowel movements, no blood in stools, no black stools.
___ any pain or burning with urination.
In the ED, initial VS were: 97.6 93 138/82 20 99%. Initial exam
notable for abdominal distension, biopsy site clean, dry, and
intact. Labs notable for sodium 117, WBC 15 with 85% PMNs, plts
521, Hgb 11.5. Lactate 1.6
Currently the patient reports feeling ok; denying any abdominal
pain, more so endorsing abdominal distension.
Past Medical History:
Diabetes mellitus
Social History:
___
Family History:
Denies any history of cancers; reports family history of DM,
strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 150/90 98 18 98RA
GENERAL: well-appearing man in NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - distended, +fluid wave, no tenderness to palpation
throughout, +BS, no hepatomegaly appreciated
EXTREMITIES - warm, well perfused, no ___ edema noted
Neuro: alert and appropriate, muscle strength and sensation
grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 98.9F 98.1 ___ 85-104 18 99% RA
I/O: ___ net -740
GENERAL: Alert, interactive, in NAD
HEART: RRR, nl S1-S2, no MRG
LUNGS: CTAB no wheezes, rales or rhonchi
ABDOMEN: Firm and tense but non-tender, moderately distended,
tympanetic around umbilicus with dullness laterally to bilateral
flanks, no masses or HSM appreciated
EXTREMITIES: WWP
NEURO: awake, A&Ox3, CNs II-XII grossly intact, no focal
deficits
Pertinent Results:
ADMISSION LABS:
___ 11:37PM ___ PTT-32.9 ___
___ 09:15PM GLUCOSE-126* UREA N-8 CREAT-0.5 SODIUM-119*
POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-21* ANION GAP-11
___ 09:15PM CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-1.9
___ 09:15PM OSMOLAL-251*
___ 07:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 03:15PM ___ COMMENTS-GREEN TOP
___ 03:15PM LACTATE-1.6
___ 01:42PM GLUCOSE-214* UREA N-10 CREAT-0.5 SODIUM-117*
POTASSIUM-4.9 CHLORIDE-87* TOTAL CO2-22 ANION GAP-13
___ 01:42PM estGFR-Using this
___ 01:42PM ALT(SGPT)-36 AST(SGOT)-32 ALK PHOS-170* TOT
BILI-0.5
___ 01:42PM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.8
MAGNESIUM-2.0
___ 01:42PM WBC-15.2* RBC-4.28* HGB-11.7* HCT-35.3*
MCV-83 MCH-27.3 MCHC-33.0 RDW-12.5
___ 01:42PM NEUTS-86.1* LYMPHS-5.3* MONOS-5.8 EOS-2.4
BASOS-0.2
___ 01:42PM PLT COUNT-521*
DISCHARGE LABS:
___ 06:04AM BLOOD WBC-14.9* RBC-3.91* Hgb-10.3* Hct-32.3*
MCV-83 MCH-26.5* MCHC-32.1 RDW-13.4 Plt ___
___ 09:49AM BLOOD Glucose-268* UreaN-16 Creat-0.6 Na-132*
K-4.9 Cl-96 HCO3-27 AnGap-14
___ 06:04AM BLOOD Glucose-177* UreaN-15 Creat-0.5 Na-134
K-4.8 Cl-99 HCO3-27 AnGap-13
___ 09:49AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1
OTHER LABS:
HEMATOLOGY:
___ 06:30AM BLOOD WBC-14.9* RBC-4.12* Hgb-11.1* Hct-34.2*
MCV-83 MCH-26.8* MCHC-32.4 RDW-12.7 Plt ___
___ 05:55AM BLOOD WBC-14.5* RBC-4.14* Hgb-10.9* Hct-34.4*
MCV-83 MCH-26.3* MCHC-31.7 RDW-12.9 Plt ___
___ 06:50AM BLOOD WBC-16.2* RBC-4.07* Hgb-10.9* Hct-33.3*
MCV-82 MCH-26.8* MCHC-32.8 RDW-12.8 Plt ___
___ 06:40AM BLOOD WBC-16.0* RBC-4.33* Hgb-11.7* Hct-35.6*
MCV-82 MCH-27.0 MCHC-32.8 RDW-13.1 Plt ___
___ 06:45AM BLOOD WBC-15.8* RBC-4.25* Hgb-11.1* Hct-34.6*
MCV-82 MCH-26.1* MCHC-32.0 RDW-13.3 Plt ___
___ 07:00AM BLOOD WBC-16.6* RBC-4.23* Hgb-11.0* Hct-34.4*
MCV-81* MCH-26.1* MCHC-32.0 RDW-13.2 Plt ___
ELECTROLYTES:
___ 02:22AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-125*
K-4.6 Cl-93* HCO3-23 AnGap-14
___ 06:30AM BLOOD Glucose-163* UreaN-8 Creat-0.5 Na-125*
K-4.9 Cl-92* HCO3-23 AnGap-15
___ 05:55AM BLOOD Glucose-152* UreaN-8 Creat-0.5 Na-120*
K-4.9 Cl-89* HCO3-24 AnGap-12
___ 06:50AM BLOOD Glucose-165* UreaN-8 Creat-0.5 Na-121*
K-4.8 Cl-90* HCO3-24 AnGap-12
___ 06:40AM BLOOD Glucose-136* UreaN-9 Creat-0.5 Na-126*
K-4.8 Cl-91* HCO3-24 AnGap-16
___ 06:45AM BLOOD Glucose-150* UreaN-10 Creat-0.6 Na-120*
K-4.9 Cl-90* HCO3-24 AnGap-11
___ 09:15PM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-125*
K-4.9 Cl-91* HCO3-23 AnGap-16
___ 03:00PM BLOOD Na-126* K-5.5* Cl-92*
IMAGING:
INDICATION: ___ year old man with newly diagnosed metastatic
poorly
differentiated carcinoma, starting chemotherapy.
PROCEDURE: Placement of a single-lumen low profile chest port.
OPERATORS: Dr. ___ (resident), Dr. ___
(resident) and
Dr. ___ (attending). Dr. ___ was present and
supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administering
divided doses of 75 mg of fentanyl and 1.5 mg of Versed. The
total intraservice time was 35 minutes during which the patient
was hemodynamically monitored.
PROCEDURE DETAILS AND FINDINGS:
After explanation of the procedure, risks and benefits, written
informed
consent was obtained from the patient. The patient was brought
to the
angiography suite and placed supine on the imaging table. The
right neck and upper chest were prepped and draped in the usual
standard fashion. A
preprocedure timeout was performed per ___ protocol. Under
ultrasound-guidance, access was obtained at the right internal
jugular vein with a 21-gauge micropuncture needle. 0.018
nitinol wire was advanced into the ___. Hard copies of
ultrasound images were obtained before and after venous access
to demonstrate venous patency. A skin ___ was made at the
venotomy. The needle was exchanged for a micropuncture sheath
and the nitinol wire for a 0.035 ___ wire. The ___ wire was
advanced into the IVC to confirm venous access, and then pulled
back into the right atrium. Measurements were made from the
venotomy to the right atrium. Subsequently, a right upper chest
port pocket was created after local anesthesia with 1% lidocaine
and lidocaine with epinephrine. A skin incision with a #15
blade and blunt dissection to the pectoralis fascia was
undertaken. Then, 0 Prolene sutures were placed in the pocket.
A subcutaneous tunnel was created with a metal tunneling device
and the port tubing was advanced from the pocket to the
venotomy. The port was then sutured in the pocket. The port
was accessed without evidence of leak. Then, a peel-away sheath
was advanced over the ___ wire into the right atrium. The
wire and the inner dilator were removed and the port catheter
was advanced into the right atrium. The peel-away sheath was
peeled off. The port was accessed and blood could easily be
aspirated and flushed. The port pocket and the venotomy were
closed with ___ and ___ vicryl sutures. The port was locked
with heparin and left accessed. Steri-Strips and a sterile
dressing were applied at the venotomy site and over the port
pocket incision. A final chest radiograph was obtained
documenting the
catheter tip in the right atrium. The patient tolerated the
procedure well. There were no immediate post-procedure
complications.
IMPRESSION: Successful single lumen port placement via the
right internal jugular vein. The port was left accessed and is
ready to use.
MICROBIOLOGY:
___ 2:25 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:25 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 5:25 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 4:20 pm PERITONEAL FLUID
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.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): no growth
___ 4:20 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles (Preliminary): NO GROWTH.
Time Taken Not Noted Log-In Date/Time: ___ 7:47 am
BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) PERITONEAL
FLUID.
BLOOD/FUNGAL CULTURE (Pending): preliminary no growth
BLOOD/AFB CULTURE (Pending): preliminary no growth
Brief Hospital Course:
Mr. ___ is a ___ with history of DM, recently diagnosed
peritoneal carcinomatosis with liver mets and lung nodule found
on recent CT scan, who is presenting with increasing abdominal
distension, and decreased appetite, found to be hyponatremic.
# Hyponatremia: The patient with sodium on presentation of 117,
likely chronic given sodium was 125 at the end of ___.
Unclear etiology, but likely multifactorial in the setting of
decreased PO intake and potential pulmonary process. Initially
thought to be primarily hypovolemic hyponatremia related to
decreased PO intake with increasing ascites. Despite increased
PO intake and saline boluses, however, sodium continued to be
unstable. Salt tabs were started and renal was consulted. IT was
felt that this is most likely SIADH and he was started on
torsemide to try and increase free water excretion in the
setting of low solute intake. He became orthostatic with the
diuretic however, so this was discontinued prior to discharge.
He was sent home on TID salt tabs and will have his labs checked
with his PCP. Mental status was stable throughout
hospitalization.
# Peritoneal carcinomatosis c/b likely malignant ascites: The
patient with e/o peritoneal carcinomatosis in the setting of
malignancy. Had omental biopsy by ___ at ___, results
read as poorly differentiated metastatic carcinoma. Per
pathology, it was felt that the malignancy likely represented
either a gastric or hepatobiliary primary. Slides were sent from
___ to ___ for further review. He had a port placed
for initiation of chemotherapy and will follow up with Dr.
___ in clinic as an outpatient.
# Leukocytosis: Noted to have white count 15.6, with neutrophil
predominance. Could be in the setting of his underlying
malignancy. Currently denies any abdominal discomfort that
would make SBP concerning, and no pain on abdominal exam. UA
bland, no CXR done, though without any respiratory complaints.
Blood cultures were negative and he did not develop any signs of
infection.
# Lung nodule/liver mets: Likely that all are related to
underlying biopsy, unclear what is primary, see above.
# Diabetes mellitus: Held home oral hypoglycemics and placed
patient on insulin sliding scale.
# HTN: Continued on home atenolol with holding parameters
TRANSITIONAL ISSUES:
-final culture results from peritoneal fluid pending at time of
discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
please hold for HR<60, SBP< 100
3. Atorvastatin 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
please hold for HR<60, SBP< 100
3. Atorvastatin 5 mg PO DAILY
4. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times per
day Disp #*90 Tablet Refills:*0
5. Acetaminophen w/Codeine ___ TAB PO HS:PRN insomnia
RX *acetaminophen-codeine 300 mg-15 mg ___ tablet(s) by mouth at
bedtime Disp #*14 Tablet Refills:*0
6. GlipiZIDE *NF* 80 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Poorly differentiated abdominal carcinoma (unknown source)
complicated by malignant ascites
Hyponatremia
SECONDARY DIAGNOSIS:
Diet-controlled diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___! You were admitted with
increased abdominal fluid and swelling ("ascites"), which is due
to the tumor in your abdomen. We did several drainages of your
abdomen to improved the swelling. You will be seen by the
Oncology doctors on ___ to determine plans for
further treatment. You will also have another drainage of your
abdomen on ___.
Also, the sodium (salt) level in your blood was low. This was
probably from taking in less food from your decreased appetite,
and from some decreased regulation of sodium. You improved and
stabilized with salt tabs, and a fluid restriction. You should
continue these measures at home.
Wishing you all the best!
Followup Instructions:
___
|
19647220-DS-6
| 19,647,220 | 29,192,976 |
DS
| 6 |
2167-11-18 00:00:00
|
2167-11-18 14:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tegretol / Naprosyn / erythromycin base
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI in H&P by Dr. ___ ___:
"Ms. ___ is a ___ year old woman with a history of
anxiety, microscopic colitis, kidney stones, recurrent
pancreatitis (diagnosed in ___, s/p recent ERCP and
cholecystectomy) who was brought here from ___
with
recurrent epigastric abdominal pain similar to her prior bouts
of
pancreatitis. The pain has been ongoing for about a week
although
she has had ___ hospitalizations at ___ since she was
diagnosed in ___, this one prompting a transfer to ___.
Her pain is aching, nonradiating and crampy, across her
epigastrium, and worse with any sort of food intake, even
___
muffins and soup. She has not had any alcohol this week and her
alcohol level at the outside hospital was negative. However, she
believes her second bout of four was related to alcohol use and
she typically drinks a couple of nips every other day (more
during the holidays).
She denies any chest pain or dyspnea and her last BM was this
morning. They have been unformed for years and she attributes
this to her colitis. She c/o some urinary urgency but no burning
over the past week.
At the outside hospital, her potassium was 2 and her lipase was
over 1200. KUB there was unremarkable. While there she received
morphine, Zofran, Protonix, GI cocktail. She had some relief of
her pain prior to transfer.
In the ED:
Initial vital signs were notable for: T 97.1, HR 78, BP 108/68,
RR 16, 100% RA
Exam: diffuse abdominal pain, most pronounced in the epigastrium
and right upper quadrant. She has a positive ___ sign.
Labs:
- CBC: WBC 5.5, hgb 11.0, plt 191
- Lytes:
142 / 111 / 23 AGap=12
------------- 84
3.0 \ 19 \ 0.7
- LFTS: AST: 20 ALT: 13 AP: 66 Tbili: 0.3 Alb: 3.1
- lipase 227
- Lactate:0.8
- Triglyc: 110
- ucg negative
Studies performed include: CT a/p w contrast, showing mild
intrahepatic biliary dilatation and prominence of the common
bile
duct related to prior cholecystectomy. No evidence of fluid
collection. Otherwise, no acute intra-abdominal abnormality.
Patient was given:
___ 00:59 IV Morphine Sulfate 2 mg
___ 01:36 PO Potassium Chloride 40 mEq
___ 01:36 IVF 40 mEq Potassium Chloride / NS
___ 01:55 IV Morphine Sulfate 2 mg
___ 01:55 PO Lorazepam 1 mg
___ 04:47 IV Morphine Sulfate 2 mg
___ 06:16 IVF 40 mEq Potassium Chloride / NS
Vitals on transfer: HR 70, BP 117/61, RR 16, 100% RA
Upon arrival to the floor, she appeared mildly uncomfortable
with
scaphoid abdomen and dry MM. TTP in epigastrium with +BS
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. "
Past Medical History:
- chronic pancreatitis
- alcohol use disorder
- generalized anxiety disorder
- s/p cholecystectomy
- s/p laminectomy C5-6
- gout
- incidental finding of cerebral aneurysm on MRI - no
interventions or symptoms
- GERD
- s/p carpal tunnel surgery
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION EXAM:
___ 0930 Temp: 97.6 PO BP: 112/64 HR: 68 RR: 18 O2 sat:
100%
O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Dry MM
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, but TTP in epigastrium. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: Afebrile, HDS
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. Dry MM
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, NTND. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 07:45AM BLOOD WBC-4.1 RBC-3.43* Hgb-11.7 Hct-35.0
MCV-102* MCH-34.1* MCHC-33.4 RDW-13.2 RDWSD-49.7* Plt ___
___ 12:31AM BLOOD Neuts-54.3 ___ Monos-11.4 Eos-3.2
Baso-0.5 Im ___ AbsNeut-3.00 AbsLymp-1.67 AbsMono-0.63
AbsEos-0.18 AbsBaso-0.03
___ 04:43AM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-141
K-3.9 Cl-103 HCO3-25 AnGap-13
___ 01:20PM BLOOD ALT-11 AST-15 AlkPhos-55 TotBili-0.2
___ 04:43AM BLOOD Mg-2.0
___ 05:05PM BLOOD Triglyc-98
___ 06:40AM BLOOD TSH-0.82
___ 06:40AM BLOOD Free T4-1.1
___ 06:40AM BLOOD CRP-1.4
___ 06:40AM BLOOD tTG-IgA-2
MICRO:
Fecal culture (___): pending
C.diff (___): pending
UCx (___): Alpha hemolytic colonies consistent with alpha
streptococcus or Lactobacillus sp.
IMAGING:
KUB at ___ ___
s/p cholecystectomy with moderate fecal material. No free air.
No
air-filled dilated loops of bowel, extensive left
nephrolithiasis
is again identified.
CT A/P ___
1. No acute intra-abdominal process noted.
2. Mildly hypoattenuating pancreas, which may reflect prior
pancreatitis. No
evidence of active inflammation, on today's exam.
3. The majority of the colon is fluid-filled, which can be seen
in the setting of diarrhea.
4. Mild intrahepatic biliary dilatation and prominence of the
common bile duct, likely following cholecystectomy.
5. Numerous, nonobstructing left renal stones, the largest stone
or conglomerate of stones measuring up to 8 mm. No
hydronephrosis on either
side. No calculi seen in the right kidney.
ERCP ___
No filling defects
Biliary tree swept with balloon and small amounts of sludge were
removed.
Brief Hospital Course:
SUMMARY:
___ is a ___ yo F with anxiety, microscopic colitis,
kidney stones, recurrent pancreatitis (diagnosed in ___,
s/p recent ERCP and cholecystectomy) who was brought to ___
from ___ with recurrent epigastric abdominal pain
___ acute pancreatitis.
ACUTE/ACTIVE PROBLEMS:
# Pancreatitis
Pt has history of pancreatitis diagnosed in ___ that
is most likely ___ heavy EtOH use, and is s/p laparoscopic
cholecystectomy in ___. ERCP by ___ was performed later
that month due to recurrent abdominal pain and showed small
amounts of sludge butno filling defects. Triglycerides and
calcium are wnl. She has a significant history of alcohol abuse.
