note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
19650256-DS-7
| 19,650,256 | 29,967,260 |
DS
| 7 |
2131-06-01 00:00:00
|
2131-06-07 20:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ h/o vertigo in the past now presenting
with more sustained and severe vertigo.
Mr. ___ has recently been in his USOH without any viral
prodrome. Last night (___), he was eating some grapes in bed
when he had sudden-onset, unprovoked vertigo. He was initially
not nauseated and could walk with some difficulty. It lasted
about ___ minutes before gradually resolving. If he stayed
still, he felt fine. With head movement in any direction, his
symptoms recurred for another ___ minutes and would resolve if
he kept still. He had perhaps 3 episodes last night.
This morning (___), he woke feeling normal. When he sat up at
the edge of the bed, his vertigo recurred. He vomited for the
first time. Subsequently he has had recurrent symptoms whenever
he moves his head. He has vomited about ___ times today. He can
walk with some difficulty. His hearing is still normal without
tinnitus but he does notice that sometimes the left ear feels
full; this was present last week and has been associated loosely
with prior episodes of vertigo. Similarly, he has occasionally
had a headache over the past couple of weeks (he thinks provoked
by stress, left head, non-tender, lasting hours, non-pulsating,
resolves quickly c ibuprofen, no associated deficits).
He went to ___ this evening and they got a NCHCT
that was reportedly negative (no disc, not viewable in PACS or
LifeImage). He was transferred here for further evaluation. He
did get 1mg LZP at 1800. At the moment, he feels better without
frank vertigo at rest or on head turn. He is still symptomatic
when he gets up out of bed.
Of note, this has happened a couple of times in the past - the
first time was about ___ years ago and the second time was about
___ years ago. There was no emesis associated with those episodes.
Each episode only lasted about a day or so. Both times he sought
medical attention both times and the first time, he had a CT
scan
which was reportedly normal.
ROS: Negative for current headache, neck pain, back pain,
incontinence, trouble producing or understanding speech,
dysarthria, blurred vision, double vision, facial numbness or
weakness, dysphonia, dysphagia, focal weakness or numbness. No
fevers, chills, ear pain, fullness, tinnitus, decreased
audition,
rhinorrhea, sneeze, cough, SOB, chest pain, abdominal pain, C/D,
myalgias, arthralgias, rash, dysuria.
Past Medical History:
- Depression
- RCC s/p partial nephrectomy: ___ year ago ___
- Vertigo: Admitted to ___ once
- Bradycardia: Previously admitted to ___
Social History:
___
Family History:
- Father: ___ ___ car accident - was in good health
- Mother: DM, thyroid abnl, glaucoma - alive in ___
- 2 Sisters: healthy; 1 c HTN
- 2 children: healthy
No h/o stroke in the young, DVT, PE, recurrent miscarriage
Physical Exam:
==============================
ADMISSION PHYSICAL EXAM
==============================
97.8 66 125/72 18 99% RA
GEN: Uncomfortable, non-diaphoretic
HEENT: No ptosis
NECK: Supple, no bruits
CARD: RRR no m/r/g
PULM: CTAB no r/r/w
ABD: Soft NT ND NABS
EXTREM: WWP no c/e, clubbing vs nl variant nail morphology
NEUROLOGIC
- MS: Excellent historian, A&Ox3. Names, repeats normally.
Comprehension intact. Registers/recalls normally. No L/R
confusion, follows complex commands well. DOWIR nl.
- CN: PERRL 3 -> 2 ___. In primary position (and accentuated on
right gaze) there is a counter-clockwise torsional nystagmus. On
up-gaze and left-gaze, there is a pure vertical nystagmus
without
a torsional component. On sitting up (and more so on standing)
symptoms recur and at that time, the nystagmus is more severe
but
it is not qualitatively different. On head impulse testing, he
does NOT lose the examiner's nose. The eyes remained aligned in
all positions without any evidence of skew. EOMI. Face intact to
touch, pin. Face activates fully. Audition is equal and does not
lateralize on Weber testing. Palate and tongue are midline.
Shrug
is full.
- MOTOR: No drift. Normal tone. Full strength. Toes down, no
___. Fine motor symmetric.
- SENSORY: Intact to touch, pin, temperature, direction of
hallux movement. No Romberg.
- REFLEXES: Normal throughout.
- CEREBELLAR: No abnormalities on finger-nose, heel-shin,
mirroring. No checked reflexes. No truncal ataxia (sitting at
edge of bed, arms crossed, eyes closed).
- GAIT: Base is wide, tandems 2 steps before falling to the
left. Able to heel/toe walk. Tried to Unterberger, but after a
few steps unstable and started to vomit.
==============================
DISCHARGE PHYSICAL EXAM
==============================
Hemodynamically stable
GEN: NAD, comfortable
HEENT: MMM, NC/AT
NECK: Supple, no bruits
CARD: RRR
PULM: CTAB
ABD: Soft NT ND
EXTREM: WWP no c/e, clubbing vs nl variant nail morphology
torsional counterclockwise and right-beating nystagmus in all
gazes, worse in right gaze.
No truncal ataxia, falls and unterberger's to left.
NEUROLOGIC
- MS: Excellent historian, A&Ox3. Names, repeats normally.
Comprehension intact. Registers/recalls normally. No left-right
confusion, follows complex commands. Able to say days of month
backwards.
- CN: PERRL 3 -> 2 bilaterally. Torsional counterclockwise
nystagmus in end gaze bilaterally but greater on right gaze.
EOMI. Face intact to light touch, pin prick. Face activates
fully. Audition is equal and does not lateralize on Weber
testing. Palate and tongue are midline. Shrug is full.
- MOTOR: No drift. Normal tone. Full strength. Toes down, no
___. Fine motor symmetric.
- SENSORY: Intact to touch, pin, temperature, direction of
hallux movement. No Romberg.
- REFLEXES: Normal throughout.
- CEREBELLAR: No abnormalities on finger-nose, heel-shin,
mirroring. No checked reflexes. No truncal ataxia (sitting at
edge of bed, arms crossed, eyes closed).
- GAIT: Mildly unstable gait but able to heel/toe walk.
___'s to left.
Pertinent Results:
==========
LABS
==========
___ 04:12PM BLOOD cTropnT-<0.01
___ 05:57AM BLOOD %HbA1c-5.6 eAG-114
___ 05:57AM BLOOD Triglyc-63 HDL-58 CHOL/HD-2.6 LDLcalc-81
___ 05:57AM BLOOD TSH-0.99
___ 04:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:15PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 04:15PM URINE Color-Yellow Appear-Clear Sp ___
==============
IMAGING
==============
MRI HEAD, MRA HEAD AND NECK WITH AND WITHOUT CONTRAST (___):
1. No evidence of hemorrhage, infarction, or mass.
2. Normal MRA of the head and neck.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical history
including vertigo and renal cell carcinoma status post partial
nephrectomy who presented to ___ ED ___ with intermittent
vertiginous symptoms. As neurologic exam showed nystagmus in all
directions, there was initial concern for a central etiology.
Mr. ___ was admitted to the stroke neurology service for
further evaluation and management.
While in the hospital, Mr. ___ underwent an MRI of the head
and MRI/A of the head and neck which were unremarkable. Repeat
exams after he was admitted showed a horizontal right-beating
nystagmus that was present in midgaze and mild on left gaze, but
prominently on right gaze and was also visible as a
right-beating nystagmus when he looked up or down. He had a
Nylan-Barany maneuver down, but that did not provoke any typical
nystagmus for BPPV. He also showed turning to the left in the
___ test suggesting that the right vestibular system was
stronger then the left or that the left was weakened. Thus, it
was thought that the most likely explanation was that he had a
peripheral vestibulopathy on the left (DD: vestibular neuronitis
vs Menierre's Disease). At time of discharge, neurologic exam
showed only a subtle nystagmus in right endgaze, which
habituated, otherwise he was fine. ___ rehab was
arranged at time of discharge. Physical therapy worked with Mr.
___ during hospital stay and deemed him stable for
discharge home.
======================
TRANSITIONS OF CARE
======================
-Will need ___ rehab as an outpatient.
-Vertiginous symptoms were attributed to peripheral
vestibulopathy; stroke work-up (MRI/A head and neck) was
negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. krill oil unknown oral daily
3. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Outpatient Physical Therapy
Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vestibulopathy
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 due to symptoms of vertigo. We
were initially concerned that you may have had a small stroke to
lead to these symptoms. Fortunately, your MRI of the head did
not show a stroke. Your symptoms are likely due to an inner ear
problem (possibly "peripheral vestibulopathy"). This problem and
your symptoms should improve with time.
Please followup with your primary care physician as listed below
to for further medical care.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. We wish you all the best!
Followup Instructions:
___
|
19650283-DS-13
| 19,650,283 | 24,521,702 |
DS
| 13 |
2128-08-11 00:00:00
|
2128-08-18 16:00:00
|
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:
___ Percutaneous cholecystostomy tube placement.
History of Present Illness:
This patient is a ___ year old male who complains of
ABDOMINAL PAIN.
This patient developed abdominal pain and vomiting
approximately 2 or 3 days ago. Last bowel movement was 3
days ago. He has vomited 4 times today. He saw his PCP
earlier today who told the patient to come to the emergency
department. While the patient was taking public
transportation to the ED, he felt the major increase in the
pain and laid down and called paramedics. They measured his
blood sugar at 299, found his initial blood pressure to be
98 systolic, a respiratory rate of 34, and brought him in
here. He denies fever but endorses chills. He denies chest
symptoms. He
denies back pain. He denies urinary tract symptoms.
He has no prior history of surgery.
Past Medical History:
non-insulin dependent diabetes mellitus
hypertension
hyperlipidemia
cholelithiasis
thallasemia trait
Social History:
___
Family History:
No history of cardiac disease
Physical Exam:
Exam: AF/ HR 147/ BP 107/55 / RR35 / spO2 94% on 2 L NC
Gen: Moderate distress
CV: Tachycardic and mildly hypotensive.
Resp: Tachypneic. LCTAB
GI: Severely TTP in RUQ and RLQ/Distended. + ___ sign.
Pertinent Results:
___ 07:50AM BLOOD WBC-6.8 RBC-3.82* Hgb-9.4* Hct-29.8*
MCV-78* MCH-24.6* MCHC-31.4 RDW-15.4 Plt ___
___ 01:25PM BLOOD WBC-18.9*# RBC-5.32 Hgb-12.9* Hct-41.3
MCV-78*# MCH-24.2* MCHC-31.2 RDW-13.5 Plt ___
___ 06:44PM BLOOD WBC-17.0* RBC-4.34* Hgb-10.6* Hct-33.6*
MCV-78* MCH-24.5* MCHC-31.6 RDW-13.5 Plt ___
___ 06:20AM BLOOD ___ PTT-32.1 ___
___ 02:20AM BLOOD ___ PTT-33.4 ___
___ 07:30AM BLOOD Glucose-158* UreaN-17 Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-32 AnGap-11
___ 01:25PM BLOOD Glucose-264* UreaN-39* Creat-2.1*#
Na-120* K-7.5* Cl-82* HCO3-18* AnGap-28*
___ 06:44PM BLOOD Glucose-175* UreaN-36* Creat-1.7* Na-129*
K-3.8 Cl-98 HCO3-21* AnGap-14
___ 01:25PM BLOOD ALT-21 AST-121* AlkPhos-50 TotBili-0.9
___ 06:44PM BLOOD ALT-16 AST-36 LD(LDH)-187 AlkPhos-41
Amylase-26 TotBili-0.9
___ 01:51PM BLOOD Lactate-9.5*
___ 11:11AM BLOOD Lactate-1.3 Na-128* K-3.9
ECHOCARDIOGRAM ___: "CONCLUSIONS:The left atrium is elongated.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF 60%). The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad."
ABDOMINAL CT ___: "IMPRESSION: 1. Acute cholecystitis with
extensive surrounding fat stranding and secondary inflammation
of the hepatic flexure. Intraluminal gas within the gallbladder
is of uncertain etiology, but no fistula is clearly identified
between the gallbladder and bowel. Findings could relate to a
passed stone, or recent
intervention.
2. No intrahepatic biliary dilatation clearly identified, but
mild common bile duct dilatation is noted. The study and the
report were reviewed by the staff radiologist."
Brief Hospital Course:
Mr. ___ presented to the emergency department on ___.
There he was found in the emergency department to be in acute
cholecystitis. He was found to be in acute supraventricular
tachycardia (later determined to be atrial fibrillation). He
was found to be hypotensive, likely hypovolemic and unstable.
He was a poor operative candidate. He was intubated in the ED,
a central line was placed and interventional radiology performed
a bedside ultrasound-guided percutaneous cholecystostomy as the
patient was considered too unstable for a CT-guided procedure.