On admission, she said has not had a drink in a week
(contradicted by her brother), but prior to this endorses few
nips every other day. Prior to admission she was unable to
tolerate any PO intake and had minimal PO intake over the prior
week. With bowel rest, slow advancement of her diet, IV fluids,
and pain medication her abdominal pain improved.
# Alcohol use disorder
The patient said that she did not have any alcohol for 10 days
prior to admission. However, her brother confided privately that
the patient was known to be drinking by her fatherand aunt
within the past week. Unfortunately she refused assistance from
social work. The patient was counseled on her alcohol use and
the importance of complete abstinence from alcohol was
emphasized.
# Diarrhea
# Microscopic colitis
She was diagnosed with microscopic colitis by colonoscopy with
biopsies about ___ years ago. Her chronic diarrhea is typically
controlled with loperamide. However, over a few days prior to
admission her diarrhea has worse than normal. Stool studies were
sent to work up for infectious etiologies as well as other
secondary causes (pancreatic insufficiency, celiac,
hyperthyroidism). This workup was grossly unrevealing. After
discussing her case w/ GI, she was started on Imodium and
Lomotil PRN as well as Budesonide 9mg daily.
# Hypophosphatemia
# Hypomagnesemia
# Hypokalemia
Repleted aggressively as needed.
# Urinary urgency
She denied frequency, hematuria, and burning pain with
urination. She has a history of kidney stones and
nephrocalcinosis seen on imaging. Urine culture was consistent
with contaminant.
# Long QtC - resolved
QtC 558 on EKG on admission. QTc was 447 on EKG checked on ___.
Her electrolytes were aggressively repleted.
CHRONIC/STABLE PROBLEMS:
# Tobacco use
Patient was provided with a nicotine patch.
# Anxiety: Continued home regimen: Clonidine 0.1 mg BID ,
Alprazolam 0.5 mg qAM and 1 mg
Qpm, fluoxetine 60 mg daily
# Migraines: Continued home topiramate 50 mg qAM and 100 mg qPM
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 50 mg PO QAM migraines
2. Topiramate (Topamax) 100 mg PO QPM migraines
3. FLUoxetine 60 mg PO DAILY
4. LORazepam 0.5 mg PO QAM anxiety
5. LORazepam 1 mg PO QHS anxiety
6. CloNIDine 0.1 mg PO BID anxiety
Discharge Medications:
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
every six (6) hours Disp #*28 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tab by mouth
every six (6) hours Disp #*28 Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour 1 patch daily Disp #*30
Patch Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. CloNIDine 0.1 mg PO BID anxiety
10. FLUoxetine 60 mg PO DAILY
11. LORazepam 0.5 mg PO QAM anxiety
12. LORazepam 1 mg PO QHS anxiety
13. Topiramate (Topamax) 50 mg PO QAM migraines
14. Topiramate (Topamax) 100 mg PO QPM migraines
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Alcohol use disorder
Microscopic colitis
Hypophosphatemia
Hypomagnesemia
Hypokalemia
Generalized anxiety disorder
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 pancreatitis. This was
most likely caused by alcohol use. In order to prevent future
episodes of pancreatitis, it will be extremely important to
completely abstain from any alcohol intake. You were treated
with supportive care and your symptoms improved.
You also had ongoing diarrhea in the hospital Your stool was
sent for infectious workup which was negative.
Best wishes for your continued healing.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
19647505-DS-12
| 19,647,505 | 28,768,899 |
DS
| 12 |
2169-08-15 00:00:00
|
2169-08-15 14:10:00
|
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 leg pain
Major Surgical or Invasive Procedure:
___: Right tibial plateau open reduction internal fixation
___: Right posterolateral corner repair, Right peroneal
nerve neuroplasty
History of Present Illness:
___ transferred from an OSH for a right knee
fracture/dislocation. Patient sustained a mechanical fall while
running on the beach injuring her right knee. She was taken to
___ where an xray demonstrates a tibial plateau fx.
Past Medical History:
R knee meniscus surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
Vitals: 98 99 ___ 100% ra
Gen: A&O
CV: RRR
Pulm: CTAB
Abd: S/NT
Pelvis: stable
Right lower extremity:
- Skin intact
- Mild edema around knee. Lower leg slightly angled inward
- Soft, non-tender thigh and leg
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
On discharge:
AVSS
Gen: NAD, A&Ox3
CV: RRR
Pulm: CTAB
Abd: Soft, NT/ND
Right lower extremity: Dressing clean/dry/intact. Patient in
___ brace locked at 30 degrees and multipodus ankle boot.
Fires ___. Does not fire TA. SILT S/S/SP/DP/T nerve
distributions. Foot warm and well-perfused.
Pertinent Results:
___ 08:40PM WBC-11.6* RBC-4.20 HGB-12.5 HCT-38.0 MCV-91
MCH-29.8 MCHC-32.9 RDW-13.2 RDWSD-43.3
___ 08:40PM PLT COUNT-281
___ 08:40PM ___ PTT-26.3 ___
___ 08:40PM GLUCOSE-113* UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14
___ 06:43AM BLOOD WBC-11.6* RBC-3.06* Hgb-9.1* Hct-28.2*
MCV-92 MCH-29.7 MCHC-32.3 RDW-13.3 RDWSD-44.9 Plt ___
___ 05:35AM BLOOD Glucose-137* UreaN-9 Creat-0.8 Na-134
K-4.0 Cl-98 HCO3-28 AnGap-12
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and right fibular head
fracture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for open
reduction internal fixation of her right 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. The patient was given ___
antibiotics and anticoagulation per routine. Once her
posttraumatic swelling had improved and the full extent of her
soft tissue injuries were appreciated, the patient was taken to
the operating room on ___ for a posterolateral corner
repair and neuroplasty of her right peroneal nerve, 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. The patient was given ___ antibiotics
and anticoagulation per routine. The patient does not take any
home medications. The patient worked with ___ who determined that
discharge to rehab was appropriate. The patient had a stable
foot drop (affected tibialis anterior muscle) post-injury that
persisted through her hospitalization. Her sensory exam was
intact to light touch on admission and at discharge. For her
foot drop, we maintained the patient in a multipodus boot and
modified a prefabricated ankle foot orthosis to accommodate her
swelling. Once her right lower extremity improves at rehab, she
will need a custom AFO made for her. 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
nonweight bearing in the right lower extremity, and will be
discharged on Lovenox 40mg q12h for DVT prophylaxis. The BID
dosing of Lovenox is based on the patient's BMI. The patient
will follow up with Drs. ___ per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
None.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC Q12H Duration: 30 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous every twelve (12)
hours Disp #*60 Syringe Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right comminuted tibial plateau fracture
Right fibular head fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane or crutches).
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:
- Nonweight bearing on your right leg
- Please keep your right leg in the ___ brace, locked at 30
degrees of flexion
- Please keep the ankle foot orthosis (AFO) on at all times.
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.
- Dry sterile gauze dressing changes if saturated or wound is
draining.
- No dressing is needed if wound continues to be non-draining.
- ___ brace and ankle foot orthosis (AFO) must be left on
until follow up appointment unless otherwise instructed
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 surgeon's team (Dr. ___, Dr.
___, with ___, NP in the Orthopaedic Trauma
Clinic ___ 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:
Right lower extremity:
- Nonweight bearing RLE
- Please keep your RLE in the ___ brace, locked at 30
degrees of flexion
- Please keep the RLE ankle foot orthosis (AFO) on at all times.
Treatments Frequency:
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.
- Dry sterile gauze dressing changes if saturated or wound is
draining.
- No dressing is needed if wound continues to be non-draining.
- ___ brace and ankle foot orthosis (AFO) must be left on
until follow up appointment unless otherwise instructed
Followup Instructions:
___
|
19647697-DS-5
| 19,647,697 | 21,499,210 |
DS
| 5 |
2160-08-19 00:00:00
|
2160-08-19 16:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
scallops / innovar
Attending: ___.
Chief Complaint:
severe abdominal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ w/ factor V leiden and hx of DVT on
xarelto, giant cell arteritis and PMR on steroids, Afib s/p
ablation ___, and CKD who underwent robotic lap distal
panc/spleen ___ for IPMN w/ concerning features (path
ultimately -ve for cancer), who is presenting from clinic for
abd
pain after drain removal today - for details please refer to
clinic note. A CT A/P was obtained earlier which show a fluid
collection in surgical bed, but drain output had decreased to
<20
cc/day, and thus was removed. Shortly after removal, he
developed
sudden onset severe abd pain, initially upper and later lower
abdominal. He was monitored in clinic for some time, and after
no
relief w/ PO pain meds was txfr'ed to the ED for further
evaluation. Labs show WBC 18.9 and Cr 1.4 (baseline ~1.3).
Past Medical History:
Factor V Leiden (hx DVT, on Xarelto), HTN, giant cell
arteritis, polymyalgia rheumatic, AFib (s/p ablation ___,
thyroid nodules, CKD
Social History:
___
Family History:
no pancreatic cancer in the family but reports a history
of breast and rectal cancers in his sisters
Physical ___ - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
Abd - soft, nondistended, mild diffuse abd ttp worst in
infraumbilical/suprapubic area, no guarding, no rebound, scant
cloudy thick drainage from old drain insertion site, healing lap
port site incisional scars
MSK & extremities/skin - no leg swelling observed b/l, WWP
Pertinent Results:
___ 05:10PM BLOOD WBC-18.9* RBC-3.65* Hgb-12.0* Hct-38.0*
MCV-104* MCH-32.9* MCHC-31.6* RDW-13.2 RDWSD-51.0* Plt ___
___ 05:24AM BLOOD WBC-14.6* RBC-3.29* Hgb-10.8* Hct-34.2*
MCV-104* MCH-32.8* MCHC-31.6* RDW-13.5 RDWSD-51.8* Plt ___
___ 05:10PM BLOOD Glucose-110* UreaN-26* Creat-1.4* Na-139
K-4.9 Cl-102 HCO3-25 AnGap-12
___ 05:24AM BLOOD Glucose-100 UreaN-22* Creat-1.4* Na-141
K-4.6 Cl-103 HCO3-27 AnGap-11
Brief Hospital Course:
Patient was admitted after drain was pulled in clinic and had
severe abdominal pain. He underwent a infectious work up
including blood cultures, chest xray, ct, and ultrasound.
Patient was started on IV antibiotics. Patient did well
overnight and was switched to PO antibiotics. His pain
decreased, was able to tolerate a diet, and ambulated. He was
deemed fit for discharge and discharge on PO augmentin for 7
days
Medications on Admission:
Acetaminophen 1000 mg PO TID
Metoprolol Succinate XL 12.5 mg PO DAILY
Pantoprazole 40 mg PO Q24H
PredniSONE 7 mg PO DAILY
Rivaroxaban 20 mg PO/NG DAILY
Terazosin 4 mg PO QHS
TraMADol 50 mg PO Q6H:PRN pain
TraZODone 50 mg PO QHS
Valsartan 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 7 mg PO DAILY
6. Rivaroxaban 20 mg PO/NG DAILY
7. Terazosin 4 mg PO QHS
8. TraMADol 50 mg PO Q6H:PRN pain
9. TraZODone 50 mg PO QHS
10. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Intraductal Papillary Mucinous Neoplasm
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 here at ___
___. You were admitted to our hospital for
severe abdominal pain after drain removal. You have recovered
and are now ready to be discharged to home. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
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.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told
you otherwise.
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 the endoscopy.
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.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
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:
___
|
19647720-DS-9
| 19,647,720 | 28,146,702 |
DS
| 9 |
2179-02-23 00:00:00
|
2179-02-24 18:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zestril
Attending: ___.
Chief Complaint:
trauma: MCC:
right rib fractures ___
Right clavicle comminuted fracture
Right scapular fracture
Hematoma upper lat. R greater trochanter
Left SDH
zygomatic fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male in the emergency department for evaluation
of a polytrauma in the setting of a motorcycle accident.
Patient laid down his motorcycle. Positive x-ray. Unclear
LOC. Seen at an outside hospital complaining of right
shoulder pain. Patient underwent imaging that showed a
subdural hemorrhage, clavicle and scapular fracture as well
as multiple rib fractures. She also had multiple facial
fractures. The patient also had a large thigh hematoma.
Patient is anticoagulated. Mentating appropriately. Not
intubated.
Past Medical History:
1) Severe reflux
2) Moderate hiatal hernia
3) Asthma (last PFTs showed mild obstructive disease)
4) Type 2 diabetes mellitus (diet controlled per PCP's note on
___, although patient denies)
5) Rosacea
6) Hypertension
7) Hyperlipidemia
8) Acne
9) Left knee surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
HR: 114 Resp: 16 O(2)Sat: 99 Normal
HEENT: Right facial tenderness to palpation
No C-spine tenderness
Chest: no crepitus, clear lungs
Cardiovascular: Irregular irregular
Abdominal: Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: Tenderness to palpation over the right
Skin: Multiple abrasions
Neuro: gcs 15
Physical examination upon discharge: ___:
vital signs: 98.8, hr=85, bp=148/84, rr=18, 96% room air
GENERAL: NAD
CV: irregular
LUNGS: course BS bases bil., chest wall tenderness right side,
no crepitus
ABDOMEN: rounded, soft, non-tender
EXT: abrasion left knee, no calf tenderness, no pedal edema
bil, abrasions on hands
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 06:00AM BLOOD WBC-8.9 RBC-3.91* Hgb-12.1* Hct-36.1*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.1 RDWSD-43.6 Plt ___
___ 02:07AM BLOOD WBC-12.0* RBC-4.32* Hgb-13.6* Hct-40.8
MCV-94 MCH-31.5 MCHC-33.3 RDW-13.1 RDWSD-45.1 Plt ___
___ 08:55PM BLOOD WBC-15.6* RBC-4.94 Hgb-16.0 Hct-45.4
MCV-92 MCH-32.4* MCHC-35.2 RDW-13.1 RDWSD-43.2 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-147* UreaN-16 Creat-0.6 Na-134
K-3.6 Cl-101 HCO3-26 AnGap-11
___ 05:36AM BLOOD CK(CPK)-502*
___ 05:36AM BLOOD CK-MB-7 cTropnT-<0.01
___ 02:04AM BLOOD CK-MB-8 cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
___ 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:59PM BLOOD pO2-47* pCO2-44 pH-7.38 calTCO2-27 Base
XS-0 Intubat-NOT INTUBA
___ 08:59PM BLOOD Glucose-180* Lactate-1.9 Na-143 K-4.6
Cl-103
___ 08:59PM BLOOD Hgb-17.1 calcHCT-51 O2 Sat-80 COHgb-1
MetHgb-0
___ 08:59PM BLOOD freeCa-1.21
___: ECHO:
IMPRESSION: Dilated left ventricle with moderate global
hypokinesis. Borderline right ventricular systolic function.
Small circumferential pericardial effusion without
echocardiographic tamponade.
___: chest x-ray:
1. Right midclavicular fracture.
2. Right posterior rib fractures and right-sided pneumothorax
are better
appreciated on the outside hospital CT of the torso.
___: chest x-ray:
Small degree of the extrapleural hematoma adjacent fractures of
right upper and middle ribs. No pneumothorax or evidence of
lung trauma. Moderate cardiomegaly is new. Mild widening of
the mediastinum is not beyond that expected in any supine or
semi-erect patient. Left lung is clear. No left pleural
abnormality.
___: ct head:
. Left subdural hematoma layering along the left tentorium,
measuring 5 mm in maximum dimension with an additional focus of
extra-axial blood seen in the left operculum. There is no
evidence of significant mass effect or shifting of the normally
midline structures. No images seen on PACS for comparison.
Brief Hospital Course:
___ year old male who was the driver of a motorcycle involved in
a crash. He lost control of the motorcycle after the car in
front of him stopped. He fell onto his right side on the
pavement. Upon admission to the hospital, the patient reported
right clavicular pain. He was reported to have an abrasion on
his hand and forearms.
His injuries included a right pneumothorax, pericardial effusion
with no signs of tamponade, right ___ through 7 rib fractures,
comminuted right mid to distal clavicle, nondisplaced fracture
of the right scapula, large hematoma of the upper lateral thigh
right and hepatic cysts. No chest tube was indicated for the
small right pneumothorax and his respiratory status remained
stable. Cat scan imaging of the head was notable for a left
2mm transverse acute left subdural hematoma of indetermintate
age and a nonsdisplaced fracture of the right zygomatic arch and
the right lateral maxially sinus wall. He was initially admitted
to ___ where he was pan-scanned and transferred to
___ for further care.
Because of his injuries, he was admitted to the intensive care
unit for monitoring. A TTE was done at the bedside which showed
a small effusion with no evidence of chamber collapse. His
repeat head cat scan showed a new hemorrhage in the midbrain and
right temporal area. His neurological examination remained
normal and he continued with neurological assessments which
remained intact. Of note, he was on eliquis at the time of
admission for new onset of atrial fibrillation. This was held
upon admission per recommendations of the Neurosurgery service
because of his SDH. For seizure prophalaxsis, he was started
on a week course of Keppra.
The Orthopaedic Surgery service was consulted for management of
the right clavicle and right scapula fracture. Non-operative
management was recommended with placement of a sling for
comfort. Follow-up in the ___ clinic was recommended.
The patient was transferred to the surgical floor on HD # 3. His
vital signs remained stable and he was afebrile. He was
tolerating a regular diet. His rib and shoulder pain were
controlled with oral analgesia. He was voiding without
difficulty. There was no change in his neurological status.
Prior to discharge, the patient was evaluated by Physical and
Occupational therapy. After evaluation of the patient's
mobility, he was cleared for discharge home. There was no
indication for cognitive follow-up. He was instructed to resume
his baby aspirin in 5 days, and to discontinue it after he
starts his eliquis.
The patient was discharged home in stable condition on HD # 5
with ___ services to provide instruction in the nebulizer
treatments. Appointments for follow-up were made with the
Orthopedic, Neurology, Plastic, and Acute care service, with Dr.
___. The patient was awaiting a call from his
Cardiologist. Discharge instructions were reviewed and the
patient was instructed to call with health concerns. Family
members were present during the discharge process.
Medications on Admission:
ProAir HFA 90 mcg/actuation
- allopurinol ___ mg tablet
- Eliquis 5 mg tablet
- doxycycline hyclate 20 mg tablet
- fluticasone 50 mcg/actuation nasal
- Advair Diskus 250 mcg-50mcg/dose powder for inhalation
- omeprazole 20 mg capsule,delayed release
- pravastatin 40 mg tablet
- tamsulosin ER 0.4 mg capsule,extended release 24 hr
- Diovan 320 mg tablet
- verapamil ER 240 mg 24 hr capsule,extended release
- aspirin 81 mg tablet,delayed release.
- ___ 324mg effervescent tablet
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
5. LeVETiracetam 500 mg PO BID
last dose ___
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Verapamil SR 240 mg PO Q24H
9. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN nasal
congestion
10. Doxycycline Hyclate 20 mg PO Q12H
11. Pravastatin 40 mg PO QPM
12. Valsartan 320 mg PO DAILY
13. Apixaban 5 mg PO BID
DO NOT RESUME UNTIL YOU FOLLOW-UP WITH THE NEUROLOGIST,PLEASE
ADDRESS WITH YOUR CARDIOLOGIST
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 nebulizer every
six (6) hours Disp #*12 Vial Refills:*0
15. nebulizer
albuterol nebulizer treatment every 6 hours as needed for chest
congestion
16. Aspirin 81 mg PO DAILY
please start ___, discontinue when resuming eliquis
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
trauma: MCC crash
Right rib fx ___
Right clavicle comminuted fracture
Right scapular fracture
Hematoma upper lat. right greater trochanter
Left SDH
right zygomatic arch fx, right lateral maxillary sinus wall fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor-cycle accident. You sustained rib, clavicle, scapular
fracture, a small bleed in your head, and a facial fracture.
Your vital signs have been stable. You were evaluated by
physical therapy and cleared for discharge home with the
following instructions:
Because you sustained rib fractures, these instructions are
indicated:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Nebulizer treatments as directed will help to loosen
secretions
You also had a small bleed in your head: please report the
following:
*Severe headache
*Nausea/vomitting associated with headache
*visual changes
*difficulty speaking
*weakness one side of your body
*facial drooping
The Plastic surgery service has the following recommendations to
follow because of your facial fracture:
Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved.
Followup Instructions:
___
|
19647914-DS-6
| 19,647,914 | 26,657,392 |
DS
| 6 |
2142-10-09 00:00:00
|
2142-10-10 20:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
IVC filter placement ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
Mr. ___ is a ___ year old male with hx of Anterior Lumbar
Fusion with Dr. ___ ___ who developed a retroperitoneal
seroma post operatively and who had ___ placed drain on ___ for
reaccumulation and presented to OSH with syncope, found to have
PE.
Of note, after the surgery, the patient was not very mobile. He
noticed some gradual leg swelling. After his ___ procedure today
he had a 2 hour car ride home.
When he was getting out of his car today with felt sudden onset
shortness of breath and chest pain. He had a syncopal event.
He
went to an outside hospital and was found to be hypoxemic.
A CT angiogram was performed and this showed large bilateral
central and lobar pulmonary emboli. There was no evidence of
right heart strain. There were nodule in full involving both
lower lobes thought to be multifocal pneumonia. Patient remained
hypoxic on room air and needed a nonrebreather.
A head CT was also performed given this patient's syncopal
episode. This showed no acute intracranial findings.
He received 1 mg/kg of Lovenox (86 mg close (at the outside
hospital as well as Zosyn. He also got 325 mg of aspirin and
was
transferd to ___.
In ED, ___ was consulted was consulted for management of
Submissive PE. ___ Team activated planning and decided for AC
with lovenox. He was admitted to the MICU for Hypoxia requiring
NRB
Of note, the patient is otherwise has no significant past
medical
history.
Past Medical History:
Seasonal Allergies, Hernia
Social History:
___
Family History:
Father - CVA
No known family history of VTE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
T 36.8 HR ___ BPs 110s-120s/70s-80s 98% on RB
General: uncomfortable w/ change in position, accompanied by
wife
___: OP clear MMM no ulcers, lesions noted, NRB in place
Neck: JVP approximately 6 cm at 45 degrees
Lungs: decreased breath sounds bases, dsypneic w/ full
sentences,
no crackles/wheezing noted, on NRB, noted dyspnea + desat to ___
w/ attempted to wean
CV: RRR S1S2 no m/r/g, RV heave ++
Abdomen: soft, non-tender, non-distended, BS+, drain in place
LLQ
Extremities: LLE >> RLE, appears 2 times size, swollen, mildly
tender to palpation, bilateral upper and lower extremities warm
and well perfused
Neuro: A&Ox3, moving bilateral upper and lower extremities
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 732)
Temp: 97.7 (Tm 97.8), BP: 159/77 (121-159/77-91), HR: 68
(64-77), RR: 17 (___), O2 sat: 95% (93-100), O2 delivery: Ra
GENERAL: NAD
___: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Has a ABD pad in RLQ
with scant drainage from around the drain. seroma drain with
serous drainage.
EXTREMITIES: no cyanosis, clubbing, LLE with swelling, no
palpable cords, negative ___ sign.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 12:18AM BLOOD WBC-9.6 RBC-4.81 Hgb-14.4 Hct-44.7 MCV-93
MCH-29.9 MCHC-32.2 RDW-12.3 RDWSD-42.3 Plt ___
___ 12:18AM BLOOD Neuts-78.2* Lymphs-12.6* Monos-7.9
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.51* AbsLymp-1.21
AbsMono-0.76 AbsEos-0.05 AbsBaso-0.04
___ 12:18AM BLOOD ___ PTT-37.1* ___
___ 12:18AM BLOOD Glucose-109* UreaN-17 Creat-1.2 Na-143
K-4.7 Cl-101 HCO3-29 AnGap-13
___ 06:23AM BLOOD ALT-42* AST-34 TotBili-0.8
___ 12:18AM BLOOD cTropnT-0.83* proBNP-142*
___ 12:18AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.1
___ 12:23AM BLOOD ___ pO2-20* pCO2-53* pH-7.37
calTCO2-32* Base XS-2
___ 12:23AM BLOOD Lactate-1.5
___ 12:23AM BLOOD O2 Sat-25
DISCHARGE LABS:
==============
___ 06:23AM BLOOD WBC-4.8 RBC-4.51* Hgb-13.4* Hct-41.2
MCV-91 MCH-29.7 MCHC-32.5 RDW-12.0 RDWSD-40.3 Plt ___
___ 06:23AM BLOOD ___ PTT-30.2 ___
___ 06:23AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-144
K-4.4 Cl-106 HCO3-25 AnGap-13
___ 06:23AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
REPORTS:
=========
___ CT-PE from OSH:
1. Large bilateral central and lobular pulmonary emboli as
identified. No evidence of pulmonary infarct or right heart
strain. No evidence of saddle pulmonary embolus.
2. Nodular infiltrates involving both lower lobes likely on the
basis of multifocal pneumonia however underlying mass lesions
are not excluded.
___ IVCgram filter:
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins
and no evidence of clot.
2. Successful deployment of an infra-renal Denali IVC filter.
___ TTE:
LVEF 75%. Right ventricular cavity dilation with free wall
hypokinesis. Mild pulmonary
artery systolic hypertension. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global
biventricular systolic function.
___ CT Abd/pelvis w/o contrast:
Minimal residual collections. Appropriately positioned
percutaneous pigtail
catheter. New trace ascites. New trace right pleural fluid.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
=======================
Mr. ___ is a ___ man with no significant
past medical history who was transferred to ___ after
presenting to an outside hospital after collapsing having chest
pain hypoxia he was found to have large bilateral central
lobular pulmonary emboli. On ___ he had a L4-S1 anterior lumbar
fusion at ___, and he was discharged on ___. He noticed more
swelling in his left lower extremity the next 2 weeks, and he
noticed swelling in his abdomen. On ___ he had an ___ guided
aspiration of a retroperitoneal seroma, however this recurred
and he had a drain placed on ___. On ___ after drain placement
and a 2-hour car at home he collapsed with chest pain shortness
of breath found to have large bilateral pulmonary emboli with
evidence of right heart strain on echocardiogram and an
elevation in his troponin and BNP, and was diagnosed with a
submassive PE however he did not have any evidence of
hypotension and only a small oxygen requirement. He was admitted
to the MICU, ___ was consulted and he was started on
therapeutic Lovenox and had an IVC filter placed. He had rapid
improvement in his cardiopulmonary status, was ambulating
independently, and had bedside echocardiography which showed
improvement in his right heart function. He was ultimately
transitioned to ___ upon discharge. He continued to have
high amounts of output from his retroperitoneal drain and ___ was
consulted who recommended follow up as an outpatient
TRANSITIONAL ISSUES:
=======================
[ ] Patient has an IVC filter in place which will need to be
removed likely within one month - Dr. ___ determine
timing for removal.
[ ] Patient will follow-up with Dr. ___ the ___ team
regarding follow-up care for his pulmonary embolism.
[ ] Follow-up with interventional radiology regarding
retroperitoneal drain care and removal - they will consider
sclerosis of a lymphocele if continuing to put out drainage.
[ ] Planning to continue Apixaban 10mg BID for 1 week (until
___ and then transition to Apixaban 5mg BID.
[ ] Follow-up with orthopedic spine, Dr. ___.
[ ] Increase activity as tolerated
ACUTE/ACTIVE ISSUES:
=======================
#Submassive PE
Provoked in the setting of recent surgery and relative
immobility. Had evidence of right heart strain on echo, elevated
troponins, and elevated BNP but no hypotension. Patient required
support of oxygen. Evaluated by ___. Now status post
therapeutic Lovenox and IVC filter ___. His level of activity
rapidly increased and he was rapidly weaned off oxygen. A
bedside echocardiogram prior to discharge showed improvement in
right ventricular function. He was transitioned to apixaban
prior to discharge.
#Recent retroperitoneal seroma drainage
Postoperatively patient developed a fluid collection concerning
for retroperitoneal seroma which was drained by ___ on ___
however the fluid collection recurred and he had a drain
placement on ___ by ___. He continued to have high output from
his drain which was initially serosanguineous but cleared up and
was serous upon discharge there is some concern that the drain
was. A lymphocele may be contributing to the high output,
however it was recommended no acute intervention and ___ will
follow-up as an outpatient. He will go home with the ___ for
drain care and should continue to keep an eye on drain output
change of movement is less than 10 cc of output/day for 2 days.
CHRONIC/STABLE ISSUES:
=======================
#Recent L4 S1 anterior spinal fusion Had surgery ___ with Dr.
___.
He was seen by orthopedic spine on admission and there is no
restrictions on anticoagulations per their team. There were no
weightbearing restrictions placed as well. He will follow-up
with him in the clinic as scheduled.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 14 Doses
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
2. Apixaban 5 mg PO BID
Start after you finish your 7 day course of 10mg twice a day.
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Baclofen 5 mg PO TID:PRN Muscle Spasms
RX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
===================
Submassive pulmonary embolism
Retroperitoneal fluid collection
Secondary diagnosis:
====================
Recent L4-S1 anterior lumbar fusion.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
-You were admitted to the hospital because he had a blood clot
in your lungs which caused you to pass out
WHAT HAPPENED IN THE HOSPITAL?
==============================
-You had a scan of the lungs which showed large blood clots
-You had an ultrasound of the heart which showed that it was
working harder to push against the blood clots
-You had a metal filter placed in one of the big veins of the
body to prevent further blood clots from entering the lungs
-He was treated with a blood thinner medication
- you continue to have lots of drainage from the fluid
collection near your spine
Fusion and interventional radiology will follow up with your as
an outpatient to determine follow up recommendations.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- please continue to take all of your medications as directed
- please follow up with all the appointments scheduled with
your doctor
- If you feel new chest pain or shortness of breath please call
your doctor and return to the hospital
- If you have more pain, tenderness, drainage from around the
catheter in your abdomen please call your doctor and go to the
hospital
- If you notice that the color of the drainage from the
catheter your abdomen is changed please call your doctor or go
to the hospital
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19648488-DS-18
| 19,648,488 | 20,289,656 |
DS
| 18 |
2151-06-14 00:00:00
|
2151-06-16 10:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / amlodipine / lisinopril / ibuprofen
/ ACE Inhibitors
Attending: ___.
Chief Complaint:
Fall, ? loss of consciousness, hip fracture
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty with ___ on ___
History of Present Illness:
___ with Type II DM, hypertension, h/o AAA s/p repair, colon
cancer s/p resection and chronic kidney disease presents after a
possible syncopal episode today.
He reports that he was in his usual state of health this
morning, which per the patient includes intermittent episodes of
loss of balance. He states that this is a recurrent problem of
his. This morning, he had been up for two hours and ate his
breakfast, then proceeded to the TV room walking at his usual
slow pace with his walker. He was resting his hands on top of
some lockers, and then felt as though he was starting to lose
his balance. Denies palpitations, chest pain, shortness of
breath, narrowing of his visual fields at this time. He does not
believe he lost consciousness as he heard someone yell "man
down". Denies any post fall confusion, but did note right hip
pain after the fall. He was brought to the ___ ED for further
evaluation.
In the ED his vital signs were 98.0 63 148/82 16 100% RA. He
received 1000 mg acetaminophen, 5 mg diazepam, 50 mg tramadol
and 4 mg of IV morphine. He had multiple imaging studies that
were only significant for a comminuted, displaced and impacted
fracture of the right femoral neck. Orthopedics was consulted,
and recommended admission to medicine and they will follow
along. Plan is for OR after medical clearance.
Past Medical History:
ABDOMINAL AORTIC ANEURYSM
- s/p repair ___ c/b type II endoleak
- stable on last surveillance ___
CHRONIC RENAL FAILURE ___
- developed in ___
- etiology unclear
- fluctuates from ___ over past ___ years
- baseline 1.5 over past year
ALCOHOL ABUSE
- section 35'd in ___
- reportedly sober since ___
- abuse led to patient losing permanent housing
ANGER MANAGEMENT
BASAL CELL CARCINOMA
- left cheek
- s/p ___'s procedure in ___
COLON CANCER
- hemicolectomy ___
- multiple polyps found since
- last colonoscopy ___ with diverticulosis, adenoma in
transverse colon and hyperplastic polyp is sigmoid colon
- next ___ ___
- ? FAP given number of polyps found during surveillance over
the years
DEPRESSION
- currently on 30 mg fluoxetine daily
- previously followed by psych at ___, but not since ___
DIABETES MELLITUS
- last HbA1c 8.3% ___
- on glipizide XL 20 mg daily
- metformin contraindicated given renal function
DIVERTICULOSIS ___
- diverticulosis noted again on ___ ___
HEALTH MAINTENANCE
- last PSA 2.3 ___
HYPERTENSION
- on labetalol 200 mg BID
HYPERCHOLESTEROLEMIA
- on simvastatin 40 mg QHS
KNEE PAIN
PROSTATE DISEASE
- last PSA 2.3
PERIPHERAL EDEMA
- multifactorial d/t diet, chronic venous stasis, sleep hygeine,
renal insufficiency
- TTE without e/o failure
- LENIs negative
- Improving with compression socks
NORMOCYTIC ANEMIA
- most consistent with anemia of chronic disease
- getting colon cancer surveillance
Social History:
___
Family History:
His paternal aunt and grandmother have had insulin-dependent
diabetes and both parents have hypertension. Father and sister
with alcoholism. no known family history of syncope unknown
history of osteopenia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.3 188/117 90 16 100% RA
General: pleasant, no acute distress
HEENT: anicteric, EOMI, mucous membranes dry
Neck: supple without appreciable carotid bruits
CV: regular rhythm and rate, normal S1 and S2, no m/r/g
appreciated
Lungs: clear to auscultation bilaterally, no adventitious sounds
Abdomen: NABS, NT/ND
GU: no folen, continent of urine
Ext: warm and well perfused, feet dry without maceration, no
edema, 2+ DP pulses bilaterally
Neuro: no focal deficits in upper extremity, unable to assess
motor function adequately in right lower extremity because of
hip injury, decreased sensation to pinprick at level of ankle
bilaterally
DISCHARGE PHYSICAL EXAM:
VSS
General: pleasant, no acute distress
HEENT: anicteric, EOMI, mucous membranes dry
Neck: supple
CV: regular rhythm and rate, normal S1 and S2, no m/r/g
appreciated
Lungs: clear to auscultation bilaterally, slight ronchi
appreciated at bilateral lung bases
Abdomen: NABS, NT/ND
Ext: R hip bandaged. both lower extremities warm and well
perfused without edema. 2+ DP pulses bilaterally, moving feet
and toes without difficulty
Neuro: no new focal deficits appreciated
Pertinent Results:
ADMISSION LABS:
___ 10:01AM BLOOD WBC-4.7 RBC-3.29* Hgb-10.1* Hct-31.4*
MCV-96 MCH-30.6 MCHC-32.1 RDW-12.5 Plt ___
___ 10:01AM BLOOD Glucose-310* UreaN-26* Creat-1.5* Na-136
K-5.1 Cl-107 HCO3-20* AnGap-14
___ 09:05PM BLOOD CK(CPK)-117
___ 09:05PM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:01AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.6
___ 10:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT LABS:
___ 07:20AM BLOOD Glucose-151* UreaN-21* Creat-1.2 Na-136
K-4.4 Cl-102 HCO3-24 AnGap-14
___ 08:00AM BLOOD Glucose-155* UreaN-31* Creat-1.4* Na-137
K-4.4 Cl-103 HCO3-24 AnGap-14
___ 08:00AM BLOOD Glucose-230* UreaN-44* Creat-1.7* Na-139
K-4.9 Cl-104 HCO3-22 AnGap-18
___ 11:05AM BLOOD Glucose-222* UreaN-44* Creat-1.7* Na-132*
K-4.6 Cl-102 HCO3-22 AnGap-13
___ 08:00AM BLOOD Glucose-271* UreaN-38* Creat-1.4* Na-135
K-4.3 Cl-103 HCO3-25 AnGap-11
___ 07:20AM BLOOD CK(CPK)-130
___ 11:05AM BLOOD CK(CPK)-178
___ 07:20AM BLOOD Mg-2.3
___ 08:00AM BLOOD Mg-1.9
___ 08:00AM BLOOD Calcium-7.8* Phos-4.1# Mg-1.8
___ 11:05AM BLOOD Mg-1.7
___ 08:00AM BLOOD Mg-2.0
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-5.9 RBC-2.46* Hgb-7.8* Hct-23.7*
MCV-96 MCH-31.7 MCHC-33.0 RDW-12.5 Plt ___
___ 07:40AM BLOOD Glucose-165* UreaN-26* Creat-1.2 Na-135
K-5.0 Cl-103 HCO3-29 AnGap-8
EKG:
___ Sinus rhythm. Normal ECG. Compared to the previous tracing
of ___ no significant change.