From there he was transferred to the SICU. Pressors were
initially required to maintain his blood pressure. He was given
IV antibiotics for his infection. Infectious disease was
consulted and remained involved in his care. There his
condition substantially improved. On ___ the patient was
extubated. On ___ the patient was transferred to the floor
where he needed no respiratory support or blood pressure
support. Blood cultures resulted showing pan-sensitive
enterobacter bacteremia. On ___ the patient was transitioned to
oral ciprofloaxcin where he remained. On the floor cardiology
was consulted for management of newly identified atrial
fibrillation with RVR. They started him on a regimen of
metoprolol and recommended starting warfarin ___ a CHADs score
of 3. For the rest of the patient's course on the floor he was
stable, tolerated a full diet and was found to have good ability
to ambulate with assitance. ___ evaluation recommended home
physical therapy. With the patient considered medically stable
he was discharged from the hospital for scheduled follow-up.
Neurologic: sedation required during intubation, but none
required afterwards
Cardiovascular: hemodynamically stable, brief runs of Afib w/RVR
as described above now controlled and started anticoagulation.
Cardiac function found to be good (EF 60% by echo).
Gastrointestinal: Perc. chole placed and draining well, LFTs
within normal limits,
Genintourinary: unremarkable
Infectious: On ciprofloxacin to be discharged home to finish up
a total 2 week course of antibiotics
Endocrine: slightly high blood sugars on sliding scale, well
controlled on home medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D 4000 UNIT PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. GlipiZIDE XL 2.5 mg PO DAILY
6. Enalapril Maleate 20 mg PO DAILY
7. Lovastatin 40 mg Oral qd
8. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN itching
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Enalapril Maleate 20 mg PO DAILY
3. GlipiZIDE XL 2.5 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth TWICE
DAILY Disp #*12 Tablet Refills:*0
6. Metoprolol Tartrate 100 mg PO BID
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
8. Vitamin D 4000 UNIT PO DAILY
9. Lovastatin 40 mg Oral qd
10. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN itching
11. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. OxycoDONE (Immediate Release) 5 mg PO Q6H pain
RX *oxycodone 5 mg 1 tablet(s) by mouth EVERY SIX HOURS Disp
#*20 Tablet Refills:*0
13. Indomethacin 50 mg PO DAILY
RX *indomethacin 50 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth DAILY Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholecystitis
Sepsis
Atrial fibrillation
Discharge Condition:
Medically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were seen in the hospital for an infection of your
gallbladder called acute cholecystitis. You were treated by
placing a catheter into your gallbladder to allow it to drain.
This tube will remain in place for now and will be cared for by
a visiting nurse. You will follow up in ___ clinic on ___ for tube reevaluation and to discuss when the tube will be
removed and when we will permanently remove your gallbladder to
prevent future episodes of this infection.
You were found to have an infection in your blood which is being
actively treated with an antibiotic known as ciprofloxacin. You
must take the full course of ciprofloxacin as directed.
You were found in hospital to have an abnormal heart rythm known
as atrial fibrillation. You were treated for this rythm by
adjusting your metoprolol dosing to take metoprolol tartrate
100mg twice daily. Your home medication of metoprolol succinate
(a once daily dosing) should be stopped. You will make an
appointment to follow up with Dr. ___ in cardiology
clinic. You were also started on a blood thinner called
warfarin (also known as Coumadin) for which you will need
regular blood testing to make sure it is acting at an
appropriate level. You will make an appointment as directed
below to have your first level tested on ___.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* You may take a shower after 24 hours from your surgery have
passed, but do not bathe or go swimming until instructed by your
surgeon.
* No strenuous activity until instructed by your surgeon
Followup Instructions:
___
|
19650344-DS-17
| 19,650,344 | 23,442,126 |
DS
| 17 |
2179-12-15 00:00:00
|
2179-12-15 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dislodged J-Tube
Major Surgical or Invasive Procedure:
___: ___ J-tube replacement
History of Present Illness:
This is a pleasant ___ year-old gentleman with history of gastric
cancer s/p chemotherapy and more recently a robotic-assisted
laparoscopic gastrectomy with Roux-en-Y esophagojejunostomy and
jejunostomy feeding tube placement on ___, presenting
today to our ED following accidental dislodgement of his feeding
tube. Patient was last seen in clinic earlier this week and
found to be
recovering nicely from his procedure, apart from persistent
hiccups that have recently turned into nausea and occasional
episodes of small amounts of emesis. He admits that over the
past week, he has been having problems flushing his tube. He has
been taking approximately six cans of tube feedings per day, but
has also been tolerating a diet to some degree. He was admitted
for J-tube replacement.
Past Medical History:
Past medical history:
Gastric adenocarcinoma
Past surgical history:
- Robotically assisted laparoscopic total
gastrectomy with retrocolic Roux-en-Y reconstruction and
extensive lymphadenectomy and omentectomy; jejunostomy feeding
tube placement: ___
- Appendectomy at age ___
Social History:
___
Family History:
father with bone cancer
Physical Exam:
Admission Physical:
Vital signs - 98.0 76 122/75 19 98% RA
Constitutional - Well appearing, in no distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs. CTAB
Abdominal - Well healed laparoscopic incisions. Right sided
former jejunostomy tube insertion site appears intact, with an
opening that measures approximately 5-6 mm, not actively
drainaing, with no surrounding erythema.
Extremities - Atraumatic, well perfused
Neurologic - Grossly intact. Alert and oriented x 3
Discharge Physical:
- VS:
- Gen: Well-appearing, NAD
- CV: RRR, normal S1/S2
- Resp: CTAB
- Abd: Soft, NT/ND. Well healed incisions from prior surgery.
J-tube in place, dressing c/d/i, no surrounding erythema
- Neuro: AAOx3
Brief Hospital Course:
The patient was admitted for further management of his dislodged
J-tube. The J-tube was not able to be placed and it was decided
against further aggressive manipulation to replace the tube.
Therefore, interventional radiology was consulted to replace the
tube. On ___, the patient underwent fluoroscopically-guided
jejunostomy tube placement with good result. He tolerated the
produre well and was discharged on the day of the procedure.
While admitted, the patient was seen by nutrition who discussed
switching the patient's tube feeds due to nausea. The patient
was switched to Promote w/ fiber - 80 cc/hr cycled daily for 12
hours. Nutrition will follow him to ensure adequate caloric
intake and he will follow with the nutrition clinic as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO Q4H:PRN anxiety
2. Ondansetron 4 mg PO Q8H:PRN nausea
3. Baclofen 10 mg PO TID
4. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
5. Omeprazole 20 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Jevity 1.5 Cal (lactose-free food with fiber) 0.06 gram-1.5
kcal/mL Via J-Tube Daily for 16 Hours
8. Beneprotein (protein;<br>whey protein isolate) 6 gram-25
kcal/7 gram Via J-tube tid
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Beneprotein (protein;<br>whey protein isolate) 6 gram-25
kcal/7 gram Via J-tube tid
3. Lorazepam 1 mg PO Q4H:PRN anxiety
4. Omeprazole 20 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
7. Promote with Fiber (lactose-free food with fiber) 80 cc/hr
oral cycled daily for 12 hours
Promote w/ Fiber @80 mL/hr over 12 hours (960 kcal/60 g protein)
RX *lactose-free food with fiber [Promote with Fiber] 80 cc/hr
via J-tube Cycled daily for 12 hours Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastric Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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. Avoid heavy lifting until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Do not drive or operate heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
J tube Care:
*You may shower.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the tube attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19650367-DS-20
| 19,650,367 | 21,055,110 |
DS
| 20 |
2151-01-18 00:00:00
|
2151-01-18 16:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Visual defects
Major Surgical or Invasive Procedure:
none
History of Present Illness:
NIHSS was performed within 6 hours of patient presentation or
neurology consult at 00:20.
HPI:
Mr. ___ is a ___ right-handed man with history
notable
for paroxysmal atrial fibrillation (not on anticoagulation)
transferred from ___ after presenting with acute-onset
vision change as well as transient confusion.
Mr. ___ was reportedly in his usual state of health until
18:30 this evening, during which time he was squatting in the
kitchen to organize a low-lying cupboard. On rising quickly to a
standing position, he reported onset of marked lightheadedness
(without vertigo or disequilibrium) as well as "blurring" of his
vision. Mr. ___ son noted that during this period, he asked
about some unrelated matters, such as whether his son "had taken
care of the car keys" or about the whereabouts of a spatula,
prompting his son to ask him to lie down. No dysarthria or
word-finding difficulty was noted during this period. After
reclining, Mr. ___ lightheadedness and speech changes
resolved, though he continued to have "blurring" and "darkening"
of his vision, prompting EMS activation and referral to ___. There, by about 19:00, his vision was starting to
improve, ultimately returning to baseline around 20:00; at its
nadir, however, Mr. ___ reports "barely seeing anything" in
the ambulance. He did recall a mild, bifrontal headache at the
time, but denies associated photo- or phonophobia, nausea, or
vomiting. At ___, EKG demonstrated sinus rhythm, and CTA
head and neck was notable for incidental discovery of a
pituitary
mass, prompting transfer to ___ for further evaluation.
Neurology is consulted for evaluation of speech disturbance.
On review of systems, aside from the above, Mr. ___ denies
recent vertigo, diplopia, hearing change, dysarthria, dysphagia,
focal weakness, paresthesiae, bowel or bladder incontinence,
gait
disturbance, fevers, chills, galactorrhea, gynecomastia, nausea,
vomiting, cough, dyspnea, chest discomfort, abdominal pain, or
changes in bowel or bladder habits. He does note brief episodes
of palpitations and sharp chest pain associated with exertion in
the days preceding presentation.
Past Medical History:
Paroxysmal atrial fibrillation (not on anticoagulation)
Social History:
___
Family History:
FAMILY HISTORY:
Negative for neurological disorders, thrombotic complications,
or
early miscarriages.
Physical Exam:
Admit PHYSICAL EXAM:
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty in ___. Speech is fluent with intact
comprehension and naming of both high- and low-frequency
objects.
No dysarthria. No prosopagnosia or hemineglect with normal clock
drawing and line cancellation. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL (3 to 2 mm ___ with bilateral ptosis,
stable compared to recent photograph. No lid lag, lid twitch, or
fatigable ptosis. Temporal hemianopia OS and superior temporal
as
well as inferior nasal quadrantanopias OD. EOMI, no nystagmus.
V1-V3 without deficits to light touch bilaterally. No facial
movement asymmetry. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline with good excursions.
- Motor: No pronator drift. FFM intact. No fatigability on
deltoid pumping.
[Delt][Bic][Tri][ECR][FEx][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
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0
R 1+ 1+ 1+ 1+ 0
- Sensory: No deficits to light touch bilaterally. Graphesthesia
intact bilaterally. No extinction to DSS. Negative Romberg.
- Coordination: No dysmetria with FNF bilaterally.
- Gait: Narrow-based and steady.
**********
Discharge Physical Exam:
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty in ___ and ___.
- Cranial Nerves: PERRL (3 to 2 mm ___ with bilateral ptosis,
stable compared to recent photograph. No lid lag, lid twitch, or
fatigable ptosis. Improving temporal hemianopia OS and superior
temporal as well as inferior nasal quadrantanopias OD. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline with good excursions.
- Motor: No pronator drift. FFM intact. No fatigability on
deltoid pumping.
[Delt][Bic][Tri][ECR][FEx][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
- Reflexes: Deferred
- Sensory: Deferred
- Coordination: No dysmetria with FNF bilaterally.
- Gait: Narrow-based and steady.
Pertinent Results:
___ 07:14AM BLOOD WBC-6.1 RBC-5.34 Hgb-15.2 Hct-46.3 MCV-87
MCH-28.5 MCHC-32.8 RDW-13.8 RDWSD-43.4 Plt ___
___ 07:03AM BLOOD WBC-6.3 RBC-5.20 Hgb-14.8 Hct-45.2 MCV-87
MCH-28.5 MCHC-32.7 RDW-13.9 RDWSD-44.2 Plt ___
___ 08:50AM BLOOD WBC-6.8 RBC-5.07 Hgb-14.6 Hct-43.3 MCV-85
MCH-28.8 MCHC-33.7 RDW-13.7 RDWSD-43.0 Plt ___
___ 07:14AM BLOOD Plt ___
___ 07:14AM BLOOD ___ PTT-30.1 ___
___ 07:14AM BLOOD Glucose-100 UreaN-12 Creat-1.1 Na-141
K-4.7 Cl-106 HCO3-23 AnGap-12
___ 07:03AM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-143
K-4.6 Cl-104 HCO3-27 AnGap-12
MRI Brain:
1. Multiple infarcts within the left thalamus and throughout the
medial right
occipital lobe, a combination of acute/early subacute infarcts.
No evidence
of hemorrhage.
2. Known sellar mass/pituitary macroadenoma measures up to 2.7
cm in maximum
___, slightly increased in size compared to the CT dated
___, however this may be due to differences in technique.
3. Fluid throughout the mastoid bilaterally, nonspecific.
Brief Hospital Course:
Brief Hospital Course:
Mr. ___ is a ___ R handed gentleman with a past
medical history significant for paroxysmal atrial fibrillation
caught on a long term monitoring device in the past but was not
on anticoagulation (taking aspirin 81mg daily at home). He
presented as a transfer from an outside hospital for
lightheadedness and visual disturbances. He was subsequently
found on imaging to have a pituitary adenoma on ct scan. On
examination here in the ER he was noted to have a LLQ field cut.