IMAGING:
___ CXR PA&LAT
Mild pulmonary vascular engorgement and trace bilateral pleural
effusions.
___ CT head w/o constrast
No acute intracranial abnormality.
___ CT C-spine w/o contrast
No acute fracture or malalignment. Moderate to severe canal
narrowing
described above predisposes the patient to cord injury in the
setting of minor trauma. If clinical concern for cord injury,
MRI can be obtained for evaluation.
___ CT-A Abd/Pelvis
1. Status post endovascular infrarenal abdominal aortic aneurysm
with type II endoleak, overall similar in size and appearance
compared to the study from ___.
2. Right impacted and comminuted subcapital femoral neck
fracture with
superior and anterior displacement and mild varus angulation.
3. Mild right hydronephrosis without any obstructive lesions
seen. This could be due to marked bladder distention with
reflux, and could be reassessed post-void with ultrasound
imaging.
___ Femur 2-view
Comminuted, displaced and impacted fracture of the right femoral
neck. No dislocation.
___ Hip 2-view
Comminuted, displaced and impacted fracture of the right femoral
neck. No dislocation.
___ Knee films
IMPRESSION: No acute bony injury. Lucencies in the proximal
fibula. These could relate to osteopenia or represent true
lesions. Recommend correlation with serum and urinary protein
electrophoresis initially. Additional evaluation can also be
performed by MRI.
___ portable CXR
Cardiac size is normal. The aorta is tortuous. Bibasilar
opacities, larger on the left side, could be atelectasis or
infection or aspiration. There is no pneumothorax or pleural
effusion. There is elevation of the left hemidiaphragm.
___ CT-A Abd/Pelvis
IMPRESSION:
1. No evidence of pulmonary embolus or acute aortic syndrome.
2. New bibasilar consolidations, most likely aspiration or
infection.
3. Stable post-surgical changes related to an endovascular
graft repair of infrarenal abdominal aortic aneurysm, which is
stable in size. Known type 2 endoleak is similar in size and
extent since previous exams.
4. Focal hyperdense areas in the colon and stomach most likely
relate to
medication administration. Correlation with melena or
hematochezia on
physical exam is recommended, to exclude a possible GI bleed.
If GI bleed is of clinical concern, consider mesenteric CTA for
further assessment.
5. Interval repair of known comminuted subcapital femoral neck
fracture with hardware placement. Overlying soft tissue edema
and subcutaneous gas is likely post-surgical.
6. Mild right hydronephrosis seen on ___ exam has
resolved.
Brief Hospital Course:
___ year old male with diabetes, hypertension, h/o AAA s/p
repair, colon cancer s/p resection and chronic kidney disease
presents with syncope vs pre-syncope of unclear etiology.
ACTIVE ISSUES
# Syncope vs. pre-syncope, fall: unclear etiology. Patient was
ruled out for myocardial infarction, and monitored on telemetry
with no significant events except for intermittent atrial
tachycardia that would last only a few seconds and then
self-terminate. There was no suggestion of seizure as there was
no report of incontinence, and no clear history consistent with
vasovagal cause. Orthostasis is a possibility given his acute
hypotension while working with ___ in the setting of volume
depletion, and orthostatic vital signs were not initially
obtained prior to fluid repletion upon admission. Also
contributing to his fall is likely balance issues secondary to
some peripheral neuropathy from diabetes and alcohol abuse. He
was continued on vitamin D supplementation for possible
balance/lower extremity strength benefit.
# Right hip fracture s/p right hemiarthroplasty: right hip
fracture was repaired on ___. On POD1 he worked with ___ and
became hypotensive as below. After IVF resuscitation, he
improved such that he was able to work with physical therapy the
next day successfully. He has ___ scheduled with ___
___ on ___. For DVT prophylaxis, he will be on
enoxaparin adjusted for his renal function until at least his
___ appointment. His pain was well controlled on tylenol
___ mg TID and prn 2.5 mg oxycodone, and he used the oxycodone
minimally. He is discharged for a short stay at rehab.
# Shock likely secondary to volume depletion: on POD #1 while
working with physical therapy, his blood pressure dropped to
50/palpable and he was quite symptomatic from this, and was also
noted to be hypoxic. His hypoxia and hypotension resolved with
2L IVF bolused in less than one hour, and he was mentating
appropriately. Urgent imaging to rule out pulmonary embolus,
surgical site hematoma, bleed from AAA repair, pneumothorax and
pneumonia were significant only for bibasilar consolidations in
his lungs concerning for pneumonia. This was managed as below.
He was continued on maintenance IVF. He should be encouraged to
take in adequate PO fluids in the future. Given his marked
decompensation in the setting of volume depletion, it is
possible that his fall was indeed related to volume depletion
and orthostasis.
# Possible aspiration pneumonia: as noted above, bibasilar
consolidations concerning for pneumonia noted on ___.
Acutely, he was placed on vancomycin/cefepime given his hospital
stay and hypotension/hypoxia. He remained afebrile and without
leukocytosis and therefore was switched to clindamycin 300 mg
q6h for an aspiration pneumonia course. Last day is to be
___.
# Diabetes mellitus: well controlled as an outpatient on
glipizide 20 mg daily. This was held while inpatient and he was
maintained on an insulin sliding scale. Post-operatively his
blood glucose average climbed from between 150-200 to the
200-400 range. He was started on 5 units insulin glargine on
___, with minimal improvement on ___. This increase is
attributed to post-operative stress. He is discharged on his
home glipizide with QACHS finger sticks recommended, he can get
supplemental insulin on a sliding scale with adjustment as
necessary in rehab. We would expect this hyperglycemia to
resolve over the short term.
# Hypertension: he was stable on his home labetalol of 200 mg
BID until the above episode of hypotension. As his blood
pressure improved, he was restarted on 100 mg BID. His blood
pressures remained stable on this dose, and therefore he was
discharged on this lower dose relative to his home regimen.
# Anemia: Mr. ___ hematocrit ___ in the setting of
aggressive fluid administration and recent hip surgery. As it
continued to slowly trend down, his discharge on ___ was
delayed pending stability. On ___, his hematocrit was 23 and
stable. He had no pain in the thigh and therefore no concern for
large bleed into the thigh. He should have a GI workup in the
future given his colon cancer history.
CHRONIC ISSUES
# h/o Alcohol abuse: serum alcohol level negative. He was
continued on folic acid and a multivitamin daily.
# GERD: stable issue while inpatient. He was continued on his
home ranitidine.
# Hyperlipidemia: stable issue while inpatient. He was continued
on his home simvastatin.
TRANSITIONAL ISSUES
- should have CBC check to trend hematocrit soon after discharge
___ or ___
- Encourage PO water intake
- on clindamycin 300 mg q6, last day ___
- ___ with orthopedics on ___, with xrays before
- on enoxaparin DVT prophylaxis at least until ___
- PCP ___ after rehab stay for balance issues
- restart glipizide 20 mg daily in rehab, but will need QACHS
finger sticks with supplemental insulin on sliding scale at
least acutely, can wean as improves
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 30 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. GlipiZIDE XL 20 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Ranitidine 150 mg PO BID
6. Simvastatin 40 mg PO HS
7. Aspirin EC 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Magnesium Oxide 800 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Fluoxetine 30 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Magnesium Oxide 800 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO BID
7. Simvastatin 40 mg PO HS
8. Vitamin D 1000 UNIT PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Clindamycin 300 mg PO Q6H
11. Enoxaparin Sodium 30 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
continue until ___ appointment
12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN
breakthrough pain not controlled by tylenol
give sparingly
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*15 Tablet Refills:*0
13. Senna 1 TAB PO BID:PRN constipation
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
give if tylenol not working, before giving oxycodone
15. GlipiZIDE XL 20 mg PO DAILY
16. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
17. Labetalol 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pre-syncope vs syncope from balance issue vs possible
orthostasis
Right hip fracture s/p right hemiarthroplasty
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care while you were
inpatient at ___. You were admitted after you fell and broke
your right hip. We think that you fell because of balance issues
related to possible neuropathy, or perhaps a component of
dizziness from decreased fluid intake. You should ___ with
your primary care doctor about your balance, and drink as much
fluid as possible!
We wish you the best with your recovery. Take care!
Followup Instructions:
___
|
19648564-DS-15
| 19,648,564 | 26,011,992 |
DS
| 15 |
2155-10-21 00:00:00
|
2155-11-05 14:30:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Iodine-Iodine Containing /
Feraheme
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/PMHx of ESRD on PD, HTN, and anemia, who presents with
dyspnea and orthostasis. Patient presented to peritoneal
dialysis today and reported to the nurse that he had been
experiencing several days of dyspnea with minimal exertion,
dizziness upon standing, and mild cough. Denied any fevers. O2
sat 92%. PD nurse found diminished breaths sounds on left; SBP
was checked and decreased from 130 seated to 110 standing (with
the pt complaining of dizziness). Patient was referred to the ED
for further evaluation.
Of note, patient was recently admitted to ___ from ___
for cough and shortness of breath that was thought to be due to
a viral URI, in addition to mild fluid overload in the setting
of less fluid drainage from peritoneal dialysis during the 2
weeks prior to admission. He had a CXR on ___ that showed left
lower opacity questionable for pneumonia, as well as new mild
cardiomegaly compared to his CXR from 1 week prior, and small
bilateral pulmonary effusions. During the admission he received
a one-time dose of levofloxacin in ED and a single dose of
azithromycin 500mg PO on day 1 of admission. Given his clinical
picture, there was low suspicion for bacterial pneumonia as a
cause for his symptoms, so antibiotics were discontinued. An
echocardiogram was not performed at that time.
On arrival to the ED, initial vitals were 97.8, 104, BP 169/78,
RR 18, 95% RA. Labs were notable for BNP 6483, Hgb 8.9 (recent
baseline Hgb 9.0), and lactate 1.6. At 13:25, he was noted to
have SpO2 88% on RA and was placed on 3L NC. Patient reported
that he can normally walk up to 200 ft, but has not been able to
over the past few days. He denied orthopnea, PND or chest pain.
He endorsed a few episodes of dizzness with ambulation last
week, but none this week. In the ED, a CXR showed increased
right pleural effusion (now moderate) with overlying atelectasis
(underlying consolidation cannot be excluded) and trace left
pleural effusion that is slightly decreased. Patient received
Lasix 40mg IV at 1530.
Vitals prior to transfer were 73 117/60 16 100% 3L NC. On
arrival to the floor, Pt's VS:
98.1, 90, 18, 100% RA.
Pt was alert and comfortable. States that he had been drinking
more fluids over the last ___ days ("70% more than normal")
because he had been feeling dizzy when standing and thought that
he was dehydrated. He also has been taking more off during his
PD, usually 800mL but now 1L for the last ___ days. He has had
dyspnea on exertion for a few weeks. No orthopnea or pain aside
from R ankle, no cough, fever, nausea vomiting, or diarrhea. Pt
still makes small amounts of urine.
ROS: (+) Per HPI, dyspnea on exertion, ankle swelling
(-) Denies fever, changes in appetite, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- ESRD (secondary to HTN, ?CIN), on peritoneal dialysis since
___
- Hypertension
- Hyperlipidemia
- Anemia
- Depression/anxiety
- H/o DVT
- Hearing loss
- Cataracts
Social History:
___
Family History:
Asthma, heart disease
Physical Exam:
PHYSICAL EXAM on admission:
98.1, 90, 18, 100% RA.
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
LUNGS - slightly decreased breath sounds on RLL. Dullness to
percussion in RLL.
ABDOMEN - soft, non-tender, umbilical hernia present and
reducible, peritoneal dialysis access port clean
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge
VS: 97.8, 131-164/80-109, 83-95, 18, 96% RA
GENERAL - NAD, comfortable, appropriate
NECK - supple, no thyromegaly, JVP elevated to 10 cm
HEART - PMI non-displaced, irregular rhythm, normal rate, nl
S1-S2, ___ systolic murmur
LUNGS - End expiratory wheeze and slightly decreased breath
sounds at B/L bases.
ABDOMEN - soft, non-tender, umbilical hernia present and
reducible, peritoneal dialysis access port clean
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
Labs on admission:
___ 01:40PM BLOOD WBC-9.3 RBC-2.84* Hgb-8.9* Hct-27.5*
MCV-97 MCH-31.3 MCHC-32.3 RDW-16.0* Plt ___
___ 01:40PM BLOOD Neuts-83.0* Lymphs-10.0* Monos-4.3
Eos-2.2 Baso-0.5
___ 09:05AM BLOOD ___ PTT-29.8 ___
___ 01:40PM BLOOD Glucose-116* UreaN-55* Creat-7.7* Na-138
K-4.0 Cl-93* HCO3-23 AnGap-26*
___ 01:40PM BLOOD proBNP-6483*
___ 09:05AM BLOOD Calcium-8.7 Phos-6.9* Mg-2.4
___ 05:30AM BLOOD VitB12-___
___ 02:07PM BLOOD Lactate-1.6
___ 09:30PM URINE Color-Straw Appear-Clear Sp ___
___ 09:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 09:30PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-3
TransE-<1
Discharge:
___ 07:20AM BLOOD WBC-8.2 RBC-2.92* Hgb-9.2* Hct-28.7*
MCV-98 MCH-31.5 MCHC-32.1 RDW-16.5* Plt ___
___ 01:40PM BLOOD Na-134 K-3.3 Cl-94*
___ 07:46AM BLOOD Glucose-104* UreaN-57* Creat-6.6* Na-133
K-2.8* Cl-93* HCO3-30 AnGap-13
___ 07:46AM BLOOD Calcium-8.2* Phos-4.9* Mg-2.2
Chest XR ___
Increased right pleural effusion which is now moderate, with
overlying atelectasis, underlying consolidation cannot be
excluded. Trace left pleural effusion, slightly decreased.
___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. The aortic valve VTI = 74 cm. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.
An echodensity is appreciated in some views going in and out of
the plane of the left atrium (clips 9, 13, 36, 54, 66); it may
represent a hiatal hernia. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. IMPRESSION: Normal left ventricular cavity
size with mild symmetric left ventricular hypertrophy and
preserved global and regional biventricular systolic function.
Severe aortic stenosis. Moderate tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension. Echodensity
going in and out of the plane of the left atrium in some views
?possibly consistent with a mobile hiatal hernia.
___ RIGHT HEART CATHETERIZATION AND CORONARY
ARTERIOGRAPHY
Hemodynamics (see above): The mean PCWP was 9 mmHg. The mean
aortic valve gradient was 41.21 mmHg. The aortic valve area was
0.77 cm2.
Coronary angiography: right dominant
LMCA: The left main had a 30% stenosis in the distal portion.
LAD: The LAD had minor lumen irregularities in the proximal and
mid portions. There was a 60-70% stenosis in the origin of the
first diagonal branch. The was a medium sized vessel.
LCX: There was a 40-50% stenosis in the origin of the left
circumflex. The LCX gave rise to a large bifurcating OMB1 and a
diffusely disease OMB2 without focal obstruction.
RCA: The RCA was a large dominant vessel with a 40-50% stenosis
in its origin. The RCA terminated in a large PDA and two large
posterolateral branches. The RCA was free of significant
disease.
Interventional details
The aortoiliac angiography showed large caliber vessel (> 9 mm)
with marked tortuousity. It could not be determined whether
tortuousity caused kinking in the external iliac or whether this
represented a calcified iliac lesion. A CT scan will be
obtained.
ASSESSMENT
1. Single vessel coronary artery disease (diagonal branch)
2. Severe aortic stenosis
3. Normal left and right filling pressures
RECOMMENDATIONS
1. Evaluate for surgical or transcatheter aortic valve
replacement.
Brief Hospital Course:
___ w/PMHx of ESRD on PD, HTN, and anemia, who presents with
exertional dyspnea and orthostasis, and is found to have
elevated BNP and worsening right pleural effusion, now new
severe aortic stenosis.
# Exertional dyspnea: Possibly related to volume overload in the
context of ESRD given Pt's report of increased fluid intake. By
his reported volumes, his PD seems to be working. No baseline,
so BNP is less useful. Symptoms could be due to CHF, but Pt had
a normal stress ECG in ___ and no other evidence of CHF. Pt has
not had an echo since ___. No evidence of infection or bloody
clots. No wheezes on exam. Repeat echo on ___ showed severe
aortic stenosis, and after much discussion, Pt was transferred
to cardiology service for further workup (see below). Pt
continued to receive peritoneal dialysis per his home regimen
and his shortness of breath improved.
# Severe aortic stenosis: Pt was found to have severe aortic
stenosis on echocardiogram during this admission. Specifically,
his echo on ___ showed severe aortic stenosis, moderate
mitral regurg, and moderate pulmonary artery systolic
hypertension. peak gradietn 53 mmgHg, median gradient 31 mmHg,
valve area 0.9cm2. EF was preserved at > 55%. Patient was seen
and evaluated by cardiac surgery and cardiology, and was
informed that his best option would be an endovascular
intervention. Patient transferred to cardiology service under
Dr. ___ further evaluation. Cardiac cath performed
___ showed 60-70% stenosis of first diagonal, otherwise no
flow limiting disease. Patient to follow up with Dr. ___
further ___ of trans aortic valve replacement.
# Leukocytosis: Pt had new leukocytosis from 8.6k to 15.1k on
___. No fever, no changes in vital signs. Mild cough and
known R pleural effusion. No other localizing symptoms. Repeat
UA bland, and leukocytosis resolved without further
intervention.
Chronic Issues:
# ESRD: Pt's peritoneal dialysis were continued per renal recs
according to his prior home regimen. He also continued his home
calcitriol, nephrocaps, sevelamer.
# HTN: Continued home losartan and metoprolol.
# Anemia: Stable chronic normocytic anemia with recent baseline
Hgb 9.0-10.0. Patient receives monthly Epoetin Alfa.
# HLD: Continued atorvastatin.
# Depression/anxiety: Continued sertraline.
Transitional Issues:
- Patient to follow up with Dr. ___ further
evaluation for TAVR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY Start: In am
2. Calcitriol 0.25 mcg PO DAILY Start: In am
3. Docusate Sodium 100 mg PO BID
4. Gentamicin 0.1% Cream 1 Appl TP DAILY
apply to exit site daily
5. Losartan Potassium 50 mg PO QAM Start: In am
6. Losartan Potassium 25 mg PO HS
7. Multivitamins W/minerals 1 TAB PO DAILY Start: In am
8. Senna 1 TAB PO BID:PRN constipation
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Nephrocaps 1 CAP PO DAILY Start: In am
11. Epoetin Alfa 150 mcg SC MONTHLY
12. Metoprolol Succinate XL 25 mg PO DAILY Start: In am
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gentamicin 0.1% Cream 1 Appl TP DAILY
apply to exit site daily
5. Losartan Potassium 50 mg PO QAM
hold for sbp < 90
6. Losartan Potassium 25 mg PO HS
hold for sbp < 90
7. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp < 90 or HR < 60
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Epoetin Alfa 3000 UNIT SC QMOWEFR
RX *epoetin alfa [Epogen] 3,000 unit/mL 3000 units Every ___,
___ Disp #*30 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: severe aortic stenosis, moderate mitral regurgitation,
moderate pulmonary artery systolic hypertension
Secondary: ESRD on peritoneal dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for shortness of breath. You
were found to have severe aortic stenosis a disorder of a valve
of your heart. This most likely explains your symptoms of
shortness of breath. You were evaluated by our cardiac surgeons
and interventional cardiologists, who felt that you may benefit
from a replacement aortic valve placed endovascularly. You had a
cardiac cath to evaluate your arteries. You will need to follow
up with Dr. ___ valve replacement.
Medication changes: epoetin 3000 units ___
Followup Instructions:
___
|
19648564-DS-17
| 19,648,564 | 21,574,334 |
DS
| 17 |
2156-06-07 00:00:00
|
2156-06-07 21:08:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Iodine-Iodine Containing /
Feraheme
Attending: ___.
Chief Complaint:
Weakness, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with ESRD on PD, HTN, severe
aortic stenosis s/p percutaneous valve replacement on ___ here at ___, presenting from PCP office for DOE and
concern for new onset afib. His outpatient nephrologist, Dr.
___ also seen him and noted that he did not look like
himself. Over just the last few days, he has been unable to walk
any distance at all without getting short of breath, functioning
quite below his baseline. His PD orders had been recently
adjusted and he believes he is drier than usual (i.e. his
"baseline" lower extremity edema is not there). He denies any
recent onset of CP or palpitations, new pain in the back,
abdomen, or headaches. Upon arrival he was noted to be
tachycardic to 111 with stable BP and comfortable on RA. The
plan for admission to Cardiology with Dr. ___ was to control
his likely paroxysmal atrial fibrillation with potential
cardioversion.
Past Medical History:
- Severe Aortic Stenosis (0.8-1.0cm2)
- ESRD (secondary to HTN, CIN), on peritoneal dialysis since
___ (every night 5 exchanges); baseline oliguric
- Hypertension
- Hyperlipidemia
- Anemia
- Depression/anxiety
- H/o DVT
- Hearing loss
- Cataracts
- L shoulder arthritis
- R rotator cuff tear
Social History:
___
Family History:
Father had a heart attack at a young age; asthma
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 98 HR: 111 BP: 138/66 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Comfortable
Chest: Clear to auscultation
Cardiovascular: Irregular, no audible murmur
Abdominal: Soft, Nontender; peritoneal dialysis catheter on
the left side of abdomen
Extr/Back: No pedal edema
Skin: Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mentation
DISCHARGE PHYSICAL EXAM:
VS: T=98.9 BP=138-173/77-86 ___ RR=18 O2 sat=95-99% RA
GENERAL: Elderly gentle. Extremely HOH. Oriented x3. Mood,
affect appropriate.
HEENT: PERRL. MMM.
NECK: Supple with JVP of 6 cm.
CARDIAC: RRR. No murmurs.
LUNGS: Crackles in R anterior lung field. Posterior lung fields
clear bilaterally.
ABDOMEN: Soft, NTND.
EXTREMITIES: WWP x 4. No lower extremity edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-12.8* RBC-3.17* Hgb-9.3* Hct-29.3*
MCV-93 MCH-29.5 MCHC-31.9 RDW-17.6* Plt ___
___ 07:49PM BLOOD ___ PTT-27.2 ___
___ 06:45PM BLOOD Glucose-113* UreaN-73* Creat-8.0*# Na-141
K-4.8 Cl-95* HCO3-24 AnGap-27*
___ 06:45PM BLOOD ___
___ 06:40AM BLOOD Calcium-9.2 Phos-7.6*# Mg-3.0*
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-9.5 RBC-3.20* Hgb-9.4* Hct-29.8*
MCV-93 MCH-29.3 MCHC-31.4 RDW-17.7* Plt ___
___ 06:40AM BLOOD ___ PTT-27.3 ___
___ 06:40AM BLOOD Glucose-130* UreaN-78* Creat-8.6* Na-144
K-4.1 Cl-97 HCO3-28 AnGap-23*
___ 08:08AM BLOOD Lactate-2.8*
Imagining:
___: CXR: Small to moderate right pleural effusion with
overlying atelectasis,
underlying consolidation is not excluded. No overt pulmonary
edema.
Procedures:
Peritoneal dialysis without fluid removed
Brief Hospital Course:
The following issues were addressed over the course of hospital
admission:
# DOE: ___ be due to mild anemia. Upon evaluation with primary
team patient denied any SOB on examination. No obvious evidence
of infection on exam, labs or radiologic stuides. Euvolemic.
Pt does not appear overloaded (no elevated JVP, no pulm edema on
CXR, not currently SOB, only trace ___ edema). He did have PD
overnight without fluid removed. Although his TnI was 0.27 on
admission, his Cr was 8.2 on admission (8.6 on discharge) which
explains the elevation. The patient had no chest pain or ST
changes on EKG. CKMB flat.
# Leukocytosis w/ AG. Met SIRS criteria on arrival w/ sinus
tachycardia and leukocytosis which both resolved by morning. No
focal signs or symptoms. CXR revealed equivocal RLL
consolidation vs. worsening known effusion. Pt had no cough, no
leukodytosis and afebrile and thus no antibiotics were required.
# Afib. In NSR on the floor. There is not EKG documenting this
hx of Afib and we spoke with nephrologist where he was referred
from. Overnight on tele he had frequent PACs and a few PVCs but
otherwise normal sinus. CHADS2 of 3. He is already beta
blocked.
# ESRD- had PD overnight. Per nephrology, 1.5% dwells until
following up with dialysis center the next day to work in a 2.5%
dwell. Patient given numbers to call to arrange follow up.
#HTN- on metoprolol; may need to be increased but given his PD
is planned to changed in near future will hold off for now to
avoid hypotension in this elderly gentleman.
#Depression.
-Con't home sertraline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO 3X/WEEK (___)
2. Nephrocaps 1 CAP PO DAILY
3. Sertraline 100 mg PO QHS
4. sevelamer CARBONATE 1600 mg PO TID W/MEALS
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Aspirin 81 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP < 100, HR < 60
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Sertraline 100 mg PO QHS
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
End stage renal disease
Aortic stenosis s/p Core valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for concerns of an abnormal
heart rhythum and difficulty breathing. Your heart rhythum was
normal in the hospital and you had no concerns with shortness of
breath here. You did have peritoneal dialysis and will need
close follow up with Dr. ___ nephrologist regarding your
dialysis.
It was a pleasure taking part in your care at ___. We wish you
a speedy recovery!
Followup Instructions:
___
|
19648767-DS-9
| 19,648,767 | 23,551,972 |
DS
| 9 |
2128-08-13 00:00:00
|
2128-08-13 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
___ is a ___ with a history of T2DM, HTN, CKD, CAD
(reported abnormal stress test in ___ at ___), and upper GI
bleed x2 secondary to aspirin use (most recently ___
requiring 2U pRBC) who presents with an abnormal stress test.
For
the past few months, he has had chest pain associated with
exertion. Associated with dyspnea, no dizziness, numbness,
tingling, n/v. He went to his outpatient cardiologist, where
nuclear stress test was markedly abnormal with STD and
hypotension so was referred to ___ ED for cath.
Per report, his stress test was:
"At baseline had 1 mm STD in lateral leads. With stress
developed
2-3 mm of planar and later downsloping STD and 1-2 mm STE in aVR
which persisted ___ min into recovery. BP could not be
auscultated at peak. At ___ min recovery he was hypotensive with
SBP went from 170 down to 92. He had SOB and mild CP with stress
and in recovery. Ultimately given aminophylline and felt
improved. Perfusion with lateral wall ischemia, SSS = 10, SDS =
10. normal systolic fxn."
Of note, he reports an abnormal stress test done in ___ at ___
with no follow up afterwards.
Past Medical History:
1. CARDIAC RISK FACTORS
- + Diabetes, diet controlled, reports A1c ___
- + Hypertension
- + Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
* CAD
* CVA
3. OTHER PAST MEDICAL HISTORY
-Macular degeneration
-History of ulcer disease
-Microalbuminuria
-Anemia
-Erectile dysfunction
-Chronic kidney disease, stage III (moderate)
Social History:
___
Family History:
Mother: CVA in ___, T2DM
Father: CVA in ___
Physical Exam:
ADMISSION PHYSICAL:
VITALS: 98.2 157/55 73 18 98 RA
GENERAL: Well-developed, well-nourished. NAD.
HEENT: NCAT. Sclera anicteric. Conjunctivae anicteric.
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, NTND
EXTREMITIES: warm, no edema
DISCHARGE PHYSICAL:
GENERAL: Well appearing gentleman laying back in bed
HEENT: AT/NC, EOMI, no JVD, neck supple
LUNGS: CTAB
HEART: RRR, s1+s2 normal, no m/g/r appreciated
ABDOMEN: +BS, non-tender, non-distended
EXTREMITIES: Pulses present, no edema, resolved hematoma in R
hand
Pertinent Results:
ADMISSION LABS:
___ 09:01PM K+-4.4
___ 08:30PM K+-5.6*
___ 07:45PM ___ PTT-28.7 ___
___ 06:38PM GLUCOSE-133* UREA N-30* CREAT-1.6* SODIUM-137
POTASSIUM-5.8* CHLORIDE-103 TOTAL CO2-22 ANION GAP-12
___ 06:38PM estGFR-Using this
___ 06:38PM ALT(SGPT)-13 AST(SGOT)-28 ALK PHOS-47 TOT
BILI-0.4
___ 06:38PM LIPASE-73*
___ 06:38PM cTropnT-<0.01
___ 06:38PM proBNP-112
___ 06:38PM ALBUMIN-4.0
___ 06:38PM WBC-5.6 RBC-3.72* HGB-11.6* HCT-35.0* MCV-94
MCH-31.2 MCHC-33.1 RDW-12.4 RDWSD-43.2
___ 06:38PM NEUTS-78.5* LYMPHS-12.9* MONOS-6.8 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-4.38 AbsLymp-0.72* AbsMono-0.38
AbsEos-0.05 AbsBaso-0.03
___ 06:38PM PLT COUNT-197
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-5.4 RBC-3.66* Hgb-11.4* Hct-34.7*
MCV-95 MCH-31.1 MCHC-32.9 RDW-12.3 RDWSD-43.2 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-87 UreaN-18 Creat-1.5* Na-144
K-4.6 Cl-109* HCO3-21* AnGap-14
___ 06:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
IMAGING:
___ Cath:
Dominance: Right
* Left Main Coronary Artery
The LMCA is small in caliber, has a tubular distal 50% stenosis
* Left Anterior Descending
The LAD courses all the way to the apex. the ostial LAD has a
40% stenosis, the mid LAD has diffuse
disease, at it tightest point the mid LAD has a 70-80-%
stenosis. There is a major diagonal branch with a
diffuse mid ___ stenosis. The distal LAD till the apex is
relatively disease-free
* Circumflex
The Circumflex has 2 segments of 99% stenosis in series
The ___ and ___ Marginal branches are small in caliber
* Right Coronary Artery
The RCA is dominant, there is a 70-80% stenosis in the mid RCA
The Right PDA and R-PL branches have diffuse disease
Impressions:
1. Moderate left main, and severe three vessel CAD in this right
dominant coronary system.
___ 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. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Quantitative (3D) LVEF = 66 %. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Moderate basal septal hypertrophy with normal
cavity size and regional/global systolic function. Normal right
ventricular cavity size and systolic function. Mild mitral
regurgitation.
MICRO:
___ 7:40 am SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
___ with a history of T2DM, HTN, CKD, CAD (reported abnormal
stress test in ___ at ___), and upper GI bleed x2 secondary to
aspirin use (most recently ___ who presents with an
abnormal stress test following episodes of stable angina. He
underwent
coronary catheterization on ___, which demonstrated diffuse
disease including 50% LMCA lesion, 3 tight circumflex lesions
and RCA lesions
not intervenable and diffuse LAD disease for a total of moderate
left
main, and severe three vessel CAD in this right dominant
coronary system.
He was started on medical management for his disease since he
was seen by
cardiac surgery who deemed him not to currently be a surgical
candidate
due to the diffuse nature of his disease. They are willing to
re-eval in
clinic in ___ months if symptoms worsen. Management was with
metoprolol,
his home lisinopril, rosuvastatin due to a prior myalgia
reaction to
atorvastatin, ranolazine, and ASA. He had an ECHO on ___
which
demonstrated EF of 65% and good regional and global systolic
function.
His metoprolol was transitioned to succinate for outpatient PO.
ACUTE ISSUES:
___ with a history of T2DM, HTN, CKD, CAD (reported abnormal
stress test in ___ at ___), and upper GI bleed x2 secondary to
aspirin use (most recently ___ who presents with an
abnormal stress test.
-CORONARIES: moderate left main, and severe three vessel CAD in
this right dominant coronary system
-PUMP: Normal EF 65% with normal systolic function
-RHYTHM: NSR
# Abnormal stress test
# Stable angina:
Report of symptoms suggestive of stable angina with stress test
with STD and hemodynamic instability (hypotension and
hypertension). Referred in for cath. Of note, history of GIB
does
raise concern for ability to be adherent to antiplatelet
therapy. Cath returned moderate left main, and severe three
vessel CAD in this right dominant coronary system. Was seen by
CT surg who recommended medical management for ___ to
demonstrate no worsening of symptoms. TTE returned normal EF of
65% with normal systolic function. He was medically managed with
metoprolol, ASA, ranolazine, rosuvastatin, and home lisinopril.
QTc on discharge 396.
#Right wrist hematoma:
Complication of right radial A catheterization, precipitated
after the event. This was monitored in holding before transfer
back to floor. Improving without any evidence of compartment
syndrome (pulses present, lack of paresthesia, pain, or
pressure).
#Constipation:
Last BM on ___ as of ___. Started bowel reg with
polyethylene glycol, senna, docusate.
CHRONIC STABLE ISSUES:
# HTN: Restarted lisinopril following cath, held prior.
# History of UGIB:
Considered discontinuing PPI for H pylori testing, which
returned negative. B9 and B12 returned normal for causes of
anemia.
# CKD: Cr at baseline (1.6). Continued to trend
# Vitamins: Continued vitamins B, D & multivitamins
TRANSITIONAL ISSUES:
[] Please f/u with Cardiology appointment and PCP ___
[] QTc on discharge 396
[] Monitor for GIB on aspirin given history of peptic ulcer
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Viagra (sildenafil) 100 mg oral DAILY:PRN
3. Pravastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chset pain
can take up to three times
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5min Disp
#*30 Tablet Refills:*1
3. Ranolazine ER 500 mg PO BID
RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth two times a
day Disp #*60 Tablet Refills:*0
4. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth once at night Disp
#*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Viagra (sildenafil) 100 mg oral DAILY:PRN
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Stable angina
Coronary artery disease
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because of your history of chest pains
and your abnormal stress test.
What was done while I was in the hospital?
- Pictures were taken that showed you have good pump function
in your heart, but that you have some diffuse disease in the
blood vessels that supply oxygen to your heart.
- Since you are not currently a candidate for surgery, you
were started on medical management for your condition with a set
of medications (beta-blockers, ACE inhibitors, statins, aspirin,
and ranolazine).
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor and cardiologist.
- If you have significant chest pains, you may take sublingual
nitro. If you take more than one please tell your primary doctor
or go to the emergency room.
- Do not take Viagra within 48-72 hours of taking
nitroglycerin
Best wishes,
Your ___ team
Followup Instructions:
___
|
19648992-DS-19
| 19,648,992 | 27,165,500 |
DS
| 19 |
2156-03-30 00:00:00
|
2156-03-30 15:43:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest discomfort
presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode.