He was admitted to the stroke service for further evaluation
including an MRI brain.
#R Occipital/ L BG infarcts:
The patient underwent MRI brain which revealed infarcts in the R
occipital lobe and L basal ganglia, as well as the previously
seen pituitary adenoma. The only deficits on exam was a LLQ
field cut without any strength, sensory or coordination issues.
-The strokes appeared embolic and given his history of pAF he
was started on Eliquis
-His cardiology office was contacted and it was confirmed that
he has documented afib. He has tolerated 5mg BID of Eliquis
without issues
-He was also started on a statin for his cholesterol
-aspirin was discontinued
#Atrial fibrillation:
-Patients home flecainide and metoprolol were continued without
change
#Eliquis insurance approval:
-Prior auth placed with patient's insurance and he was approved
for medication. Patient was cleared for home by OT.
#Pituitary Adenoma:
-The patient was found to have a pituitary adenoma on ct scan,
redemonstrated again on MRI brain. Please follow-up in the
___ clinic , you will be contacted with the appointment
date. ___ ___ if you do not hear from them by the end
of the week.
Transitional Issues:
-Please see cardiologist within 1 month of discharge
-You have been scheduled for a stroke neurology appointment,
please ___ ___ if you haven't heard from the office
once you're discharged
-Take Eliquis twice daily, do not miss any doses . Please let
your cardiologist/neurologist know if you have any procedures in
the near future
-You will be scheduled for the ___ clinic, please
___ ___ if you do not hear for them
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (X) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (X) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (X) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (X) No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - If no, why not (I.e.
bleeding risk, etc.) () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Flecainide Acetate 50 mg PO Q12H
3. Metoprolol Succinate XL 50 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
3. Flecainide Acetate 50 mg PO Q12H
4. Metoprolol Succinate XL 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic infarcts
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 dizziness and difficulty
seeing. You were seen by the stroke neurology team and underwent
imaging of your head which revealed an ISCHEMIC STROKE that has
caused some loss of vision in your left visual field. You
underwent an MRI of the brain which showed us that you had some
small strokes that likely are due to your heart condition called
ATRIAL FIBRILLATION.
To prevent you from having further strokes in the future, you
will take a blood thinning medication called ELIQUIS (also
called apixaban). This will thin the blood due to prevent blood
clots. You are at increased risk of bleeding when on this
medication however the risks of having a stroke outweigh this
bleeding risk and therefore we recommend you take Eliquis.
Please continue taking all of your other medications as
prescribed.
We will have you follow up with us in the neurology clinic in
___ months with Dr. ___. We have started the process to
schedule you for this appointment and you should hear from our
office this week.
It was a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19650367-DS-22
| 19,650,367 | 28,918,567 |
DS
| 22 |
2151-12-05 00:00:00
|
2151-12-06 11:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 01:50PM BLOOD WBC-8.1 RBC-4.02* Hgb-11.6* Hct-34.1*
MCV-85 MCH-28.9 MCHC-34.0 RDW-13.1 RDWSD-40.2 Plt ___
___ 01:50PM BLOOD Neuts-77.5* Lymphs-14.3* Monos-6.6
Eos-0.4* Baso-0.1 Im ___ AbsNeut-6.24* AbsLymp-1.15*
AbsMono-0.53 AbsEos-0.03* AbsBaso-0.01
___ 01:50PM BLOOD ___ PTT-UNABLE TO ___
___ 01:50PM BLOOD Glucose-134* UreaN-8 Creat-0.7 Na-126*
K-5.0 Cl-91* HCO3-22 AnGap-13
___ 01:50PM BLOOD ALT-61* AST-71* AlkPhos-44 TotBili-0.7
___ 01:50PM BLOOD cTropnT-<0.01 proBNP-1132*
___ 01:50PM BLOOD Albumin-3.2* Calcium-7.8* Phos-3.5 Mg-2.0
___ 01:50PM BLOOD Osmolal-270*
___ 01:50PM BLOOD TSH-0.30
___ 08:07PM BLOOD Free T4-1.8*
___ 02:39PM URINE Hours-RANDOM Creat-43 Na-107 Cl-101
___ 02:39PM URINE Osmolal-376
IMAGING:
=========
CXR (PORTABLE AP) ___
Cardiac silhouette is within normal limits and there is no
vascular congestion. There is asymmetry at the right base that
probably represents merely atelectasis and crowding of pulmonary
vessels. However, in the appropriate clinical setting, it would
be difficult to unequivocally exclude superimposed
aspiration/pneumonia in this region, especially in the absence
of a lateral view. No evidence of pneumothorax. Blunting of the
costophrenic angles could reflect small pleural effusions on
both sides.
TTE ___
EF >=70%. Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function.
CT HEAD W/O CONTRAST ___
1. Hyperdensity in the sphenoid sinuses may represent hemorrhage
product.
There is no evidence of intracranial hemorrhage.
2. Expected postsurgical changes after transsphenoidal pituitary
adenoma
resection.
3. Near complete opacification of the ethmoid and sphenoid
sinuses.
DISCHARGE LABS:
===============
___ 06:39AM BLOOD WBC-9.4 RBC-5.01 Hgb-14.6 Hct-43.8 MCV-87
MCH-29.1 MCHC-33.3 RDW-14.0 RDWSD-44.6 Plt ___
___ 06:39AM BLOOD Glucose-98 UreaN-12 Creat-1.0 Na-136
K-4.4 Cl-100 HCO3-24 AnGap-12
___ 04:54AM URINE Hours-RANDOM Na-<20 K-25
___ 04:54AM URINE Osmolal-147
Brief Hospital Course:
PATIENT SUMMARY
=================
Mr. ___ is a ___ Nepali man with afib complicated by
stroke (___) on apixaban who presented 7 days after resection
of incidentally discovered pituitary adenoma with new onset
lower extremity swelling, orthopnea, and nausea and vomiting
found to have symptomatic hyponatremia most likely due to SIADH
in setting of recent pituitary surgery. He was treated with
fluid restriction and diuresis until his serum sodium rose,
urine output increased and urine osms decreased at which point
he was allowed to drink to thirst. His serum sodium normalized
and then was stable in the normal range without any
interventions for >24 hours prior to discharge.
ACUTE ISSUES
=============
# ___
Patient presented with hypotonic hyponatremia, euvolemic exam,
elevated urine
osms and Na. Free T4 was within normal limits and he was on
stress dose steroids. Thus, presentation consistent with SIADH
secondary to recent pituitary macroadenoma resection. He was
treated with fluid restriction, salt tabs and diuretics with
gradual improvement in his serum sodium. He subsequently
developed increasing urine output, decreasing urine osmolality
and rapidly rising sodium suggestive of resolution of SIADH.
Fluid restriction, salt tabs and diuretics were stopped and his
serum sodium stabilized in a normal range. He was allowed to
drink to thirst and his serum sodium remained stable for >24
hours.
# Post-pituitary macroadenoma resection management
Seen by endocrine who recommended tapering down from stress dose
hydrocortisone (40/20) to 20mg QAM, 10mg QPM. Continued
famotidine 20 mg po bid for GI ppx. Continued sinus precautions.
# Peripheral edema
Patient presented with peripheral edema due to stress dose
hydrocortisone. Edema resolved with decreased dose of
hydrocortisone. TTE revealed no evidence of heart failure.
CHRONIC ISSUES:
===============
# pAF
Continued home flecainide and metoprolol. Restarted home
apixaban, which was held for 7 days after recent resection of
pituitary adenoma. Fractionated home metoprolol.
# Dyslipidemia
Continued home statin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Flecainide Acetate 50 mg PO Q12H
3. Metoprolol Succinate XL 50 mg PO BID
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Hydrocortisone 40 mg PO QAM
7. Hydrocortisone 20 mg PO QPM
8. Famotidine 20 mg PO BID
9. Apixaban 5 mg PO BID
Discharge Medications:
1. Hydrocortisone 10 mg PO DAILY16
RX *hydrocortisone 10 mg 1 tablet(s) by mouth Daily at 4PM Disp
#*90 Tablet Refills:*0
2. Hydrocortisone 20 mg PO QAM
RX *hydrocortisone 10 mg 2 tablet(s) by mouth Daily in the
morning Disp #*180 Tablet Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Apixaban 5 mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Famotidine 20 mg PO BID
8. Flecainide Acetate 50 mg PO Q12H
9. Metoprolol Succinate XL 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Syndrome of inappropriate antidiuretic hormone
SECONDARY DIAGNOSES:
-Diabetes insipidus
-Pituitary adenoma status post resection
-Normocytic anemia
-Atrial fibrillation
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted with swelling in your limbs and shortness of
breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have very low sodium levels. We treated you
by limiting the amount of fluids you drank and giving you water
pills to make you urinate more. These treatments helped to keep
your sodium level from decreasing further. Your sodium levels
subsequently rose and we told you to drink whenever you felt
thirsty.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to drink fluid whenever you feel thirsty.
- Please schedule an appointment with your primary care
physician on ___ or ___ or ___ to have your
blood drawn and urine studies checked to make sure your sodium
level is still in a normal range.
- The endocrine doctors ___ to schedule a follow-up
appointment with you.
- If you have to stop drinking for a prolonged period of time
(e.g. the night prior to a surgery) please tell your doctor that
you need to be given intravenous (IV) fluids to prevent your
sodium level from rising too high.
- Continue to take all your medicines and keep your
appointments.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19650793-DS-24
| 19,650,793 | 21,490,248 |
DS
| 24 |
2157-10-20 00:00:00
|
2157-10-21 14:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath, generalized weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is an ___ M w PMHx of HTN, HLD, and CVAs
with R sided weakness who presents to ___ ED with complaints
of generalized weakness and dyspnea. A ___ revealed R MCA
territory hypodensity, concerning for infarct. The below history
is provided by Mr. ___, his wife, and son.
Yesterday, Mr. ___ was in his usual state of health. At
around 1:30AM on the morning of presentation he got up to make
himself a cup of tea (this is not out of the ordinary, the son
states that "he keeps odd hours"). The family then heard a
"crash" and found Mr. ___ on the ground, with some small
scrapes on the right side of his head. Mr. ___ cannot
explain exactly why he fell, but he does state: "I knew
something was coming."
When his family saw him on the ground they report that he looked
a little "spaced out." He was scared to get up on his own, and
looked a bit unsteady. The family helped him back into bed, and
besides some general unsteadiness, they did not appreciate any
new focal deficits.
The next morning, Mr. ___ was unable to get out of bed
himself as he usually does. He was also complaining of chest
pain with movement, wheezing, and shortness of breath. He
reported some generalized weakness to his family, but again,
they did not appreciate any new deficits. They brought him into
the ED for his difficulty breathing. A ___ done for work-up
that subsequently revealed a R MCA inferior divison territory
infarct.
Of note, Mr. ___ had a reported posterior limb infarct in
___ with residual R sided weakness. Prior to that, he had
work-up done that revealed several lacunes within the L
thalamus, R centrum semiovale, in the L occipital lobe, and R
cerebellum.
Past Medical History:
Left vertebral artery stenosis on MRI ___
NSTEMI ___ cath done)
Had pMIBI ___ nl
Multiple CVAs with residual RLE weakness, ___, TIA ___
Hypertension
Hyperlipidemia
Diabetes x ___ year
Prostate cancer s/p prostatectomy ___
Urinary incontinence
Osteoarthritis of right hip and R>L shoulder
Gastric ulcer and bleed in ___ while on Plavix
Ulcerative colitis in remission for ___ years
Lumbar degenerative disc disease
Tonsillectomy as child
Social History:
___
Family History:
Father had CAD, DM, died of an MI at age ___. Mother had GI
cancer died in ___. Brother died at age ___ from an MI, HTN, DM,
kidney failure. Brother died ___ colon cancer, HTN, HLD. Sister
___ HTN, HLD.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS T97.8 HR74 BP159/66 RR20 Sat97%RA
GEN - elderly M, pleasant, NAD
HEENT - NC/AT, MMM
NECK - full ROM, supple
CV - RRR
CHEST - anterior chest TTP
RESP - wheezing, normal WOB
ABD - soft, NT, ND
EXTR - pitting edema of BLEs
NEUROLOGICAL EXAMINATION
MS - Sleepy but wakes easily to voice. Oriented to self,
"hospital" (not ___, and ___ (does not know year and
says the day of the week is ___. Able to name high
frequency objects in ___. Speech is fluent in ___ with
normal prosody and no paraphasic errors. He does appear to have
some R-L confusion. There is significant L sided motor, visual,
and tactile neglect. Motor persistence with the L hemibody.
CN - [II] No BTT over L hemifield. R pupil is 1.5->1, L pupil is
2.5->1. [III, IV, VI] Able to bring eyes just past midline to
the left volitionally; can fully left gaze with VOR. [V] V1-V3
without deficits to light touch bilaterally. [VII] Mild LNLFF at
rest with good activation. ?Weaker L eye closure and reverse
ptosis versus R eye ptosis. [VIII] Hearing intact to voice. [IX,
X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally. [XII] Tongue midline with full ROM.