Patient reports feeling significantly fatigued for the past
month much worse over the past several days. He feels that he
wants to sleep all the time and gets very tired with any
exertion. He does not have any dyspnea on exertion and does not
get lightheaded or dizzy. He has had pain in his left
subscapular region it radiates to his left axilla for the past
one month it is constant, but of variable intensity. It is worse
with movement and with deep breaths. He also noted that his
pulse felt irregular recently, which has never happened to him
before. He denies any cough, fevers, abdominal pain, nausea,
vomiting, dysuria, rash. No lower extremity pain or swelling. No
recent travel, surgery, immobilization. No history of VTE. He
spoke to his cardiologist ___ who recommended that he come to
the emergency department for evaluation.
In the ED on ___, ECG was unremarkable and he was ruled out for
MI.He was observed overnight and had an exercise stress test
with an equivocal result. Just after the stress test, he had a
presyncopal event prompting admission to ___ for further
work-up
On the floor, the patient is symptom free. Reports that he felt
slighlty dizzy post stress test. He was sweatty and lightheaded.
Denies palpitations. Although reports wife checked his pulse a
couple of days ago where it was transiently irregular
Past Medical History:
1. CAD s/p 3x18mm Resolute DES to mid LCX. Residual 60% mid-LAD
disease not intervened upon.
2. Dyslipidemia
3. Prostate CA, being monitored
Social History:
___
Family History:
Father died of an MI at age ___
Physical Exam:
ADMISSION PHYSICAL:
VS: T=98.4 BP=125/82 HR=68 RR=16 Sats 98RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly. Cn II-XII intact
DISCHARGE PHYSICAL:
Tele: No events
VS: T=97.6 BP=133/66 HR=72 RR=16 Sats 98RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly. Cn II-XII intact
Pertinent Results:
ADMISSION LABS:
___ 12:05PM ___ PTT-31.8 ___
___ 12:05PM PLT COUNT-184
___ 12:05PM NEUTS-55.8 ___ MONOS-7.2 EOS-4.6*
BASOS-0.9
___ 12:05PM WBC-5.6 RBC-4.65 HGB-14.9 HCT-44.9 MCV-96
MCH-32.0 MCHC-33.2 RDW-13.1
___ 12:05PM proBNP-94
___ 12:05PM cTropnT-<0.01
___ 12:05PM estGFR-Using this
___ 12:05PM GLUCOSE-122* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
___ 12:32PM URINE MUCOUS-RARE
___ 12:32PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:32PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:25PM cTropnT-<0.01
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-6.2 RBC-4.52* Hgb-14.5 Hct-42.7
MCV-94 MCH-32.0 MCHC-34.0 RDW-12.9 Plt ___
___ 06:35AM BLOOD Glucose-122* UreaN-19 Creat-0.9 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 06:25PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD TSH-2.6
STUDIES:
CATH (___): nl LMCA, 60% mLAD, 80% mLCX, nl RCA, s/p
3x18mm Resolute DES to mLCX
LIPIDS (___): Chol 202, ___ 96, HDL 57, LDL 126
EKG: sinus at 62bpm, nl axis and intervals, lateral Qs
in I and aVL, nonspecific inferior ST/TW changes
STRESS TEST ___
SYMPTOMS: NONE
ST DEPRESSION: EQUIVOCAL
INTERPRETATION: This ___ yar old man with a history of CAD is
referred to the lab for evaluation from the Emergency Department
after negative serial enzymes. The patient exercised on ___
treadmill protocol for 9 minutes and stopped for fatigue. The
estimated peak MET capacity is ___, a good functional
capacity for age. There were no anginal symptoms reported. There
were inferolateral upsloping ST segment depressions noted near
peak exercise. The rhythm was sinus with rare PACS, PVCS and
ventricular couplets. The blood pressure response to exercise
was normal.
IMPRESSION: No anginal symptoms with equivocal ECG changes for
ischemia near peak exercise.
Brief Hospital Course:
___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode.
#SYNCOPAL EPISODE: Patient did not lose consciousness.
Unwitnessed. No events on tele. Patient likely had vasovagal
event after exercising in stress test. No hx of urinary
incontinence or confusion to suggest seizure. No diuresis/bleed
to suggest orthostasis. Normal fingertsick glucose levels and
TSH 2.6. Patient was asymptomatic throughout hospital stay on
floor.
#CHEST PAIN: Patient originally came in for chest pain.
Equivocal stress test in ED. Ruled out for MI. EKG shows no
ischemic changes. Plavix was discontinued as it has been a year
since stensts placed. Pain actually around top of shoulder
blade and reproducible on palpation. Labetalol was added to
medical regimen given very high heart rate during stress test.
Patient was continued on aspirin and atorvastatin.
#HLD:
-continued atorvastatin
TRANSITIONAL ISSUES:
[] CODE: Full (confirmed)
[] EMERGENCY CONTACT:Wife : Dr ___ (___)
[]please ensure cardiology follow up
[]Please monitor hemodynamics on new beta blocker
[]please consider decreasing aspirin to 81mg from 325mg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vasovagal presyncope
Secondary: CAD, HLD
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 having you here at the ___ ___
___. You were admitted here after you were having
chest pain and an episode of feeling lightheaded. A stress test
done here was equivocal. We feel your lightheadedness was an
adverse reaction after your exercise stress test. We
discontinued your plavix and started you on a medication for
blood pressure called labetalol. Please keep your follow up
appointments below.
We wish you the very best
Your ___ medical team
Followup Instructions:
___
|
19649250-DS-23
| 19,649,250 | 26,228,242 |
DS
| 23 |
2150-12-19 00:00:00
|
2150-12-19 17:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Losartan
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ year old woman with a PMH of mechanical
___ and prosthetic valve GBS endocarditis on suppressive
cephalexin, AFib, pacemaker due to complete heart block, CHF who
is admitted for dyspnea and orthopnea.
Patient with prior mech ___ for endocarditis, last echo ___
with increased AV velocities now presenting with increased
dyspnea for ___ days. Patient reports that her symptoms came on
gradually for the past ___ days. She is still able to walk up
one flight of stairs and do ADLs. She has not been able to lie
flat and has been sleeping sitting up.
ED COURSE:
- Initial vitals: 5 96.6 78 143/48 22 96% RA
- EKG: ? SR, indeterminate axis, no ST changes
- TTE: EF 55-60%, Well seated mechanical aortic and mitral
valves. Elevated transvalvular aortic valve gradient. Preserved
moderate tricuspid regurgitation with mild pulmonary
hypertension.
- CXR: worsening moderate pulmonary vascular congestion and new
small bilateral pleural effusions.
- Labs/studies notable for: K 5.7, Cr 1.2, BNP 714 INR 3.1
- Patient was given: Lasix 40IV, dilt 180, amlodipine 2.5mg
- Vitals prior to transfer: 0 74 134/52 16 96% RA
On the floor patient reports improvement in her shortness of
breath with the Lasix she received in the ED. She is still
having difficulty lying flat. She has slight lower extremity
edema and occasional non-productive cough. Denies fevers,
chills, chest pain, nausea, vomiting, abdominal pain. No known
sick contacts.
Past Medical History:
# atrial fibrillation
# type 2 diabetes
# hypertension
# hyperlipidemia
# ASD repair at ___ in the 1990s
# Mechanical MVR and ___ in ___ ___ c/b CHB
# s/p ICD/pacer placement in ___ (not MRI compatible)
# Mitral/Aortic Endocarditis ___ (group B Streptococcus)
# Moderate TR
# Moderate MR
Social History:
___
Family History:
significant for diabetes and heart disease. No family history of
malignancy or autoimmune disease
Physical Exam:
ADMISSION EXAM:
VS: 98.0 PO 130 / 65 74 16 91 Ra
Admit weight: 53.8 kg
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 13 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. III/VI systolic murmur throughout
precordium,
mechanical S2.
LUNGS: Diffuse crackles bilaterally with limited air movement
and decreased breath sounds bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
==================
DISCHARGE EXAM:
VS: AF, 66-81, BP 117-146/66-96, RR ___, O2 94-97% on RA
Weight: 51.9 <- 51.44kg <- 53.8kg ___ admit)
I/O: 24 hr: 760/800; Since MN: ___
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. anicteric. PERRL. MMM
NECK: Supple with JVP of 7 cm.
CARDIAC: Normal S1, mechanical S2. III/VI systolic murmur at
RUSB/LUSB and with holosystolic component radiating to axilla
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No lower extremity edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
===============
___ 06:20AM BLOOD WBC-4.4 RBC-4.05 Hgb-10.1* Hct-35.4
MCV-87 MCH-24.9* MCHC-28.5* RDW-15.9* RDWSD-50.4* Plt ___
___ 06:20AM BLOOD Neuts-82.2* Lymphs-10.5* Monos-5.9
Eos-0.7* Baso-0.2 Im ___ AbsNeut-3.60 AbsLymp-0.46*
AbsMono-0.26 AbsEos-0.03* AbsBaso-0.01
___ 06:20AM BLOOD ___ PTT-54.1* ___
___ 06:20AM BLOOD Glucose-185* UreaN-29* Creat-1.2* Na-144
K-5.7* Cl-106 HCO3-27 AnGap-17
___ 06:20AM BLOOD proBNP-714*
___ 06:20AM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD cTropnT-0.01
___ 06:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.8
___ 06:25AM BLOOD Lactate-0.7
IMAGING:
========
CXR (___): Severe cardiomegaly with mild congestive heart
failure including worsening moderate pulmonary vascular
congestion and new small bilateral pleural effusions. More focal
patchy left basilar opacities may reflect atelectasis but
infection is not excluded.
TTE ___ EF 55% to 60% Well seated mechanical aortic and
mitral valves. Elevated transvalvular aortic valve gradient.
Preserved global and regional biventricular systolic function.
Moderate tricuspid regurgitation with mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___,
the gradients across the aortic valve are similar; the right
ventricle appears more vigorous; the degree of tricuspid
regurgitation appears less; the estimated pulmonary arterial
systolic pressure is lower in the current study.
Brief Hospital Course:
___ year old woman with a PMH of mechanical ___ and
prosthetic valve GBS endocarditis on suppressive cephalexin,
AFib, pacemaker due to complete heart block, CHF who was
admitted for dyspnea and orthopnea consistent with heart failure
exacerbation.
Patient presented with dyspnea on exertion and orthopnea for ___
days prior to admission. Has history of ___ and moderate TR
and elevated transvalvular aortic valve gradient. Appears volume
overloaded on exam with elevated JVP and crackles in lung bases.
CXR with pulmonary vascular congestion and pleural effusions.
TTE on admission with EF 55-60%, with well seated mechanical
aortic and mitral valves, elevated transvalvular aortic valve
gradient and moderate tricuspid regurgitation with mild
pulmonary hypertension. Patient had improvement in dyspnea with
IV Lasix boluses. Patient discharged at 51.9 kg on Lasix 40mg
PO. Also during admission pt was supratherapeutic 3.9, warfarin
held ___, then INR downtrended to 1.8 on ___. Pt was discharged
with lovenox bridge, on home Coumadin dose and with follow up at
___ clinic.
=====================
CARDIAC STATUS:
# CORONARIES: Unknown
# PUMP: 55% to 60% with 2+ MR mechanical ___ and MVR
# RHYTHM: sinus/afib
=====================
ACTIVE ISSUES:
#HFpEF: Patient presented with dyspnea on exertion and orthopnea
for ___ days prior to admission. Has history of ___ and
moderate TR and elevated transvalvular aortic valve gradient.
Appears volume overloaded on exam with elevated JVP and crackles
in lung bases. CXR with pulmonary vascular congestion and
pleural effusions. TTE on admission with EF 55-60%. Patient had
improvement in dyspnea with IV Lasix. Patient discharged on
Lasix 40mg PO.
# Mechanical ___: ___ GBS endocarditis. she was continued on
her home Keflex suppression. She was continued on warfarin with
goal INR 2.5-3.5. On admission she was supratherapeutic.
Warfarin was held for one day on ___, then INR 1.8 on ___.
Restarted home warfarin and bridged with Lovenox.
CHRONIC ISSUES:
# CKD: at baseline (Cr 1.1-1.3)
# A-fib: she remained in afib on tele. She was continued on
warfarin, diltiazem 180mg ER.
# DM2: she was monitored on insulin SS while in-house, held home
Glipizide and Metformin.
# Complete heart block: Pacemaker in place, continue to monitor
# HLD: she was continued on her home pravastatin
# HTN: she was continued on her home amlodipine
=========================
TRANSITIONAL ISSUES:
New Medications: Lasix 40mg, lovenox 50 mg BID
- Follow up labs: Please check chemistry panel in 1 week given
iniatiation of Lasix.
- Discharge weight: 51.9 kg
- Discharge diuretic: Furosemide 40 mg
- HFpEF: Please evaluate volume status and titrate Lasix dose,
consider initiation of beta blocker and ACE inh given heart
failure.
- Anticoagulation: Please check INR on ___. Patient was
supratherapeutic to 3.9 on ___ so warfarin was held, then
subtherapeutic on ___. Restarted home warfarin and bridged with
Lovenox.
# CODE: DNR/DNI
# CONTACT: ___ (daughter/HCP) Phone number:
___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin B Complex 1 CAP PO DAILY
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cephalexin 500 mg PO Q8H
5. Diltiazem Extended-Release 180 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
8. Pravastatin 20 mg PO QPM
9. Warfarin 8 mg PO 2X/WEEK (MO,FR)
10. Warfarin 6 mg PO 5X/WEEK (___)
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Medications:
1. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 50 mg SQ twice a day Disp #*10
Syringe Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cephalexin 500 mg PO Q8H
6. Diltiazem Extended-Release 180 mg PO DAILY
7. GlipiZIDE XL 10 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
RX *metformin 500 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
9. Pravastatin 20 mg PO QPM
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
11. Vitamin B Complex 1 CAP PO DAILY
12. Warfarin 8 mg PO 2X/WEEK (MO,FR)
13. Warfarin 6 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Heart failure with preserved ejection fraction
exacerbation
Secondary: Atrial fibrillation, aortic valve replacement/mitral
valve replacement, complete heart block, diabetes mellitus,
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were having difficulty
breathing and you were unable to lie flat without becoming short
of breath. You were given a medication called Lasix to help
remove the fluid. You will continue taking this medication when
you go home.
Because your INR was low, you were started on lovenox to thin
your blood until your INR is back up. Follow up with coagulation
clinic in order to monitor your INR and determine when to stop
lovenox.
Please follow up with your Cardiologist and your Primary Care
Physician. You will need to have labs drawn in one week to check
your kidney function and electrolytes.
Please weigh yourself daily and call your doctor if your weight
increased by more than 3lbs in one day. Also call your doctor if
you develop swelling in your legs. Please keep a low sodium diet
to help prevent these symptoms from recurring.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
19650099-DS-9
| 19,650,099 | 20,417,161 |
DS
| 9 |
2154-01-19 00:00:00
|
2154-01-19 08:01:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
mangoes
Attending: ___
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
___. Insertion traction pin, right distal femur.
2. Application posterior splint, left lower extremity.
___. Intramedullary nailing of right femur fracture with
Synthes retrograde nail, 12 x ___.
2. Open reduction internal fixation of left bicondylar
tibial plateau fracture with both medial and lateral
plating.
3. Open reduction internal fixation of left ankle fracture
with plating of distal fibula.
4. Examination under anesthesia with external rotation and
stress for assessment of mortisSe stability.
5. Closed treatment of tibial spine fracture, right side.
History of Present Illness:
Mr. ___ is a ___ year old male passenger involved in a
high-speed MVC. Patient was driving with a
friend going over 65mph. The vehicle went over a hill and became
airborne for a short period of time. When the wheels hit the
ground the driver lost control and the vehicle struck a tree.
Following a ___ hour extrication both driver and passenger were
brought to ___ for further care. On initial trauma evaluation
the below injuries were identified.
Right upper lobe pulmonary contusion
Left frontal sinus fracture
Left sphenoid sinus fracture
Left zygomatic arch fracture
Left orbit lateral fracture
Left tibia, distal fibula fracture
Right femur fracture
The patient was admitted to the ___ service for further
management.
Past Medical History:
Unknown at time of admission
Family History:
Non-contributory
Physical Exam:
On admission per ED note:
Constitutional: Collar and backboard
HEENT: Left supraorbital abrasions and ecchymosis and
tenderness
, Extraocular muscles intact, Pupils equal, round and
reactive to light
Neck is nontender, collar. There is a small amount of blood
coming from the right ear but there is no hemotympanum
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Right hip ecchymosis. Right hip deformity. Right
lower extremity is neurovascular intact there is a left
proximal tib-fib deformity as well. Left lower extremity is
neurovascular intact. The right ankle has an ecchymosis but
no significant tenderness. Right elbow has an abrasion but
there is no significant tenderness or deformity. Right upper
extremity is neurovascular intact the
Neuro: Speech fluent he is awake alert oriented x3. Normal
motor normal sensory cranial nerves II through XII intact
normal rectal tone
On discharge:
VS 99.1, 108, 112/65, 99% on room air
Pertinent Results:
___ 04:20PM BLOOD WBC-16.5* RBC-5.15 Hgb-16.1 Hct-48.0
MCV-93 MCH-31.2 MCHC-33.5 RDW-12.8 Plt ___
___ 12:28AM BLOOD WBC-13.9* RBC-4.11* Hgb-13.0*# Hct-37.9*#
MCV-92 MCH-31.7 MCHC-34.3 RDW-13.1 Plt ___
___ 08:41PM BLOOD Hct-26.7*
___ 02:16PM BLOOD Hct-23.9*
___ 06:00AM BLOOD WBC-12.4*# RBC-2.63* Hgb-7.5* Hct-23.2*
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.6 Plt ___
___ 06:05AM BLOOD WBC-11.9* RBC-2.69* Hgb-7.8* Hct-24.5*
MCV-91 MCH-29.0 MCHC-31.8 RDW-14.8 Plt ___
___ 05:48AM BLOOD Neuts-73.2* ___ Monos-3.7 Eos-2.7
Baso-0.5
___ 05:36AM BLOOD Neuts-73.1* ___ Monos-4.3 Eos-2.4
Baso-0.4
___ 06:00AM BLOOD Neuts-83* Bands-0 Lymphs-9* Monos-5 Eos-1
Baso-1 ___ Metas-1* Myelos-0
___ 06:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-1+
___ 04:20PM BLOOD ___ PTT-25.4 ___
___ 05:36AM BLOOD Ret Aut-4.1*
___ 04:20PM BLOOD ___ 05:50AM BLOOD Glucose-114* UreaN-11 Creat-0.7 Na-136
K-3.8 Cl-97 HCO3-26 AnGap-17
___ 06:00AM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-135
K-4.3 Cl-97 HCO3-27 AnGap-15
___ 05:36AM BLOOD ALT-49* AST-55* LD(LDH)-249 AlkPhos-127
TotBili-0.8
___ 06:00AM BLOOD ALT-64* AST-45* AlkPhos-113 TotBili-1.1
___ 05:50AM BLOOD Calcium-8.6* Phos-3.9 Mg-1.6
___ 06:00AM BLOOD Calcium-8.6* Phos-3.2 Mg-2.1
___ 05:36AM BLOOD Hapto-359*
___ 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
___ CT head without contrast
1. Multiple facial bone and skull base fractures, better
evaluated on
accompanying facial bone and cervical spine CTs.