MOTOR - Complicated by compliance and pain (OA, chest pain).
Prefers to keep BUEs adducted at shoulders and flexed at elbows,
?increased tone vs splinting vs paratonia.
=[Delt] [Bic] [Tri] [ECR] [FEx] [IO] [IP] [Quad] [Ham] [TA]
[Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L * 4+ 4 4 4 4 4 5 4 4+ 5
R * 4+ 4+ 4+ 4+ 4+ 3 5 4+ 3 4
*Unable to test due to B/L shoulder OA pain, at least 3s
\\ ?LUE weaker than RUE, RLE weaker than LLE
SENSORY - Reports intact to LT over R and L hemibody. Reports
decrement to PP over L hemibody. Extinguishes over the L
hemibody to DSS.
REFLEXES -
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 2 1
R 3 3 3 3 1
Plantar response mute on L, down on R.
COORD - Complicated by compliance and weakness; no gross
evidence of appendicular or truncal ataxia
GAIT - deferred
Neuro Exam at Transfer (___)
AAO x self, hospital, month, year. Inattentive but can name
___. Severe dysarthria. Some difficulty with naming
___ ___ ___. Left visual spatial neglect
CN- reduced L BTT, chronic R facial weakness with new L NLF
flattening
MOT- chronic right mild hemi, on the order of 4+/5 in UMN
pattern, now with LUE/LLE weakness as well, most notably in
triceps and ham. Exam complicated by motor neglect.
DISCHARGE PHYSICAL EXAM
VS: 98.0, BP 157/50, 70, 16, 97% on RA
GENERAL: well appearing, no acute distress
HEENT: sclera anicteric
NECK: JVP at clavicle
CARDIAC: RRR, nl s1 S2, no murmurs/rubs/gallops
LUNGS: clear to auscultation bilaterally in anterior lung fields
ABDOMEN: soft, nontender, nondistended, NABS
EXTREMITIES: WWP, DP 2+ b/l, no edema
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-9.5 RBC-3.63* Hgb-11.8* Hct-35.7*
MCV-98 MCH-32.5* MCHC-33.1 RDW-14.2 RDWSD-51.9* Plt ___
___ 01:00PM BLOOD Neuts-69.2 ___ Monos-7.8 Eos-1.5
Baso-0.5 Im ___ AbsNeut-6.58* AbsLymp-1.96 AbsMono-0.74
AbsEos-0.14 AbsBaso-0.05
___ 01:00PM BLOOD Glucose-114* UreaN-17 Creat-1.0 Na-137
K-3.3 Cl-101 HCO3-25 AnGap-14
___ 01:00PM BLOOD ALT-21 AST-36 AlkPhos-39* TotBili-0.9
___ 01:00PM BLOOD proBNP-7016*
___ 01:00PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.3 Mg-1.9
___ 07:49PM BLOOD %HbA1c-5.7 eAG-117
___ 05:50AM BLOOD Triglyc-113 HDL-31 CHOL/HD-5.4
LDLcalc-114
___ 01:00PM BLOOD TSH-0.82
___ 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-13.1* RBC-4.17* Hgb-13.5* Hct-41.3
MCV-99* MCH-32.4* MCHC-32.7 RDW-14.7 RDWSD-53.0* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-102* UreaN-27* Creat-0.9 Na-147*
K-3.7 Cl-107 HCO3-27 AnGap-17
___ 05:45AM BLOOD CK-MB-3 cTropnT-0.02*
___ 05:45AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.2
IMAGING/STUDIES:
___ - ___
Right MCA inferior division territory acute infarct. No
intracranial hemorrhage.
CXR - ___
Lung volumes are lower on the current exam with secondary
crowding of the bronchovascular markings. There is mild
superimposed pulmonary edema. More discrete opacities in the
right mid to lower lung as well as in the retrocardiac region
are now seen. Moderate cardiac enlargement is grossly similar
given lower lung volumes. Degenerative changes noted at the
shoulders. Old right lateral rib fractures are seen. Surgical
clips seen in the right upper quadrant.
Opacities in the retrocardiac region and right mid to lower lung
which could be due to atelectasis given lower lung volumes on
the current exam. Superimposed infection would be difficult to
exclude. Cardiomegaly and mild pulmonary edema.
CTA H&N + PERFUSION ___
Relative paucity of blood vessels in the M5/M6 of the right
middle cerebral artery. No abrupt change in vessel caliber is
detected distally in the area. Patent vessels of the circle of
___ and its principal tributaries without significant
stenosis, occlusion or aneurysm greater than 3 mm.
Infundibular origin of the left posterior communicating artery
and right superior cerebellar artery.
Calcified and tortuous basilar artery.
Calcification of the carotid siphons bilaterally.
Non-filling of the V4 segment of the left vertebral artery. The
left
vertebral artery is hypoplastic from the origin to the
visualized distal segments, likely congenital. Small left
foramen transversarium compared to the right.
Calcification at the carotid bifurcations bilaterally.
Matching areas of decreased blood flow, decreased blood volume
and increased mean transit time in the M5/M6 area of the right
middle cerebral artery, corresponding with the previously seen
area of infarct on the noncontrast CT.
MRI HEAD ___
Acute right MCA territory infarct.
Lack of flow related signal in the left vertebral artery as seen
on recent
CTA.
ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with septal
akinesis. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). 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. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to increased stroke volume due to aortic regurgitation. Moderate
(2+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small,
circumferential pericardial effusion with preferential fluid
deposition posterior to the inferolateral wall measuring up to
1.0 centimeters. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mildly reduced left
ventricular systolic function with regional wall motion
abnormalities consistent with proximal left anterior descending
coronary artery disease. Increased left ventricular filling
pressure. Moderate aortic regurgitation. Small pericardial
effusion without echocardiographic evidence of tamponade.
NUCLEAR STRESS TEST ___
1. No regional perfusion abnormality. 2. Moderately dilated
left
ventricular cavity size. 3. Moderately decreased systolic
function (LVEF 32%).
No anginal symptoms with ST segments that are uninterpretable
for ischemia in the presence of baseline ECG abnormalities.
Appropriate hemodynamic response to the Persantine infusion.
Atrial tachycardia noted pre-infusion (above) with short run of
PAT noted during the infusion. Nuclear report sent separately.
MICROBIOLOGY: N/A
Brief Hospital Course:
___ year old ___ man with HTN, HLD, prior L internal capsule
infarct with residual R weakness (___), who presents with
generalized weakness, shortness of breath and a fall, found
incidentally with R MCA inf division infarct, found on stroke
work up to have regional wall motion abnormalities with
depressed EF on echo and global left ventricular systolic
dysfunction without ischemia on nuclear stress test.
# Acute Ishcemic MCA stroke: Pt presented after sustaining fall
at home in the middle of the night (fell to the right). He went
back to bed after being helped by family, then the following
morning was unable to get out of bed. He reported SOB,
wheezing, chest discomfort with generalized weakness "all over".
On CT scan he was found to have right MCA inferior division
ischemia and was admitted to Neurology. Exam on admission was
notable for inattention, not oriented to year, left
visuo/spatial/tactile neglect, left NLF flattening, relatively
symmetric antigravity strength complicated by left motor
neglect. The deficits were thought to be consistent with the
known R MCA inf division infarction and M2 cutoff seen on
imaging. Vessel imaging showed diffuse atherosclerosis. The
etiology of stroke was thought to be atheroembolic vs.
cardioembolic. It was decided to switch dipyridamole/aspirin to
clopidogrel, after extensive discussion of risks/benefits with
team and patient, as the patient likely sustained this new
stroke in the setting of aspirin therapy. It was thought that
prior bleeding complications from clopidogrel were in the
setting of GI ulcer/exctasia that had since been treated. The
patient was discharged with zeopatch monitor for further
evaluation for any underlying atrial fibrillation. If any
evidence of atrial fibrillation, warfarin can be started safely
following 10 days after the stroke.
# Acute Systolic Heart Failure, coronary artery disease: On
stroke work up, the patient was found to have a septal akinesis
and mildly decreased LV systolic function (EF 40%). These
findings were new compared to last recorded TTE in ___. Given
the patient's history of CAD, NSTEMI s/p DES to the LAD, the
patient was evaluated for further ischemia. Troponin was at
baseline. P-MIBI showed no regional perfusion abnormality. The
patient was treated with IV diuresis with improvement in dyspnea
and in physical exam. He was started on lisinopril 10mg PO
daily. His home furosemide regimen was adjusted to 20mg PO PRN
to maintain net even fluid status given his poor PO intake (see
below). The patient carvedilol was increased to 12.5mg PO BID.
He was continued on clopidogrel as above. His ASA/dipryidamole
was stopped as above. He was continued on his home atorvastatin.
The patient will f/u with cardiology for further evaluation and
management.
# Nutrition: The patient was evaluated by speech and swallow
during his admission, who recommended a diet of ground solids
and nectar thick liquids. Due decreased appetite, distaste of
hospital food, and dislike of nectar thick liquids, the patient
had some difficulty keeping up with PO fluid intake. The patient
furosemide was adjusted to as needed given his decreased PO
intake in order to maintain net even fluid status each day. The
patient should consider further follow up with speech and
swallow as his functional status improves to liberalize/modify
diet as he is able.
# Hypertension: The patient was started on lisinopril 10mg PO
daily and carvedilol 12.5mg PO BID.
# Leukocytosis: the patient was found to have elevated WBC which
was thought to be secondary to stress response. This trended
down over time. The patient had no other localizing
signs/symptoms of infection
Transitional Issues
- Please discuss starting anti-depressant with the patient. His
family thinks he would benefit from this.
- Pt with poor PO intake due to decreased appetite and distaste
of hospital food and nectar thickened liquids. Furosemide 20mg
PO daily was held at discharge. The patient should have goal net
even fluid balance daily. He can receive furosemide 20mg as
needed to maintain this balance
- f/u with neurology for further management of stroke
- Continue zeopatch monitor, with results reported to Dr. ___
___ to determine if evidence of arrhythmia or atrial
fibrillation as etiology of stroke
- Consider discontinuation or reduction of fenofibrate given
interaction with atorvastatin high dose (pt on both of these
medications at home)
- Consider further evaluation with speech and swallow if diet
can be modified/liberalized in future as patient's functional
status improves
Please note the following medication changes:
START Carvedilol 12.5mg by mouth, two times per day
START Clopidogrel 75mg by mouth, daily
START Lisinopril 10mg by mouth, daily
START Furosemide 20mg by mouth as needed to maintain even fluid
balance
STOP: dipryidamole/aspirin 1 cap by mouth two times per day
# CODE: Full
# CONTACT: ___ (son___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dipyridamole-Aspirin 1 CAP PO BID
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. Vitamin D ___ UNIT PO 1X/WEEK (MO)
5. Fenofibrate 160 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Carvedilol 12.5 mg PO BID
3. Fenofibrate 160 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN to maintain even fluid balance
as needed for ___ edema, shortness of breath
7. Vitamin D ___ UNIT PO 1X/WEEK (MO)
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute Ischemic Stroke, Acute Systolic Heart Failure,
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with a stroke. You were
started on a medication call clopidorgel or Plavix to help thin
your blood and prevent additional stroke.
While in the hospital, you were found to have decreased cardiac
function. This was seen on an ultrasound of your heart. We
evaluated you with a stress test which showed normal blood flow
to your heart. We started you on medications to help control
your blood pressure and help your heart function. We also
increased your water pill to help prevent fluid from building up
in your body.
After discharge, you will have a heart monitor to record any
possible abnormal heart rhythms. You should follow up with your
cardiologist for further evaluation. You should also follow up
with your neurologist for further help with your stroke.
Please note the following medication changes:
START Carvedilol 12.5mg by mouth, two times per day
START Clopidogrel 75mg by mouth, daily
START Lisinopril 10mg by mouth, daily
START Furosemide 20mg by mouth as needed to maintain even fluid
balance
STOP: dipryidamole/aspirin 1 cap by mouth two times per day
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19650793-DS-28
| 19,650,793 | 20,792,056 |
DS
| 28 |
2160-02-20 00:00:00
|
2160-03-29 14:02:00
|
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 and vomiting
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy drain placement ___
History of Present Illness:
Mr. ___ is a ___ yo male with history of multiple ischemic
strokes with persistent focal neurologic deficits, CAD s/p MI in
___, COPD, PVD, paroxysmal A. fib on Coumadin, CHF (EF 35%) and
remote history of ulcerative colitis now in remission who
presented with abdominal pain and vomiting.
Per the patient and his family the vomiting started last night
around 10 ___. This was 2 hours after his dinner of meatballs
and Coke and 1 hour after his dessert that included tea and
toast. They stated that he had ___ episodes of dark emesis from
10 ___ until about 4 AM. He did not have a fever but around 2 AM
did have chills. He also had a blood pressure in the 200s at
home so they brought him into the ED. During this time he denied
lightheadedness and shortness of breath to his family but did
endorse chest heaviness and abdominal pain. He has not had any
episodes like this before. They do note that he missed all of
his medications today.
In the ED his initial vitals were 99.7, 97, 225/115, 18, 98% RA.
He was noted to be hypertensive with profound leukocytosis,
elevated lactate, and abdominal pain. Given his vascular
history a CTA was obtained that did not show any evidence of
aortic aneurysm or dissection.
His physical exam was notable for equal bilateral pulses with a
tender abdomen. POCUS without acute findings however of right
upper quadrant ultrasound did show findings concerning for acute
calculus cholecystitis. Chest x-ray also showed findings
concerning for left-sided pleural effusion so he was initially
started on antibiotics for pneumonia however CT chest showed no
pleural effusion with only mild bronchial wall thickening most
prominent in the bilateral lung bases and atelectasis.
Patient received:
___ 08:00 IV Ondansetron 4 mg
___ 09:00 IV CefePIME
___ 09:45 IV Acetaminophen IV 1000 mg
___ 09:46 IV CefePIME 2 g
___ 09:47 IV Levofloxacin
___ 11:35 IV Vancomycin 1000 mg
___ 12:17 IV Levofloxacin 750 mg
___ 14:35 IVF LR 1000 mL
A left-sided triple lumen femoral line was placed and surgery
was consulted. Surgery evaluated the patient and determined
that he was high risk for surgery and therefore recommended
percutaneous drainage of his gallbladder. He was admitted to
the ICU for advanced age with elevated lactate and mild hypoxia.
Vitals on transfer: Heart rate 84, BP 148/56, RR 30, 94% 2L NC
Upon arrival to ___ his family endorses the above story. The
patient is also endorsing shortness of breath while lying flat
and would like to sit up. He no longer has chest pain or
abdominal pain but does endorse some discomfort. He is not
nauseous. No recent falls per the family and the patient. He
denies diarrhea and constipation.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
-COPD/obstructive lung disease
-Multiple CVAs with residual weakness in his extremities
-Chronic systolic heart failure with EF of 35%
-Paroxysmal atrial fibrillation on Coumadin
-Remote history of ulcerative colitis in remission
-Coronary artery disease
-History of DVT
-Mitral regurgitation
-CKD stage II
-Hypertension
-Hyperlipidemia
-Aortic aneurysm
-Cholelithiasis
-Deconditioning
Social History:
___
Family History:
Per OMR: Father had CAD, DM, died of an MI at age ___. Mother had
GI cancer died in ___. Brother died at age ___ from an MI, HTN,
DM, kidney failure. Brother died ___ colon cancer, HTN, HLD.
Sister ___ HTN, HLD.
Physical Exam:
Admission exam:
===============
VITALS: temperature 98.7, HR 88, BP 170/60, RR 21, O2 100% on 2L
NC
GENERAL: Elderly man lying in bed in no apparent distress
appears fatigued
HEENT: PERRL, EOMI, Sclera anicteric, MMM dry, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds, regular rate and rhythm, unable to
appreciate murmurs or extra heart sounds.
ABD: soft, non-distended, bowel sounds present, tender ro
palpation of the RUQ
EXT: Warm, well perfused, 2+ pulses, trace edema bilaterally
SKIN: no rashes
NEURO: somnolent but follows commands, no facial deficits,
strength not tested.
Discharge exam:
===============
Pertinent Results:
Admission labs:
===============
___ 07:40AM BLOOD WBC-29.0* RBC-4.31* Hgb-13.9 Hct-42.9
MCV-100* MCH-32.3* MCHC-32.4 RDW-13.2 RDWSD-47.6* Plt ___
___ 07:40AM BLOOD Neuts-84.7* Lymphs-6.9* Monos-7.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-24.57* AbsLymp-2.01
AbsMono-2.05* AbsEos-0.00* AbsBaso-0.05
___ 07:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Schisto-OCCASIONAL
Burr-1+* Tear ___
___ 07:50AM BLOOD ___ PTT-28.3 ___
___ 07:48PM BLOOD ___ 12:41AM BLOOD Ret Aut-1.6 Abs Ret-0.06
___ 07:40AM BLOOD Glucose-161* UreaN-18 Creat-1.1 Na-143
K-4.2 Cl-99 HCO3-22 AnGap-22*
___ 07:50AM BLOOD ALT-29 AST-35 AlkPhos-88 TotBili-1.0
___ 07:50AM BLOOD Lipase-26
___ 07:50AM BLOOD cTropnT-0.10*
___ 12:30PM BLOOD cTropnT-0.08*
___ 07:48PM BLOOD cTropnT-0.06*
___ 07:50AM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.7 Mg-1.7
___ 12:41AM BLOOD calTIBC-196* ___ Ferritn-403*
TRF-151*
___ 07:56AM BLOOD Type-CENTRAL VE FiO2-98 pO2-26* pCO2-38
pH-7.43 calTCO2-26 Base XS-0 AADO2-636 REQ O2-100 Intubat-NOT
INTUBA
___ 07:56AM BLOOD Lactate-4.7*
Microbiology:
=============
___ urine culture: STAPHYLOCOCCUS, COAGULASE NEGATIVE >100,000
CFU/mL.
___ blood culture x3: ************
___ bile: *******
___ blood culture: ****
___ c difficile PCR: negative
Studies:
========
___ CXR: 1. Ill-defined opacity the bilateral bases are
nonspecific and could represent atelectasis. Pneumonia cannot
be ruled out. 2. Large left-sided pleural effusion. 3. Mild
cardiomegaly.
___ CTA torso:
1. No evidence of aortic dissection or central pulmonary
embolism.
2. Moderate cardiomegaly and trace pericardial effusion.
3. Dilation of the main pulmonary artery up to 3.4 cm concerning
for pulmonary arterial hypertension.
4. Distended gallbladder containing stones, correlate clinically
for possible acute cholecystitis.
5. Stable coarse calcification in the region of segment 4A
likely reflects old injury/intervention.
___ Abdominal ultrasound:
Distended gallbladder, nonmobile gallbladder neck stone,
positive ___ sign. Findings raise concern for acute calculus
cholecystitis.
___ CT head w/o:
No acute intracranial process. Specifically, no acute
intracranial hemorrhage.
___ TTE:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate global
left ventricular hypokinesis (biplane LVEF = 31 %). Systolic
function of apical segments is relatively preserved. 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 (?#).
Mild to moderate (___) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. IMPRESSION: Mild symmetric left
ventricular hypertrophy with moderate global hypokinesis in a
pattern most suggestive of a non-ischemic cardiomyopathy.
Mild-moderate aortic regurgitation. Mild mitral regurgitation.
Mildly dilated ascending aorta. Compared with the prior study
(images reviewed) of ___, the severity of aortic
regurgitation and mitral regurgitation are now reduced (may be
related to lower systemic blood pressure). Left ventricular
cavity size was similar on review of the prior study. CLINICAL
IMPLICATIONS: The left ventricular ejection fraction is <40%, a
threshold for which the patient may benefit from a beta blocker
and an ACE inhibitor or ___.
___ CXR: Lungs are low volume with small bilateral effusions
left greater than right. Cardiomediastinal silhouette is
stable. No pneumothorax is seen. There is mild pulmonary
vascular congestion.
___ perc drain placement: Successful ultrasound-guided placement
of ___ pigtail catheter into the gallbladder. Samples was
sent for microbiology evaluation.
___ RUQ US
1. Appropriately placed percutaneous cholecystostomy tube,
within a
nondistended gallbladder. There is no gallbladder wall
thickening or
pericholecystic fluid.
2. There is a shadowing gallstone at the gallbladder neck.
Otherwise,
unremarkable abdominal ultrasound.
___ CT Abd/Pelvis
1. Decompressed gallbladder containing a pigtail catheter. Note
that while
two side ports are located outside the gallbladder lumen, the
pigtail is
intraluminal, and no inflammatory changes are seen surrounding
the
gallbladder.
2. Multiple bladder diverticula containing foci of air, new from
prior
correlate with history of instrumentation. If no history
exists, recommend
urinalysis.
Brief Hospital Course:
___ M PMHx CVAs with residual focal neurologic deficits, CAD,
chronic systolic CHF, peripheral vascular disease, paroxysmal
atrial fibrillation on warfarin admitted ___ with septic
shock secondary to acute cholecystitis with impacted gallstone
in the cystic duct, subsequently status post percutaneous
cholecystostomy placement, on antibiotics, recent course
complicated by worsening leukocytosis of unclear etiology
# Septic Shock secondary to Acute Cholecystitis
Patient was admitted to the ICU with leukocytosis, fever, with
exam and imaging concerning for acute cholecystitis. ICU course
was notable for onset of hypotension prompting fluid
resuscitation, and urgent ultrasound guided percutaneous
cholecystostomy tube placement for source control place. He was
initially treated broadly with vancomycin and zosyn, which was
then narrowed to unasyn. With clinical improvement he was
changed to PO augmentin. His course was complicated by
worsening leukocytosis. Infectious workup did not yield any
additional potential sources for infection. Repeat imaging was
concerning for displacement of perc cholecystostomy tube....
# Hypertensive emergency
# Type 2 NSTEMI
Upon arrival to the ICU, Mr. ___ was noted to have
hypertensive emergency to 170-200 systolic and significant ST
depressions in the lateral leads on EKG with elevated troponin
in the setting of known coronary artery disease. Cardiology was
consulted and recommended treatment with full dose aspirin, his
home atorvastatin 80mg and no anticoagulation in anticipation of
percutaneous cholecystostomy while he was therapeutic on
warfarin. He received 100mg of PO labetalol for treatment of his
hypertension and his blood pressure improved.
# Acute hypoxic respiratory failure secondary to
# Acute on Chronic Systolic CHF
In setting of acute illness and volume resuscitation, patient
developed hypoxia. Imaging and exam were notable for pulmonary
edema. He was diuresed with IV Lasix with resolution of
hypoxia.
# Aspiration:
In setting of his acute illness, he failed speech/swallow. Per
discussion with family regading risks of aspiration, they were
comfortable accepting risk of potential aspiration, as long as
patient was able to eat the foods he wanted to eat.
# Paroxysmal atrial fibrillation
Continued Warfarin
# COPD: Continued home Advair, albuterol
# Prior CVA: continued aspirin, statin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. FLUoxetine 20 mg PO DAILY
3. Furosemide 40 mg PO QAM
4. Lisinopril 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Warfarin 2.5 mg PO DAILY16
7. Vitamin D 800 UNIT PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Multivitamins 1 TAB PO DAILY
10. Furosemide 20 mg PO QPM
11. Atorvastatin 80 mg PO QPM
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob/wheezing
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active:
Septic shock, secondary to
Acute severe cholecystitis,
Gallstones, with impacted stone at cystic duct, status post
percutaneous cholecystostomy
Hypoxemic respiratory failure secondary to,
Acute on chronic systolic heart failure
Discharge Condition:
ambulate with assistance, clear mental status
Discharge Instructions:
Mr. ___
___ was a pleasure caring for you at ___. You were admitted
with a serious infection of your gallbladder (acute
cholecystitis). You were treated with antibiotics and a drain
in your gallbladder.
During your hospital stay you were also found to have difficulty
with swallowing. You and your family decided that it was more
important to be able to eat the foods you like, then to not be
able to eat these foods, even if there was a risk for aspirating
these foods.
The Visiting Nurse needs to draw an INR, CBC and Liver Function
Tests on ___ (this ___. Your INR on discharge was
1.7, we are increasing your dose to 2mg daily from 1.5. Your
primary care doctor can help adjust the Coumadin dose depending
on your INR.
Followup Instructions:
___
|
19650793-DS-30
| 19,650,793 | 20,216,056 |
DS
| 30 |
2160-04-17 00:00:00
|
2160-04-18 11:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dislodged PTBD, vomiting
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ with h/o HFrEF (EF 35%), AF on warfarin,
CAD s/p PCI, COPD, HTN, history of multiple ischemic strokes
with
residual neuro deficits, and recent cholecystitis s/p
cholecystostomy tube who presents with dislodged PTBD and
vomiting.
Patient's wife reports that patient had been in his recent usual
state of health until ___ when he was standing up and looked
like
he was going to fall. His wife grabbed his shirt to stabilize
him
and the PTBD became dislodged. He denies any abdominal pain,
fevers/chills, dizziness/lightheadedness.
A few hours after the PTBD drain became dislodged, he was eating
and had sudden episodes of non-blood vomiting. No diarrhea at
home. He had ___ episodes total, and was brought to the ED.
His wife also notes his PO intake has been poor and he has had
lethargy for the past 2 months since initial cholecystitis
admission. He denied any dizziness with standing. Of note, per
OMR, his family recently refused home ___.
Patient was recently admitted ___ - ___ with abdominal
pain, found to have septic shock secondary to cholecystitis. He
had percutaneous cholecystostomy drain placement ___ and
completed antibiotic course. T-tube study on ___ showed patent
cystic duct with back pressure. T-tube was clamped with plans
for
removal in clinic.