2. Tiny hyperdensity along the anterior left temporal lobe
adjacent to a left
sphenoid fracture could be artifactual but trace extra-axial
hematoma is quite
possible given adjacent fractures. A follow-up CT should be
considered for
surveillance if clinically indicated.
___ CT sinus/mandible/maxilla
1. Several facial bone and skull base fractures. Fractures are
detailed
above and involve the posterior sphenoid sinus wall, tuberculum
sella,
posterior clinoid process and orbital apex, including sellar
involvement with
air in the sellar region and suprasellar cistern, although exact
location is
uncertain, possibly intruding into the caverous sinus; along the
floor of the
left middle cranial fossa, including the left sphenoid body and
greater wing;
left maxillary sinus posterolateral wall; anterior and posterior
tables of the
left frontal sinus with pneumocephalus; left orbital lateral and
medial wall;
and left zygomatic arch.
2. Fluid in the right external auditory canal and air in the
right
temporomandibular joint suggest a subtle right petrous apex
fracture, though a
discrete fracture line is not visualized.
3. Tiny hyperdensity adjacent to left sphenoid fractures in the
left temporal
lobe may be artifactual but is concerning for extra-axial
hematoma. This
could be further evaluated with a repeat head CT.
___ CT chest, abdomen, pelvis with contrast
1. Small left lower lobe ___ ground glass opacities,
consistent with
aspiration.
2. Small right upper lobe anterior ground-glass opacity, most
consistent with
pulmonary contusion. No pneumothorax.
___ Left tib/fib (AP and lat)
1. Complex bicondylar fracture of the tibial plateau,associated
lipohemarthrosis, articular surface depression and distraction
of the fracture
fragments at the level of the articular surface. Recommend CT
for better
characterization prior to surgical fixation.
2. Poorly visualized lateral and medial malleolar fractures of
the left ankle
with minimal displacement. The dedicated left ankle radiograph
is recommended
to assess.
___ Right femur (AP & lat)
Comminuted fracture through the mid shaft of the right femur.
Joint effusion at the right knee for which dedicated views of
the right knee
are recommended to further assess for a tibial plateau fracture.
___ CT low ext w/o c left
Comminuted tibial plateau fracture, Schatzker type VI.
___ CT head without contrast
1. Partial opacification of the right mastoid air cells and
middle ear cavity
compared to ___. This raises the possibility of a
right temporal
bone fracture, which could be further evaluated with dedicated
CT if
clinically indicated.
2. Multiple facial bone fractures better evaluated on the
preceding facial
bone CT of ___.
3. No acute intracranial hemorrhage.
4. Subtle effacement of the cerebral sulci raises the
possibility of cerebral
edema although the gray-white interface appears relatively
preserved and basal
cisterns are patent.
___ Lower extremity vein studies
1. No evidence of DVT in the right leg.
2. No evidence of DVT in the left common femoral and superficial
femoral
veins. The left popliteal and calf veins are not well
visualized due to
overlying skin incisions.
___ EEG
This is an abnormal routine EEG due to the presence of a slow,
disorganized background with superimposed bursts of generalized
slowing. These
findings indicate the presence of a moderate encephalopathy
which suggests
diffuse cerebral dysfunction but is non-specific as to etiology.
No focal or
epileptiform features were seen. Note is made of tachycardia on
the cardiac
rhythm strip.
___ CT orbit, sell and IAC w/o contrast
Multiple facial fractures as described above. No new fractures.
No new bone fragments. The fracture involves the left inferior
wall of the
optic canal.
___ CT chest w/contrast
1. Bilateral, diffuse ground-glass opacities with slight lower
lobe
predominance, suggestive of an infectious process, likely
atypical in
etiology.
2. There are no collections within the abdomen or pelvis. There
are multiple
small lymph nodes along the mesentery, not enlarged by CT
criteria.
___ MRI head without contrast
Scattered white matter abnormalities without restricted
diffusion. Differential would include subacute infarcts or
demyelination
given the periventricular location of some of these
abnormalities. Please
note that MRI of the orbits would be sensitive for detection of
changes in the
optic nerve.
Brief Hospital Course:
As previously discussed, Mr. ___ is a ___ year old male who
was a passenger in a high-speed ___. His injuries include:
Right upper lobe pulmonary contusion
Left frontal sinus fracture
Left sphenoid sinus fracture
Left zygomatic arch fracture
Left orbit lateral fracture
Left tibia, distal fibula fracture
Right femur fracture
The patient was admitted to the Trauma ICU under the Acute Care
Surgical (ACS) service for further management. ICU course is as
follows:
He was initially admitted to ___ then transferred out to floor.
On ___ he was taken to OR for right femur pinning. The
procedure went well and he was alert and oriented post
operatively with increased dilaudid PCA overnight. On AM rounds
patient was found to be poorly responsive. He underwent stat
head CT that was evaluated by neurosurgery with no acute
radiographic changes. He was then transferred to SICU for closer
monitoring.
By systems:
Neuro: He was maintained on q1 neuro checks, sinus precautions,
and kept on antibiotics for facial fractures. He did have a fair
amount of agitation following extubation requiring intermittent
haldol, but this resolved with time.
CV: On ICU admission he was in sinus tachycardia which resolved.
Resp: He was extubated following his ORIF. He was weaned to
room air.
Gastrointestinal / Abdomen: Following extubation his diet was
advanced to regular diet.
ID:
- cipro/dex eardrops
- Unasyn Q6 for facial fractures
Mr. ___ was transferred to the inpatient ward on ___. The
non-ICU course is as follows:
Neuro: The patient's neurologic status improved over time. His
pain was treated with narcotic and non-narcotic analgesics. Due
to waxing and waning of his mental status, a MRI of the head as
well as a 20 minute EEG was obtained. Those results were
non-specific in nature. Mr. ___ was assessed frequently
throughout this time and his behavior was consistent with
traumatic brain injury.
HEENT: The patient continued on Ciprodex ear drops for his
right ear laceration per recommendations by ENT.
CARD: Mr. ___ was hemodynamically stable during his
inpatient stay. Intermittent tachycardia was often due to pain
and/or agitation.
PULM: The patient had no issues of respiratory compromise
during his inpatient floor stay. He was saturating well on room
air. CT results of the chest had shown bilateral ground-glass
opacities in the lung bases. The patient has maintained a
normal oxygen saturation > 98%, has had no respiratory
compromise, no tachypnea, no cough, dyspnea, secretions.
GI: Mr. ___ was tolerating a regular diet without issue. A
number of days had passed where he had no bowel movements. He
was given an aggressive bowel regimen consisting of daily
Colace, senna and Miralax. H was also given one dose of
methylnaltrexone, and PRN dulcolax suppositories, magnesium
citrate (2 doses) and mineral oil. Those medications were
successful in facilitating a bowel movement.
GU: The patient was unable to void on ___ after the removal of
his urinary catheter. The Foley was replaced and he was started
on Flomax. The second catheter was removed on ___ and he has
voided fine since that time.
ID: Unasyn was initiated for empiric therapy (for facial
fractures) during the post-operative period. Due to
intermittent febrile states, Infectious Disease was consulted.
Based on their recommendations, the patient was started on
vancomycin and cefepime; Unasyn was discontinued. Lower
extremity doppler studies were negative for a DVT. Cultures had
been negative. The patient never had a sputum specimen since he
had no cough or sputum production. While on antibiotics, Mr.
___ WBC increased from 7 to 12 on ___. Further testing was
conducted, including urine legionella, blood and urine cultures.
All test have been negative to date. During this time, the
patient has felt well and was anxious to move to a
rehabilitation facility. Since there was no data supporting an
infectious process, i.e. normal vital signs, no cough, his
leukocytosis and intermitted febrile states were attributed to a
SIRS response from his multi-traumatic injuries.
On ___, the patient was noted to have a red, raised rash on his
buttocks and lower back. With the likelihood of a fungal
process, the patient was started on three days of fluconazole
PO.
HEME: The patient was transfused three units of PRBCs
intra-operatively on ___. On ___, Mr. ___ hematocrit was 20
and was experiencing tachycardia in the 120s. He was transfused
one unit of PRBCs. His post-transfusion HCT bumped
appropriately to 23.8. His H/H has been stable since that time.
Mr. ___ underwent both physical and occupational therapy
during his stay. From a physical standpoint, he could place
weight on his right leg and partial weight on his right.
According to ___ notes, he has made improvement from this
standpoint. From a cognitive standpoint, Mr. ___ has also
made great improvements. As recommended by Occupational
Therapy, he should continue to receive cognitive therapy
secondary to traumatic brain injury and he should also follow up
with Cognitive Neurology on an outpatient basis.
At the time of discharge, Mr. ___ was hemodynamically stable
and in no acute distress.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Bisacodyl 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
5. Fluconazole 200 mg PO Q24H
Last dose ___. Lorazepam 0.5 mg PO Q6H:PRN anxiety
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 2 TAB PO BID
10. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Right external ear canal laceration
- Right upper lobe pulmonary contusion
- Left frontal sinus fracture
- Left sphenoid sinus fracture
- Left zygomatic arch fracture
- Left petrous ridge fracture
- Left lateral orbit fracture
- Left tibial, distal fibula fracture
- Right femur fracture
- Concussion/Traumatic Brain Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to ___ on
___ after you were involved in a motor vehicle accident. On
further evaluation, you were found to have the following
injuries:
- Right external ear canal laceration
- Right upper lobe pulmonary contusion
- Left frontal sinus fracture
- Left sphenoid sinus fracture
- Left zygomatic arch fracture
- Left petrous ridge fracture
- Left lateral orbit fracture
- Left tibial, distal fibula fracture
- Right femur fracture
- Concussion, traumatic brain injury
You were seen by the Orthopedics, Opthalmology, Infectious
Disease, ENT and Neurology services for the above injuries.
Ear laceration: ENT started you on ear drops (antibiotics) to
prevent an ear infection. No follow-up is needed.
Sinus fractures: The Plastic surgery team evaluated your
numerous sinus fractures. They were non-operative in nature.
You should continue to follow "sinus precautions" (as noted
below) until follow-up with the Plastic Surgery service
(appointment below).
Concussion: You were evaluated by Neurosurgery and Occupational
Therapy related to your traumatic brain injury. You have
recovered well from your head injury. You will continue to
receive cognitive therapy at the rehabilitation facility. You
should also follow-up with Cognitive Neurology (Dr. ___
___ at the appointment noted below.
Orthopedic injuries: You were taken to the operating room on
___ and ___ for repair of your left tibial, distal fibula and
right femur fracture. You tolerated those procedures well.
Post-operatively, you were seen by Physical Therapy on multiple
occasions. At this time, you are allowed to bear full weight as
tolerated to your right leg and touch-down weight bearing on
your left. You will continue to receive physical therapy at the
rehabilitation facility. You'll be following up with Orthopedic
surgery at the appointment noted below.
Your care will continue to be managed by ___
___.
Followup Instructions:
___
|
19650110-DS-13
| 19,650,110 | 21,783,576 |
DS
| 13 |
2171-12-19 00:00:00
|
2171-12-19 16:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
Periaortic gas
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of afib (holding coumadin due to recent GI
bleed), TAAA s/p EVAR (___) c/b type 1 endoleak s/p fenestarted
TAAA repair (___) c/b graft infection s/p explantation and
repeat repair (___) c/b spinal cord ischemia, left
hemothorax
s/p L VATSx2 (___). He had an episode of dyspnea
and increased serous leakage from his prior left chest tube site
at rehab so he was sent to thoracic clinic for further
evaluation. He is now sent into the ER from thoracic surgery
clinic
after obtaining CT chest showing locules of air around the
aortic
graft. His left-sided chest findings are stable. In the ED he
was
asymptomatic and on room air, denying dyspnea or chest pain.
Denies fevers or chills, abdominal pain, po intolerance. He is
continuing on his IV antibiotics (vanc/zosyn) at rehab.
Past Medical History:
AAA: S/p EVAR ___ ; re-do EVAR ___ ; open repair ___
paraplegia since ___ spinal cord infarct post-operatively
HTN
Hyperlipidemia
Psoriasis
Iron deficiency anemia with ___ work up ___
H pylory diagnosed on EGD biopsy ___, unclear if treated
Social History:
___
Family History:
Family history and review of systems are detailed
in the health questionnaire, but are otherwise noncontributory
Physical Exam:
General- well-appearing, NAD
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes
Cardiac- RRR
Chest- CTAB. well-healing incision. prior chest tube site
sutured
with small surrounding erythema, no drainage.
Abdomen- soft, nontender, nondistended. No rebound or guarding.
Well-healed midline incision extended to left chest wall
(staples removed), several cm area of stable eschar without
erythema or purulence.
Ext- WWP, 1+ edema, palpable ___ pulses bilaterally.
Neuro-lower extremities paralyzed bilaterally. persistent
numbness in feet but sensation improving proximally up legs.
Pertinent Results:
___ 03:55PM cTropnT-0.24*
___ 12:26PM cTropnT-0.23*
___ 11:54AM cTropnT-0.23*
Brief Hospital Course:
Due to elevated troponins at presentation, cardiology was
consulted and recommended aspirin 81 mg daily, metop succinate
12.5 mg daily, atorvastatin 80 mg daily, Transthoracic echo to
eval for wall motion abnormality, They also recommend
consideration of warfarin initiation for goal INR ___ if ongoing
stability with bleeding issues and assurance of
close INR monitoring. The patient should also follow up with Dr.
___ at ___ Cardiology on discharge.
In terms of his on-going infection, infectious disease was also
consulted and recommend Vancomycin 1000 mg IV Q 24H and
Piperacillin-Tazobactam 4.5 g IV Q8H. His antibiotic course was
also extended from ___ to ___. OPAT will follow up as an
outpatient and the patient will require weekly blood work that
should be communicated to ___ services at ___. (See patient
instructions).
For on-going aortic graft issues, the patient will follow up in
clinic in 2 weeks with further imaging.
Due to wound on his coccyx, the patient was also seen by the
wound care nurse for recommendations. Staples from the
thoraco-abodominal incision and the groin incisions were also
removed.
Medications on Admission:
MEDICATIONS:
1. Amiodarone 200 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation erate
5. Pantoprazole 40 mg PO BID
6. Piperacillin-Tazobactam 2.25 g IV Q6H
7. Senna 8.6 mg PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO QHS
9. Vancomycin 1250 mg IV Q 24H
10. atorvastatin 80mg qpm
11. dronabinol 5mg BID
12. furosemide 40mg BId
13. ativan 0.5mg po q6 prn anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*42 Vial Refills:*0
5. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1 g IV q24h Disp #*14 Vial Refills:*0
6. Amiodarone 200 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Collagenase Ointment 1 Appl TP DAILY
9. Docusate Sodium 100 mg PO BID
10. Dronabinol 5 mg PO BID
11. Furosemide 40 mg PO BID
12. LORazepam 0.5 mg PO Q6H:PRN anxiety
13. Pantoprazole 40 mg PO Q24H
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Concern for ___ graft air
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:
WHAT TO EXPECT:
- It is normal to have incisional and leg swelling; Wear loose
fitting pants/clothing (this will be less irritating to
incision) Elevate your legs above the level of your heart with
___ pillows every ___ hours throughout the day and at
night; Avoid prolonged periods of standing or sitting without
your legs elevated
- It is normal to have a decreased appetite, your appetite will
return with time You will probably lose your taste for food and
lose some weight Eat small frequent meals It is important to
eat nutritious food options (high fiber, lean meats,
vegetables/fruits, low fat, low cholesterol) to maintain your
strength and assist in wound healing To avoid constipation: eat
a high fiber diet and use stool softener while taking pain
medication Take all the medications you were taking before
surgery, unless otherwise directed- Take one enteric coated
aspirin daily, unless otherwise directed
ACTIVITIES:;
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit You may shower (let the soapy water
run over incision, rinse and pat dry) Your incision may be left
uncovered, unless you have small amounts of drainage from the
wound, then place a dry dressing over the area
CALL THE OFFICE FOR : ___ Redness that extends away
from your incision A sudden increase in pain that is not
controlled with pain medication Temperature greater than 101.5F
for 24 hours Bleeding from incision New or increased drainage
from incision or white, yellow or green drainage from incisions
Warfarin:
- Follow up with your Gi doctor and your PCP regarding when to
restart coumadin after your evaluation for GI is bleed is
complete. They will discuss when it is safe to restart this
medication.
Coccyx Wound care instructions:
Topical Therapy:
CLEANSE WOUND WITH NORMAL SALINE ONLY!
Pat the tissue dry with dry gauze.
Apply thin layer of antifungal criticaid to periwound skin to
protect periwound skin.
Apply nickel thick layer of Santyl gel to the open wound.
Cover with moistened (with normal saline) 2 x 2 gauze.