In the ED, initial vitals were: 96.1 110 164/77 12 92% RA
- Exam notable for: PTBD fully dislodged, site without erythema
or active drainage
- Labs notable for: WBC 17.7, Hgb 11.8, INR 2.7, Lactate 3.4
-->
1.6
- Imaging was notable for:
CXR
No acute cardiopulmonary process.
CT C/A/P
1. 1.5 x 1 cm tiny rim enhancing thick-walled fluid collection
adjacent to the right lateral wall at the site of prior
percutaneous cholecystostomy is concerning for a tiny abscess
given the provided clinical history.
2. 3-mm distal CBD stone appears new from prior. Relatively
stable CBD caliber and mild intrahepatic central biliary
dilation
since prior.
3. Trace bilateral nonhemorrhagic pleural effusions lower lobe
atelectasis. No focal pneumonia.
4. Small hiatal hernia.
5. Urinary bladder diverticula.
- Patient was given: Zosyn 4.5g q8h, vanc 1g x1, NS, Tylenol 1g
Interventional radiology was consulted in the ED who noted no
indication for PTBD replacement or other intervention at this
time.
Upon arrival to the floor, patient reports feeling very well and
back to his baseline. He denies any abdominal pain,
nausea/vomiting. He is having diarrhea, which patient and wife
report usually happens when he is on antibiotics. Denies chest
pain/pressure, dyspnea, dysuria, BRBPR, melena.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- CAD s/p PCI to LAD (___)
- Systolic congestive heart failure
- Hypertension
- Paroxysmal atrial fibrillation
- History of CVA with residual weakness to extremities
- COPD
- Depression
- Cholecystitis s/p cholecystostomy
Social History:
___
Family History:
Father had CAD, DM, died of an MI at age ___.
Mother had GI cancer died in ___.
Brother died at age ___ from an MI, HTN, DM, kidney failure.
Brother died ___ colon cancer, HTN, HLD.
Sister ___ HTN, HLD.
Physical Exam:
ADMIT EXAM
==========
VITAL SIGNS: ___ 0753 Temp: 97.4 PO BP: 150/73 L Sitting
HR: 88 RR: 16 O2 sat: 93% O2 delivery: Ra
GENERAL: Well appearing, NAD
HEENT: PERRL, MMM
NECK: unable to assess JVP
CARDIAC: RRR, s1/s2, no mgr
LUNGS: minimal apical exp wheezes b/l, bibasilar crackles
ABDOMEN: Soft, NTND, no rebound/guarding
EXTREMITIES: Warm, no edema
NEUROLOGIC: AOx2 (baseline per son). L>R UE weakness. R hip
flexion ___ (lifts slightly to gravity), L hip flexion ___,
plantar/dorsiflexion ___ b/l. All baseline and residual from
stroke per family.
DC EXAM
=======
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 97.4 (Tm 98.3), BP: 153/68 (128-161/57-68), HR: 70
(66-70), RR: 18 (___), O2 sat: 93% (93-96), O2 delivery: RA,
Wt: 133.38 lb/60.5 kg
GENERAL: Alert, cheerful, no acute distress
HEENT: Sclera anicteric, droopy right eyelid, MMM, oropharynx
clear.
LUNGS: Mild crackles at bilateral lung bases, bilateral
expiratory wheezing, no increased WOB
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes or jaundice. Stage 2 decub on gluteal cleft
NEURO: Alert, responding to questions appropriately, follows
commands
Pertinent Results:
ADMIT LABS
=========
___ 10:20PM BLOOD WBC-17.7* RBC-3.76* Hgb-11.8* Hct-36.7*
MCV-98 MCH-31.4 MCHC-32.2 RDW-14.5 RDWSD-51.4* Plt ___
___ 10:20PM BLOOD Neuts-77.7* Lymphs-12.4* Monos-6.3
Eos-2.5 Baso-0.3 Im ___ AbsNeut-13.74* AbsLymp-2.20
AbsMono-1.11* AbsEos-0.44 AbsBaso-0.06
___ 10:20PM BLOOD ___ PTT-24.4* ___
___ 10:20PM BLOOD Glucose-171* UreaN-8 Creat-0.7 Na-139
K-4.9 Cl-102 HCO3-19* AnGap-18
___ 10:20PM BLOOD ALT-24 AST-58* AlkPhos-99 TotBili-0.8
DirBili-<0.2 IndBili-0.8
___ 10:20PM BLOOD Lipase-25
___ 10:20PM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.5 Mg-1.6
___ 10:30PM BLOOD Lactate-3.4*
___ 08:53AM BLOOD Lactate-1.6
___ 05:05AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:05AM URINE RBC-8* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
IMAGING
=======
CXR 5.3
No acute cardiopulmonary process.
CT-Torso ___. 1.5 x 1 cm tiny rim enhancing thick-walled fluid collection
adjacent to the
right lateral wall at the site of prior percutaneous
cholecystostomy is
concerning for a tiny abscess given the provided clinical
history.
2. 3-mm distal CBD stone appears new from prior. Relatively
stable CBD
caliber and mild intrahepatic central biliary dilation since
prior.
3. Trace bilateral nonhemorrhagic pleural effusions lower lobe
atelectasis.
No focal pneumonia.
4. Small hiatal hernia.
5. Urinary bladder diverticula.
CXR ___
Comparison to ___. The patient has no developed
pulmonary edema of
moderate severity. Moderate cardiomegaly. The presence of a
small left
pleural effusion cannot be excluded. Moderate retrocardiac
atelectasis.
MICRO
=====
___ 5:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:30 pm BLOOD CULTURE X 1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0656 ON
___ - ___.
GRAM NEGATIVE ROD(S).
___ 6:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
PERTINENT/DISCHARGE LABS
==========================
___ 12:50AM BLOOD WBC-42.2* RBC-3.65* Hgb-11.4* Hct-34.9*
MCV-96 MCH-31.2 MCHC-32.7 RDW-14.7 RDWSD-50.7* Plt ___
___ 06:01AM BLOOD WBC-34.6* RBC-3.27* Hgb-10.1* Hct-32.2*
MCV-99* MCH-30.9 MCHC-31.4* RDW-14.8 RDWSD-53.0* Plt ___
___ 04:32AM BLOOD WBC-21.1* RBC-2.99* Hgb-9.4* Hct-29.0*
MCV-97 MCH-31.4 MCHC-32.4 RDW-15.0 RDWSD-52.5* Plt ___
___ 06:40AM BLOOD WBC-10.6* RBC-3.36* Hgb-10.6* Hct-32.5*
MCV-97 MCH-31.5 MCHC-32.6 RDW-14.6 RDWSD-51.6* Plt ___
___ 12:50AM BLOOD Neuts-95* Bands-0 Lymphs-1* Monos-3*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-40.09*
AbsLymp-0.42* AbsMono-1.27* AbsEos-0.00* AbsBaso-0.42*
___ 06:40AM BLOOD ___ PTT-35.4 ___
___ 06:40AM BLOOD Glucose-129* UreaN-6 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-21* AnGap-16
___ 06:01AM BLOOD ALT-24 AST-36 LD(LDH)-224 CK(CPK)-31*
AlkPhos-88 Amylase-23 TotBili-0.8
___ 12:50AM BLOOD CK-MB-1 cTropnT-0.05*
___ 06:01AM BLOOD CK-MB-1 cTropnT-0.04*
___ 07:00AM BLOOD proBNP-___*
___ 06:40AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ y/o male with h/o CVA, extensive cardiac
history, and recent hospitalization for cholecystitis s/p
cholecystostomy tube admitted with dislodged PTBD, vomiting, and
leukocytosis with imaging notable for small ___
fluid collection. ___ consulted and felt drain was no longer
necessary. Course was complicated by acute on chronic systolic
heart failure and likely pneumonia.
ACUTE ISSUES:
# ___ fluid collection
# Recent cholecystitis s/p cholecystostomy tube
Patient presented after PTBD dislodged while at home. CT showed
small ___ fluid collection, unclear abscess vs
infectious changes from PTBD. ___ was consulted and felt no need
to drain fluid or replace PTBD. Patient developed E. coli
bacteremia as noted below with repeat CT scan demonstrating
interval improvement of the previously seen high-density fluid
pocket in the perihepatic space with mild residual linear soft
tissue thickening likely representing tube tract. ___ again felt
that no intervention was warranted.
# E coli bacteremia
# Septic shock
Patient developed new hypotension on evening of ___ and was
transferred to MICU due to Levophed requirement. Blood cultures
were drawn and he was found to have E. coli bacteremia. He was
initially started on broad spectrum antibiotics and narrowed to
IV ceftriaxone. He was weaned off pressors and returned to
medicine floor. ID was consulted and antibiotics were narrowed
to po ciprofloxacin with plan for a total of 2 weeks of
antibiotics (last day on ___ for presumed biliary source of
infection.
# Acute on chronic HFrEF
Patient has had his furosemide held over the past several months
during his recent hospitalizations. He was felt to be total body
overloaded during hospitalization, with bilateral crackles up to
midback. He was initially diuresed with IV 40mg Lasix before
transitioning to 40mg po Lasix. He was restarted on lisinopril
at 5mg daily and his carvedilol was changed to 6.25mg BID. His
BNP during hospitalization was ___ and downtrended to 6809 at
time of discharge. Discharge weight of 60.5kg.
# Diarrhea:
Patient's wife reports patient frequently gets diarrhea while on
antibiotics. Cdiff was negative and diarrhea improved.
# Weakness/lethargy:
Patient's wife reported his functional status acutely worsened 2
months ago during initial cholecystitis admission. Since that
time, he has continued to be weak and have poor energy, likely
___ recent illness. Family declined rehab and requested patient
be discharged to home with services.
CHRONIC/STABLE ISSUES:
====================
# Paroxysmal atrial fibrillation: CHADS2Vasc is 6. INR initially
therapeutic at time of admission but downtrended to
subtherapeutic. Given prior CVAs, he was bridged with SQ
lovenox. He is discharged on warfarin 1.5mg daily. Discharge INR
of 1.9. He will need a repeat INR check on ___ to ensure
stability while on ciprofloxacin.
# Hypertension: Started on lisinopril 5mg daily. Carvedilol
changed to 6.25mg BID.
# Prior CVA: Continued home ASA, statin
# COPD: Remained on home Flovent and albuterol PRN.
# Depression: Continued home fluoxetine
TRANSITIONAL ISSUES
=================
[] Discharge weight: 60.5kg
[] Weigh self daily and increase furosemide dose if gaining
weight
[] Complete 14 day course of po ciprofloxacin for E. coli
bacteremia - last day on ___
[] Will need repeat CXR in 6 weeks (___) for evaluation of
resolution of consolidation
[] Recheck CBC, Chem-10, BNP, and INR on ___
[] Pt will require to take meds crushed in apple sauce going
forward to help prevent further aspiration episodes
[] Continue uptitration of lisinopril and carvedilol for BP/HR
control as tolerated
On the day of discharge, he has no abdominal pain, fevers, CP,
SOB. A comprehensive 10 point ROS was obtained and otherwise
negative.
>30 minutes were spent in discharge related activities.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FLUoxetine 20 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Multivitamins 1 TAB PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Vitamin D 800 UNIT PO DAILY
8. Warfarin 1.5 mg PO DAILY16
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob/wheezing
10. Carvedilol 12.5 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. FLUoxetine 20 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob/wheezing
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 800 UNIT PO DAILY
13. Warfarin 1.5 mg PO DAILY16
14.Outpatient Lab Work
Collect CBC, BMP, INR, BNP
Fax: ___
ICD-10: I48.0, I50.2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Dislodged PTBD
___ fluid collection
Heart Failure with Reduced Ejection Fraction
Pneumonia
E. Coli bloodstream infection
SECONDARY
=========
Paroxysmal atrial fibrillation
Hypertension
Hx of CVA
COPD
Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you!
WHY WERE YOU ADMITTED?
- You were admitted to ___ after your drain fell out and you
had vomiting at home.
WHAT HAPPENED DURING YOUR HOSPITALIZATION
- You were evaluated by the team who placed your drain and
decided it did not need to be replaced.
- You were found to have bacteria in your blood. You were
started on antibiotics to treat this infection.
- You were re-started on a medication called Lasix to help
remove the fluid from your lungs.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- You should take all of your medications as prescribed. This
should be done with apple sauce.
- You should follow up with all of your doctors as ___
below.
- You should weigh yourself everyday and call your doctor if
your weight is increasing.
Again, it was a pleasure taking care of you!
All the best,
Your ___ Team
Followup Instructions:
___
|
19650793-DS-31
| 19,650,793 | 22,181,949 |
DS
| 31 |
2160-07-07 00:00:00
|
2160-07-07 13:16:00
|
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, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: ___
HPI: Mr. ___ is a ___ male with past medical
history
notable for HFrEF (EF 35%), AF on warfarin, CAD s/p PCI, COPD,
HTN, history of multiple ischemic strokes with residual neuro
deficits, and recent cholecystitis s/p cholecystostomy (tube
removed in ___ who presents with nausea and vomiting.
History obtained from ED records and son (primary care giver) as
patient speaks limited ___ and tired:
Patient was in his normal state of health on morning prior to
admission. At ~530pm on day prior to admission had dinner (feta
cheese) and soon afterwards reported epigastric discomfort and
had emesis. He kept vomiting every 1 hour with the last 3 being
bilious in nature. He was then sent to the emergency room.
He reports epigastric discomfort has improved and resolved after
emesis episodes. He denies any fevers, chills, chest pain,
shortness breath, belly pain, urinary or bowel symptoms. Of note
has had no bowel movement in ~2 days. No history of head strike
or head injuries. He denies dysuria (though 2 weeks prior to
admission, there was concern for a UTI with foul smelling urine,
however once urine culture came back negative, abx were
discontinued)
Of note, son says patient is full code. Patient is partially
independent when in good health, but needs one assist at all
times from family members.
In the ED:
- Initial vitals: 95.2 113 163/99 18 95% RA
- Exam notable for: abdomen being soft, NT, ND
- Labs:
+ CBC: WBC 21.5 Hgb 13.2 Plt 233
+ Chem 10: Na 142, K 3.4 Creat 0.8
+ Coags: ___ 44.6 PTT 28.5 INR 4.2
+ LFTs: ALT 22, AST 33, Alkphos 97 T bili 0.9
+ Trop 0.13 CKMB 3 CK 55
+ Lactate 4.2-> 3.2
- Imaging:
+ CT abdomen pelvis: choledocholithiasis with minimal upstream
biliary dilatation. Also relevant for persistent mild
inflammatory changes at the gall bladder fossa.
+ Liver ultrasound: Unchanged mild intra and extrahepatic
biliary
dilatation.
+ Chest xray: possible retrocardiac opacity likely atelectasis
but cannot rule out infection
- Patient was given Vanc, Zosyn, 1L NS, fluoxetine and lorazepam
- On transfer vitals were 64 143/45, 18 99% on 2L NC
On arrival patient states he's fatigued and asking for water.
Story as above from son.
Past Medical History:
- CAD s/p PCI to LAD (___)
- Systolic congestive heart failure
- Hypertension
- Paroxysmal atrial fibrillation
- History of CVA with residual weakness to extremities
- COPD
- Depression
- Cholecystitis s/p cholecystostomy
Social History:
___
Family History:
Father had CAD, DM, died of an MI at age ___.
Mother had GI cancer died in ___.
Brother died at age ___ from an MI, HTN, DM, kidney failure.
Brother died ___ colon cancer, HTN, HLD.
Sister ___ HTN, HLD.
Physical Exam:
VITALS: Afebrile and VS stable
GENERAL: Alert and in no distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, slightly
dry mucous membranes
CV: Heart regular, II/VI SEM at ___, no S3, no S4. JVP 6cm
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation, no CVA
tenderness
MSK: Neck supple, moves all extremities, L-sided weakness arm >
leg, baseline per wife
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, L-sided weakness (baseline), able to count
backwards from 10 (though misses several numbers)
PSYCH: pleasant, appropriate affect
Pertinent Results:
___
WBC-10.8* RBC-3.22* Hgb-10.0* Hct-30.8* MCV-96 MCH-31.1
MCHC-32.5 RDW-15.9* RDWSD-55.7* Plt ___
Glucose-140* UreaN-9 Creat-0.7 Na-143 K-3.7 Cl-107 HCO3-23
AnGap-13
ALT-13 AST-22 AlkPhos-72 TotBili-1.0
Lactate-1.8
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ w/ HFrEF (EF 35%), AF (Coumadin), CAD s/p PCI, COPD, HTN,
history of multiple ischemic strokes with residual L-sided
weakness and cognitive impairment, and recent cholecystitis s/p
PBCT (tube removed in ___ admitted w/ n/v/abdominal pain
(resolved, ?biliary colic) and found to have UTI.
**
# Nausea (RESOLVED)
# Vomiting (RESOLVED)
# Sepsis(RESOLVED)
# Leukocytosis
# UTI:
Presented with n/v/abdominal pain with leukocytosis to 21,
lacate
4, tachycardic. Initially suspicious for biliary source given
recent cholecystitis s/p cholecystostomy tube (now removed), but
CT A/P without obvious inta-abdominal source (though continues
to
have gallstones including CBD stone, but unchanged mild biliary
dilation and decompressed GB) with normal LFTs. Symptoms
resolved by the time the patient as admitted to the floor.
Symptoms may have represented biliary colic given that they were
so closely associated with eating dinner. No respiratory
symptoms or diarrhea. UA grossly
positive (>182 WBC, positive nitrite) and so also diagnosed with
UTI, though not totally clear this is the explanation for his
presenting symptom. Initially started on vancomycin/zosyn,
transitioned to ceftriaxone on the morning after admission. UCx
grew pan-sensitive Klebsiella and so discharged on ciprofloxacin
to complete a 7-day course (___). BCx NGTD, but pending at
the time of discharge. Given history of gallstone and
cholecystitis GI was curbsided re: possibility that this was
biliary colic and if further workup or intervention might be
warranted. During his initial admission for cholecystitis in
___, ACS surgery service was consulted and felt that patient
was not a candidate for CCY given functional status and
comorbidities, which have not changed since that time. In ___,
___ was consulted re: whether percutaneous cholecystostomy tube
should be replaced after it was dislodged; however, given normal
LFT and decompressed GB on imaging (despite CBD stone), they did
not feel replacement was warranted. On this admission, LFTs are
normal and imaging findings on CT A/P are unchanged; thus, after
discussion with GI it was felt that further workup or
intervention was not warranted at this time. Patient and his son
were informed of increased risk of cholecystitis, cholangitis,
or biliary obstruction going forward and warning signs to look
for.
**
# Hypokalemia: K 2.9 on AM labs the morning after admisson.
Likely related to vomiting that brought him into the hospital.
Repleted and K wnl on discharge.
**
# Troponinemia: Likely TII NSTEMI I/s/o demand from hypovolemia
and infection. Troponin 0.13 --> 0.09 with CK-MB 3 x2 on ___.
EKG without
changes. Denies chest pain or other anginal symptoms.
**
# HFrEF: EF 35%. Appeared euvolemic on discharge. Held Lasix
during admission, restarted on discharge. Continued caverdilol
6.25mg BID today
**
# Paroxysmal atrial fibrillation: CHADS2Vasc is 6. INR elevated
to 4.2 on admission and so Coumadin was held. INR was 2.7 on
discharge with plan to resume Coumadin at discharge.
**
#Discharge Planning: Patient lives on the second floor of his
home. Per family he has 24 hour supervision from his family. He
cannot ambulate without assistance, but family helps him from
bed to chair and with ADLs. Family members transport him to/from
the second floor when he needs to leave the house for an
appointment. On last admission ___ recommended rehab and family
declined. This admission family again states that patient and
family preference is for patient to return home with prior
arrangement for care.
CHRONIC/STABLE ISSUES:
=======================
# Hypertension: Continued home Lisinopril and carvedilol
# Prior CVA: Continued home ASA, statin
# COPD: Continued home Flovent and albuterol PRN.
# Depression: Continued home fluoxetine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FLUoxetine 20 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN constipation
5. Vitamin D 800 UNIT PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob/wheezing
9. Carvedilol 6.25 mg PO BID
10. Lisinopril 5 mg PO DAILY
11. Furosemide 10 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Twice
daily Disp #*9 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. FLUoxetine 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Furosemide 10 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN sob/wheezing
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 800 UNIT PO DAILY
13. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with nausea and vomiting. We
did a CT scan of you abdomen and did not find an explanation for
your symptoms. You continue to have gallstones in your
gallbladder, but no signs of infection or inflammation of the
gallbladder. We found on your urine testing that you had a
urinary tract infection and treated you with antibiotics, which
you will continue at home through ___. Because you will
have gallstones, you are at increased risk of developing
gallbladder inflammation or infection in the future. You should
come back to the hospital if you have fevers, worsening
___ pain, or yellowing of the skin/eyes.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19651050-DS-16
| 19,651,050 | 23,270,468 |
DS
| 16 |
2143-05-08 00:00:00
|
2143-05-08 16:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Neck and Back pain
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Mr. ___ is a ___ year-old left-handed man with PMH notable
for partial transverse myelitis of of the cervical cord (C5
level) in ___ and currently on treatment with Copaxone
(he
follows with Dr. ___ in clinic) who presents with progressive
neck pain and stiffness for the past 5 days.
Regarding his initial presentation in ___, he developed
discomfort in his neck followed by ascending numbness and
paresthesias beginning in the left toes and rising to the level
of his breast over several days. He does not believe there has
been significant recovery since onset. He did receive treatment
with intravenous methylprednisolone, approximately two months
after onset, but this did not affect his symptoms. He had no
previous neurological symptoms, illnesses or immunizations prior
to the onset of the symptoms that led to his initial evaluation.
Since initial presentation, he continues to have decreased
temperature sensation on his left hemibody, but has not had neck
pain (until this presentation), limb weakness or incoordination
and no bowel or bladder dysfunction.
Beginning last ___, he awoke with pain in his neck. He
described this pain initially as stiffness and the pain was
exacerbated with movement. He does not recall any recent neck
trauma or whiplash injuries. The following day, his neck was
stiffer and he developed sharp pains in his neck, in addition to
the stiffness, that would occasionally radiate down to his
mid-back. Over the last few days, the stiffness and pain
continued to worsen to the point where he tried to maintain his
neck steady because any movement would excaerbate the pain. He
had difficulty sleeping last night because of the pain and even
noted the pain work him out of sleep. He does not note any
similar neck pain of similar severity in the past. He has not
had
any recent fevers or chills. He notes that since onset of his
neck symptoms, he has had occasional burning sensation in his
upper back (each episode lasts a few seconds and has occurred
about 10x daily). Aside from the burning, he does not report any
new neurologic symptoms, including no new parasthesias, numbness
or weakness. He does note his gait has been cautious because he
is afriad of moving his neck, but otherwise no unsteadiness. No
new symptoms of urinary urgency or incontinence. No Lhermitte's
sign. He does note that since about the beginning of ___, his
Copaxone was tapered down to three times a week from daily.
Neuro ROS: Positive for neck pain as per HPI. No loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. No difficulties
producing or comprehending speech. He has decreased temp.
sensation over left hemibody. No focal weakness or
parasthesiaes.
No bowel or bladder incontinence or retention. No difficulty
with
gait.
General ROS: Positive for left shoulder pain. No fever or
chills.
He does report URI symptoms about 2 weeks ago. No cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. No rash.
Past Medical History:
-partial transverse myelitis of of the cervical cord (C5 level)
Social History:
___
Family History:
Maternal cousin with MS. ___ mother and father are
healthy.
Physical Exam:
Vitals: T: 98.2 P: 60 R: 16 BP: 132/81 SaO2: 99%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: +meningismus. Severely limited neck ROM.
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall ___ at 5 minutes. No evidence of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. No RAPD VFF to confrontation.
Funduscopic exam revealed no papilledema or optic disc pallor.
No
red desaturation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch or proprioception. He
reports
diminished cold temp. and pinprick over left hemibody with
sensory level slightly above nipple. Vibratory sense 17 sec at
right great toe and 18 sec at left great toe. No extinction to
DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF. RAMs intact b/l.
Gait: steady standard gait.
Pertinent Results:
___ 09:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
___ ___ 09:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-61
Brief Hospital Course:
Mr. ___ is a ___ year-old left-handed man with PMH notable
for partial transverse myelitis of of the cervical cord (C5
level) in ___ and currently on treatment with Copaxone
(he follows with Dr. ___ in clinic) who presents with
progressiveneck pain and stiffness for the past 5 days with no
new neurologic symptoms. His exam is notable meningismus and
decreased temp. and pinprick to level slighly above his nipple
on the left consistent with his prior cervical cord lesion and
exam findings. There are no current infectious symptoms to
suggest a meningitis, but given the degree of neck stiffness, LP
is warranted for further evaluation. Given that his prior
episode of partial transverse myelitis began with neck
discomfort prior to neurologic symptom onset, he should also
undergo C-spine imaging
for evaluation of possible new cervical cord lesion resulting in
his current neck pain and stiffness, though it is reassuring
that he has no new neurologic deficits on exam.
Neuro: Mr ___ was admitted to the neurology service after
evaluation in the ED. He had an LP in the ED that was
unremarkable for sign of acute infection or inflammatory
process. He also underwent a MRI c spine that did not show any
new lesions or enhancing lesions to account for his symptoms.
His exam remained stable throughout his hospital course. He was
given baclofen 5mg and oxycodone for pain with some relief of
his symptoms.
His presentation was discussed with Dr. ___ agreed with
Mr. ___ being discharged with follow up in about one month's
time. We discussed starting Mr. ___ on gabapentin for
possible neuropathic causes of his symptoms at 300mg TID and
baclofen was perscribed (5mg TID PRN) for muscle spasm
contributing to his pain. While his pattern of symptoms did not
relate fully to musculoskeletal pain, this could be a
contributing factor. We did discuss whether there ___ have been
a demyelinating process in the thoracic spine that could be
contributing to his presentation but at this time with his exam
having been stable with no new deficits to further support this,
it was not felt that imaging was necessary when discussed with
Dr. ___. He will continue on his current dose of copaxone.