Then place small softsorb over.
Secure with pink hy tape.
Change daily
IV Antibiotics:
Start Date: ___
Projected End Date WAS PREVIOUSLY ___ --> Extended by at
least 3 weeks through to ___
You will need blood work after you leave the hospital to monitor
the antiobiotics regimen.
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
VANCOMYCIN / PIP-TAZO: WEEKLY: CBC with differential, BUN, Cr,
Vancomycin trough
*PLEASE OBTAIN WEEKLY CRP
FOLLOW UP APPOINTMENTS:
ID/OPAT - to be determined
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
It is important to go to all of your follow up appointments. It
is recommended that you follow up with your PCP ___ ___ weeks as
well.
Followup Instructions:
___
|
19650111-DS-6
| 19,650,111 | 20,103,702 |
DS
| 6 |
2140-03-07 00:00:00
|
2140-03-07 12:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
omeprazole / Dexilant
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP with biliary stent placement
History of Present Illness:
___ yo presents with abdominal pain and nausea due to biliary
obstruction. Pt presented initially to PCP. CT scan found
pancreatic ductal dilitation with filling defect at lower end of
CBD. Pt instructed to present to ED for further eval. She
reports 4 months of intermittent epigastric pain which worsened
over the past few weeks. Pain is associated with nausea, loose,
pale stool, orange urine and yellowing of eyes and skin for the
past week. Pain is not worse with food.
In ED pt had RUQ US which showed massive biliary dilation. ERCP
notified.
On arrival to floor pt currently has no complaints. Denies pain
or nausea. Has been npo.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
___ esophagus
palpitations
NPH
HLD
Pernicious anemia
osteopenia
Surgeries: shunt in brain for NPH, thyroidectomy, lump removed
from breast, tonsillectomy
Social History:
___
Family History:
mother w/colon ca in ___
father w/pancreatic ca in ___
Physical Exam:
Vitals: T:99.6 BP:132/87 P:86 R:18 O2:98%ra
PAIN: 0
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge:
Afebrile 123/79 p64 R18 99RA
GEN: well appearing, comfortable
HEENT: improving icterus
RESP: CTA B.
CV: RRR.
Abd: benign
Skin: improving jaundice.
Pertinent Results:
___ 05:15PM BLOOD WBC-8.2 RBC-3.13* Hgb-9.5* Hct-30.8*
MCV-99* MCH-30.3 MCHC-30.7* RDW-16.0* Plt ___
___ 06:20AM BLOOD WBC-7.1 RBC-2.94* Hgb-9.5* Hct-29.8*
MCV-102* MCH-32.3* MCHC-31.8 RDW-16.4* Plt ___
___ 05:15PM BLOOD Neuts-78.1* Lymphs-15.6* Monos-5.1
Eos-0.8 Baso-0.5
___ 05:15PM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-138
K-3.1* Cl-102 HCO3-26 AnGap-13
___ 06:20AM BLOOD Glucose-55* UreaN-7 Creat-0.5 Na-139
K-4.1 Cl-105 HCO3-23 AnGap-15
___ 05:15PM BLOOD ALT-263* AST-175* AlkPhos-571*
TotBili-11.2*
___ 06:35AM BLOOD ALT-242* AST-159* AlkPhos-534*
TotBili-10.5*
___ 06:30AM BLOOD ALT-197* AST-142* AlkPhos-492*
TotBili-12.6*
___ 06:20AM BLOOD ALT-171* AST-97* AlkPhos-514*
TotBili-15.0*
___ 06:10AM BLOOD ALT-143* AST-90* AlkPhos-442*
TotBili-10.7*
___ 05:15PM BLOOD Lipase-189*
___ 06:20AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
___ 06:35AM BLOOD calTIBC-381 VitB12-GREATER TH Ferritn-23
TRF-293
___________________________
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
IMPRESSION: Massive dilation of the intra- and extra-hepatic
biliary duct as well as the pancreatic duct. Cause of
underlying obstruction is a rounded homogeneous structure in the
region of the ampulla without shadowing to suggest that it is a
stone. Further evaluation of this mass is suggested by MRCP
and/or ERCP.
___________________________
CTA ABD W&W/O C & RECONS Study Date of ___ IMPRESSION:
1. 2.3 cm ampullary mass with enlargement of multiple
periportal/peripancreatic and retroperitoneal lymph nodes, the
significance of which is uncertain, particularly in the context
of VP shunt history.
2. CBD stent is located in the distal CBD, slightly lower
positioned than
typically seen. Correlate with procedure history.
___________________________
ERCP Impression:
The scout film revealed a VP shunt.
A 3 cm friable intra-ampullary mass was seen
The common bile duct, common hepatic duct, left hepatic ducts
and left biliary radicles were filled with contrast and well
visualized. The right ductal system not was not well visualized.
A severe diffuse dilation was seen at the biliary tree with the
CBD and CHD measuring 12 mm.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification.
Opacification of the gallbladder was incomplete.
The left hepatic ducts and left intrahepatic branches were
dilated as well.
As mentioned, the right intrahepatic ducts were not well
visualized.
Cannulation of the pancreatic duct was successful and
superficial with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in partial opacification.
A moderate dilation was seen at the main pancreatic duct
Cytology samples were obtained for histology using a brush.
Cold forceps biopsies were performed for histology at the major
papilla.
A 6cmx10Fr Cotton ___ biliary stent was placed successfully.
There was excellent flow of bile at the end of the procedure.
Recommendations: Return to floor under ongoing care.
IV hydration with LR at 200 cc/hr as tolerated.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
No aspirin, Plavix, NSAIDS, Coumadin for 5 days
Case will be discussed directly with Dr. ___ left).
We will arrange for a CTA prior to D/C home.
The patient will follow-up with Dr. ___ of general
surgery)
__________________________
PENDING:
___ Pathology Tissue: AMPULLA OF VATER, BIOPSY
___ Cytology BRUSHING
Brief Hospital Course:
___ with several months of intermittent epigastric abdominal
pain and one week of jaundice found to have very high bilirubin
and CBD dilation. Pt underwent ERCP with finding mass at ampulla
concerning for probable malignancy. Pt has been evaluated by Dr.
___, and will undergo surgical resection after
discharge.
#Biliary Duct Obstruction:
She presented with several months of intermittent epigastric
abdominal pain and one week of jaundice and was found to have
elevated bilirubin and common bile duct dilation on ultrasound.
There was low suspicion for infection on presentation given she
was afebrile, normal WBC count. Ultrasound showed possible mass
versus stone at the ampulla. She underwent ERCP with finding of
a friable ampullary mass causing biliary obstruction. A biliary
stent was placed with good bile flow. She will be treated with 5
days of Cipro to minimize risk of cholangitis, per ERCP
recommendations. Her LFT's subsequently downtrended prior to
discharge. A CTA abdomen was performed for surgical planning,
and Dr. ___ was consulted for surgical evaluation. Pt is
deemed a surgical candidate, and she will follow up with Dr.
___, with surgical date of ___. She will
present to Perioperative Testing to complete preop testing
immediately following discharge.
# Iron deficiency anemia
# Pernicious anemia
Unclear baseline hematocrit but found to have normocytic amemia.
B12 was normal. Iron studies were consistent with iron
deficiency (low ferritin). She reported having a colonoscopy in
the past several months. Her HCT remained stable, and further
evaluation and management was deferred to outpatient management.
CHRONIC:
Hypothyroid: continued on synthroid
___ Esophagus: nexium was restarted at discharge
Palpitations: continued on metoprolol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg IM/SC Q1MO
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. NexIUM (esomeprazole magnesium) 40 mg oral daily
4. Levothyroxine Sodium 88 mcg PO 3X/WEEK (___)
5. Levothyroxine Sodium 100 mcg PO 3X/WEEK (MO,FR)
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO 4X/WEEK (___)
2. Levothyroxine Sodium 100 mcg PO 3X/WEEK (___)
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*4 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg IM/SC Q1MO
6. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Bile duct obstruction
# 2.3 cm friable intra-ampullary mass, concerning for probable
malignancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were found to
have evidence of bile duct obstruction on imaging and lab work.
You underwent ERCP which showed a mass that is concerning for
probable cancer. Your bile duct was stented and your jaundice
improved. You were evaluated by Dr. ___, and you
will follow up with him for surgery to remove the mass.
Followup Instructions:
___
|
19650163-DS-11
| 19,650,163 | 20,124,156 |
DS
| 11 |
2201-06-20 00:00:00
|
2201-06-20 20:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, inability to ambulate
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ left hip replacement, HTN presents w/ recurrent back
pain. Says it began about a week ago, does not recall any
injuries or inciting events. Pain is in left flank pain, sharp,
non-radiating, worse with sitting up, bending over, movement.
Has been unable to walk secondary to pain for past 2 days.
Denies trauma, fever/chills, urinary retention (incontinent at
baseline), bowel incontinence, focal neuro weakness or numbness.
Denies any dysuria, hematuria. Nursing facility notes she has
had increasing urinary incontinence for the past few days. Came
to ED yesterday, CT neg for retroperitoneal process, fracture,
stone. Dc'd with ibuprofen. Returns for recurrent pain.
In the ED, initial vitals 97.4 102 120/80 18 95%
On arrival to the floor, vitals were 97.4, 132/92, 87, 16,
97%/RA. Patient alert and oriented, denies any pain when lying
quietly, but reports that pain is "excrutiating" when she moves.
Unwilling to sit up or roll to the side for exam out of fear re:
pain. No other complaints.
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:
left hip fracture ___ with left hip ORIF
atrial fibrillation
HTN
hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS - 97.4 102 120/80 18 95%
GENERAL - Well-appearing ___ yo F lying comfortably in bed
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Lungs CTA in anterior lung fields
HEART - irregularly irregular, no murmurs appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). ___ test. some trochanteric bursa.
NEURO - awake, A&Ox3, good fund of knowledge, CNs II-XII grossly
intact, muscle strength grossly equal in bilateral lower
extremities, although somewhat difficult to assess due to back
pain with left leg raise, sensation grossly intact throughout
Discharge:
VS - Tmax 98.4 130-140/70-80, 85-92, 18, 94%/RA
GENERAL - ___ yo F lying comfortably in bed, visibly
uncomfortable when head of bed raised
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - Lungs CTA in anterior lung fields
HEART - irregularly irregular, no murmurs appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, compression stockings in place.
Patient reports back pain with both active flexion of the left
hip, mild pain with passive flexion, no tenderness to palpation
noted
NEURO - awake, A&Ox3, somewhat slow to respond, CNs II-XII
grossly intact, muscle strength grossly equal in bilateral lower
extremities, although exam limited by pain, sensation grossly
intact throughout
Pertinent Results:
Admission labs:
___ 08:00PM BLOOD WBC-10.3 RBC-4.63 Hgb-14.3 Hct-43.1
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.5 Plt ___
___ 08:00PM BLOOD Neuts-72.3* ___ Monos-7.8 Eos-0.2
Baso-0.2
___ 10:40AM BLOOD ___ PTT-150* ___
___ 08:00PM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-141
K-4.0 Cl-102 HCO3-30 AnGap-13
___ 02:43PM BLOOD Calcium-9.7 Phos-3.2 Mg-1.7
Coagulation labs:
___ 01:20PM BLOOD ___ PTT-65.8* ___
___ 06:12AM BLOOD ___ PTT-62.7* ___
___ 05:45AM BLOOD ___ PTT-52.6* ___
Imaging:
___ CT of abdomen and pelvis
ABDOMEN: There is cardiomegaly. The lung bases demonstrate
dependent
atelectasis. Both breasts show calcifications. The liver
demonstrates a
subcentimeter hypodensity within the dome as well as further
down in the right lobe, too small to characterize likely
representing cysts (4:9 and 24). The gallbladder shows no
stones or wall edema. Spleen is normal in size. The adrenal
glands are normal. The pancreas demonstrates at least two
subcentimeter hypodensities in the head and body (___) that
likely represent cysts or small side branch IPMNs, but require
no further follow-up in a patient of this age. The kidneys
enhance with and excrete contrast symmetrically without evidence
of hydronephrosis or stones. A focal area of cortical
thickening in the left lower pole likely represents prior
infarct or infection (4:31). The small and large bowel show no
evidence of obstruction or wall edema. There is no free air,
free fluid, or lymphadenopathy. The aorta is of a normal caliber
along its course with calcified atherosclerotic disease
primarily in its infrarenal portion.
PELVIS: The bladder and rectum appear unremarkable. There is
no free fluid or lymphadenopathy.
BONES: Multilevel degenerative changes ranging from moderate to
severe are seen throughout the lumbosacral spine and femoral
neck fracture fixation hardware is present on the left without
evidence of hardware failure or loosening in its visualized
portion. Otherwise, there is no aggressive-appearing lytic or
sclerotic lesion.
IMPRESSION: No acute intra-abdominal process.
MRI of lumbar spine ___
FINDINGS: There is scoliosis of lumbar spine seen convexed to
the right in the lower lumbar and to the left in the upper
lumbar region.
From T11-12 to L2-3, disc degenerative changes and bulging
identified. There is mild to moderate narrowing of the right
foramen seen at L2-3 level. There is a small area of low signal
within the T12 vertebral body which appears to be secondary to a
bone island.
At L3-4, disc bulging and facet degenerative changes identified
secondary to scoliosis are predominantly seen on the left side
with moderate to severe left subarticular recess narrowing and
moderate left foraminal narrowing.
At L4-5, disc bulging is seen without spinal stenosis. Mild
narrowing of the left foramen seen.
At L5-S1 level, disc bulging is noted with mild anterolisthesis
of L5 over S1 secondary to facet degenerative changes. There is
severe left subarticular recess narrowing and moderate to severe
left foraminal narrowing.
The paraspinal soft tissues are unremarkable. The distal spinal
cord shows normal signal intensities.
IMPRESSION:
1. Scoliosis of lumbar spine convexed to the right in the lower
lumbar and to the left in the upper lumbar region.
2. Moderate to severe left foraminal narrowing at L3-4 and
L5-S1 levels. Moderate right foraminal narrowing at L2-3 level.
3. Severe left subarticular recess narrowing at L3-4 and L5-S1
levels due to disc and facet degenerative changes.
4. Other changes as described above.
Brief Hospital Course:
___ year old female with hx of htn and remote left hip fracture
presenting with left flank pain that is severe with motion.
Acute issues:
# Back pain: Patient initially presented the day prior to
admission with increased pain limiting ambulation and possibly
increased urinary incontinence. CT showed degenerative changes
of the spine, but no acutes processes, and patient was
discharged. However, she re-presented the next day as pain
continued to be severe. Patient seemed to be neurovascularly
intact on exam, but cord compromise was a concern given
significant degenerative disease and acute inability to
ambulate, so MRI was performed which showed multi-level
foraminal narrowing (particularly at L3-L4 and L5-S1) and
subarticular recess narrowing (L3-L4 and L5-S1). Orthopedic
spine service was consulted. They did not recommend any acute
interventions or surgical management, but recommended that the
patient follow up as an outpatient for discussion of options
such as injections. Pain was determined to be most likely
musculoskeletal in nature, and was treated aggressively with
tramadol and lidocaine patch. Patient was discharged to rehab
for physical therapy and restoration of functional capacity.
# Afib: anticoagulation with warfarin. ___ INR was
supratherapeutic at 5.8, so warfarin was held. Discharge INR was
4.3. Supratherapeutic levels may be due to the levofloxacin that
patient was taking as empiric treatment for UTI. This was held
during admission and patient had no fevers, normal white count
or dysuria.
Chronic issues:
# hypertension: well controlled on home lisinopril, atenolol,
furosemide
# hyperlipidemia: continued home simvastatin
# Anxiety: continued home buspirone
Transition issues:
- INR supratherapeutic. Will recheck INR in 1 day (___) and
have results faxed to ___ NP, who will restart if needed
- recommend neuropsychiatric testing to evaluate for dementia
- can follow up with Ortho Spine for discussion of spinal
injections in future
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from assisted living facility.
1. Atenolol 25 mg PO BID
2. Atenolol 12.5 mg PO QAM
3. BusPIRone 10 mg PO BID
4. Daily Vitamin *NF* (multivitamin) 1 tablet Oral daily
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL ___ SPRY NU DAILY
7. Furosemide 20 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Oyst-Cal-D 500 *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
10. Reguloid *NF* (psyllium husk;<br>psyllium seed (sugar)) 1
teaspoon Oral daily
in ___ oz water
11. Simvastatin 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 3.5 mg PO DAILY
14. Acetaminophen 650 mg PO TID:PRN pain
15. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
16. TraMADOL (Ultram) 50 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO TID:PRN pain
2. Atenolol 25 mg PO BID
3. Atenolol 12.5 mg PO QAM
4. BusPIRone 10 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL ___ SPRY NU DAILY
7. Furosemide 20 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO QID pain
hold for oversedation
11. Vitamin D 1000 UNIT PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to left lower back daily, 12hr on 12hr off
13. Daily Vitamin *NF* (multivitamin) 1 tablet Oral daily
14. Oyst-Cal-D 500 *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
15. Reguloid *NF* (psyllium husk;<br>psyllium seed (sugar)) 1
teaspoon Oral daily
in ___ oz water
16. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN
cough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Back pain
Foraminal narrowing of L3-L4 and L5-S1
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 ___,
___ were admitted to the hospital with severe back pain. We did
an MRI of the spine which showed degenerative changes and nerve
impingement, but did not show any signs of spinal cord
compromise. Our spine surgeons saw ___ and did not recommend
surgery, but ___ can follow up with them as an outpatient to
talk about other options for pain management. We are discharging
___ to a rehab facility for more intensive physical therapy.
Changes to your home medications include:
-tramadol 50mg four times daily for pain
-lidocaine patch for your back
-acetaminophen 1000mg three times daily
-do NOT take your warfarin until told to do so by your primary
care physician
___ was ___ pleasure taking care of ___ during your hospitalization
and we wish ___ a speedy recovery and all the best going
forward.
Followup Instructions:
___
|
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