Cardio/Pulm:
No acute issues during his hospital stay
FENGI:
Regular diet throughout hospitalization. Electrolytes were
within normal limits
ID:
No sign of acute infection
Dispo:
Mr. ___ was scheduled to see Dr. ___ in follow up in ___
and prescriptions provided for baclofen and gabapentin. He was
advised to take ibuprofen as needed for lumbar spine soreness
resulting from his LP.
Medications on Admission:
-Copaxone 20 mg SQ qMWF
Discharge Medications:
1. glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous ___ ().
2. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed for neck pain.
Disp:*20 Tablet(s)* Refills:*0*
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Neck and Back Pain possibly due to musculoskeletal etiology vs.
demyelination
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 evaluation of your neck and back pain and
stiffness. We did a lumbar puncture to make sure there was no
sign of infection or meningitis and those studies were found to
be normal. We also did a MRI of your cervical spine to look for
a cause of your symptoms and no new lesions were identified.
It is possible that your pain could be caused by musculoskeletal
injury or demyelination but your neurologic exam has remained
stable and at this time you do not require any further
treatment. Your admission was also discussed with Dr. ___
will see you in clinic in ___.
We made the following changes to your medications:
Started the following:
Baclofen 5mg three times daily as needed (this is a muscle
relaxant to help with the pain you are experiencing)
Gabapentin 300mg three times daily for neuropathic pain
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
Fever greater than 101
Chills
Any other symptoms that concern you
Dizziness or lightheadedness
Numbness or tingling
Change in vision
Confusion
Headache
Weakness in arm, leg, or face
Difficulty walking
Difficulty talking
Loss of balance
Incontinence of urine or stool
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
19651112-DS-19
| 19,651,112 | 27,680,226 |
DS
| 19 |
2122-03-27 00:00:00
|
2122-03-27 17:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip fracture
Major Surgical or Invasive Procedure:
___ - Right hip hemiarthroplasty
History of Present Illness:
___ otherwise healthy female ~9 days s/p insidious onset of R
hip pain with difficulty ambulating secondary to pain. The
patient notes the pain was sudden in onset while walking on
___ but no frank fall was appreciated. She had difficult
ambulating immediately after the pain began and had to receive a
ride home. She spent the next week with limited ability to
ambulate at her home in ___. She was transported from ___ to
___ by family, taken to family's primary care doc who sent
her
to ___ ED for further evaluation.
Past Medical History:
PMH:
Hypertension
Osteoporosis
PSH:
Multiple benign breast tumors removed
Right tibia ORIF ___ years ago
Social History:
___
Family History:
N/C
Physical Exam:
AVSS
NAD
AAOx3 though intermittent confusion/delirium overnight
RIGHT LOWER EXTREMITY:
Wound c/d/i
Extremity without obvious deformity
No skin tenting, or lesions indicative of open fracture
___ FHL ___ TA PP Fire
SILT LFCN, PFCN, Obturator, Saphenous, Sural, DP, SP, Plantar
2+ DP, ___ pulses; foot warm, well-perfused
Compartments soft (thigh, leg, foot)
Minimal pain to passive stretch of toes
No noted knee effusion
Pertinent Results:
___ 06:15PM GLUCOSE-126* UREA N-25* CREAT-0.6 SODIUM-144
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14
___ 06:45PM ___ PTT-27.2 ___
___ 06:15PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 06:15PM WBC-6.6 RBC-4.10* HGB-9.8* HCT-31.3* MCV-76*
MCH-23.9* MCHC-31.3 RDW-16.4*
___ 04:58PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-MOD
___ 04:58PM URINE RBC-0 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:58PM URINE HYALINE-15*
___ 04:58PM URINE MUCOUS-MANY
Brief Hospital Course:
Ms. ___ was admitted to the Orthopedic service on ___
for right hip fracture after being evaluated and treated with
closed reduction in the emergency room. She underwent open
reduction internal fixation of the fracture (hemiarthroplasty)
without complication on ___. Please see operative report for
full details. She was extubated without difficulty and
transferred to the recovery room in stable condition. She was
transfused 1unit with stable post-transfusion Hct. In the early
post-operative course she did well and was transferred to the
floor in stable condition. She was transfused an additional
unit pRBC on POD1 for falling Hct after which her Hct remained
stable without tachycardia or signs of bleeding.
The medicine service was consulted for her management. She had
a questionable U/A for which she was treated with ciprofloxacin
for 2 days but discontinued per medicine recommendations. OR
tissue cultures remained prelim negative. She was noted to have
mild delirium in the evenings, improved with reduction of pain
medication, tethers, and ciprofloxacin. Her blood sugars were
mildly elevated on POD2 and an insulin sliding scale was started
with outpatient instructions for management.
She had adequate pain management and worked with physical
therapy while in the hospital. The remainder of her hospital
course was uneventful and she is being discharged to ___
___ in stable condition.
Medications on Admission:
Alprazolam 0.25 mg TID
Sucralfate 1 gram BID
Amlodipine-Benazepril ___ mg qd
Caltrate 600 qd
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)): 30 mg each night for
2 weeks.
Disp:*15 syringe* Refills:*2*
11. oxycodone 5 mg Tablet Sig: ___ Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*35 Tablet(s)* Refills:*0*
12. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Begin on ___.
Disp:*25 Tablet(s)* Refills:*2*
13. insulin regular human 100 unit/mL Solution Sig: One (1)
units Injection ASDIR (AS DIRECTED): Insulin sliding scale per
protocol.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip femoral neck fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight bearing as tolerated on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox for 2 weeks to prevent blood
clots.
- You are being started on a Bisphosphonates to help prevent
fragility fractures. Take Alendronate weekly as prescribed
starting 2 weeks after the fracture. Take first thing in the
morning on an empty stomach. Take with at least 8 ox of water.
Remain upright for at least 30 minutes. Do not eat, drink or
take other medications for at least 30 minutes.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
ROMAT
Treatments Frequency:
Suture/staple removal at 2 week follow up appointment
Please follow patient blood sugars and administer insulin
sliding scale as needed per protocol. Patient will require
hemoglobin A1C as outpatient.
Patient has intermittent delirium. Please minimize tethers and
increase behavioral orientation.
Followup Instructions:
___
|
19651373-DS-18
| 19,651,373 | 26,728,227 |
DS
| 18 |
2124-01-09 00:00:00
|
2124-01-11 11:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
History of Present Illness:
___ year-old male with a history of BPH presents with shortness
of breath and chest 'discomfort'. He reports that yesteday
morning, he developed shortness of breath while walking at a
normal pace for him. He was surprised by this, but continued on
with his day. His symptoms resolved with rest, but occured
multiple times throughout the day. He also experienced a chest
'discomfort' across his upper chest bilaterally, which also
resolved with rest. His symptoms were worse when he walked up
two flights of stairs at home and was 'completely out of
breath'. He reports being able to easily walk up the stairs
prior.
.
He had a similar, but less severe, symptom set in ___. He
underwent a pMIBI which revealed normal myocardial perfusion,
normal wall motion with an ejection fraction of 57%.
.
The patient rested well overnight, but was concerned enough
about this symptoms the day prior that he decided to come to the
ED. He began walking, but decided to take a cab when he became
SOB.
.
In the ED, initial vitals were 96.7 78 132/83 16 100% RA. His
labs were significant for: Trop 0.27, Na 140, K 4.8, BUN 25, Cr
1.2, WBC 6.8, hct 41.3, plt 235. An ECG was concerning for ST
elevations in v4-6 with biphasic twaves. He was started on a
heparin gtt and taken to the cath lab.
.
He underwent angiography that showed a small RCA with clean
coronaries. He was noted to have coronary spasms and received
nitro with relief. During the episode of spasms he endorsed pain
in his left tricep and deltoid.
.
On arrival to the floor, patient reports feeling well. He is
currently experiencing a slight 'discomfort' in his left deltoid
and a 'discomfort' that is 'pulsating' under his right scapula.
He reports his breathing had improved, but gradually he was
being to feel likely dyspneic. He is otherwise feeling well. No
F/C, no SSCP, no abdominal pain, no N/V, no D/C.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Hyperplastic colonic polyps
-Bilateral benign renal cysts.
-Gross hematuria x1, ___.
-BPH
Social History:
___
Family History:
Brother died of a MI at age ___, Father with CAD.
Physical Exam:
Admission:
VS: afebrile, 127/86, 67, 18, 100% on RA.
GENERAL: Well appearing, well nourished man in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3-4 cm above the clavicle.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. WWP
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+
Discharge:
Pertinent Results:
Admission:
___ 07:50AM BLOOD WBC-6.8 RBC-4.61 Hgb-13.6* Hct-41.3
MCV-90 MCH-29.5 MCHC-32.9 RDW-12.5 Plt ___
___ 07:50AM BLOOD Neuts-45.3* ___ Monos-4.8
Eos-7.9* Baso-1.8
___ 07:50AM BLOOD Glucose-100 UreaN-25* Creat-1.2 Na-140
K-4.8 Cl-108 HCO3-20* AnGap-17
___ 06:50AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1
Discharge:
___ 06:50AM BLOOD WBC-7.8 RBC-4.28* Hgb-12.4* Hct-37.9*
MCV-89 MCH-29.1 MCHC-32.8 RDW-12.6 Plt ___
___ 06:50AM BLOOD Glucose-95 UreaN-20 Creat-1.2 Na-144
K-4.7 Cl-110* HCO3-26 AnGap-13
Cardiac Enzymes:
___ 07:50AM BLOOD cTropnT-0.27*
CTPA (___):
1. No evidence of PE or acute aortic pathology.
2. Moderate to severe emphysema predominantly in the upper
lobes.
3. Two 6-mm nodules in the right and left lower lobes
respectively. Six-month followup chest CT is recommended to
document stability of the nodule in the right lower lobe.
Alternatively comparison with prior outside studies would help
determine stability.
CXR (___):
IMPRESSION: Probable mild atelectasis at the right lung base,
though
pneumonia cannot be excluded in the right clinical setting. A
more optimized PA and lateral chest radiograph may be useful to
further characterize this finding.
Cardiac Cath (___):
-COMMENTS:
1. Selective coronary angiography of this left dominant system
demonstrated no angiographically significant coronary disease.
The LMCA was patent. The LAD was patent with a relatively long
segment of intramyocardial brdige in the mid-vessel. The LCX was
dominant and patent. The RI was patent. The RCA wa sa small
non-dominant vessel with intense catheter-induced spasm (initial
image without spasm) with incomplete response to 200mcg of
nitroglycerin IC. Additional selective engagement of the
coronary were avoided and anti-spastic medication injection were
given due to symptoms of left pectoral chest tightness that
corresponded with each engagement as well as pressure dampening.
2. Limited resting hemodynamics revealed normotension.
-FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Long intra-myocardial brdige in the mid-LAD
3. Intense catheter-induced RCA spasm
TTE (___):
-The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
apical hypokinesis to akinesis. No apical thrombus seen (cannot
definitively exclude). There is a mild resting left ventricular
outflow tract obstruction. Chordal systolic anterior motion is
seen. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
-Compared with the prior study (images reviewed) of ___,
apical wall motion abnormality, chordal ___ and significant
mitral regurgitation are new.
Brief Hospital Course:
___ yo M with limited PMH presenting with DOE and chest
'discomfort' for 1 day. Noted to have lateral ST elevations and
a troponin of 0.27. Cath did not reveal narrowing of his
coronaries but vasospasms were induced.
# Shortness of breath
The patient reports that he began to have DOE and chest
discomfort that resolved with rest. He had a similar
presentation in ___, after which he underwent a pMIBI which
was wnl. Upon arrival, the patient had ST elevations and a
positive troponin and he was taken to the cath lab. Cath
revealed did not reveal narrowing on his coronary arteries. He
felt well after cath, but transiently experienced b/l chest and
left tricep discomfort. He was started on diltiazem to help
control vasospasms. He underwent a CTPA which was negative for
PE, but did reveal emphysematous changes and two 6-mm nodules in
the right and left lower lobes respectively. He also underwent
a surface echo which was significant for apical wall motion
abnormalities and mitral regurgitation. Given the pattern of
his coronary artery anatomy, the patient should under go a
stress echo as an outpatient.
# BPH
He was continued on his home medications: finasteride and
tamsulosin
================================================
TRANSITIONS OF CARE:
================================================
-Pt needs repeat CT in 6 month or review of prior imaging due to
nodules seen on CTA (___).
-Pt would benefit from stress echo as an outpatient in with in
___ weeks.
Medications on Admission:
-FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily - No
Substitution
-TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s)
by mouth daily
-ASPIRIN [ADULT LOW DOSE ASPIRIN] - (OTC) - 81 mg Tablet,
Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
-NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every ___ minutes x 3 as needed for chest pain ***
pt reports never taking this medication
Discharge Medications:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Coronary artery vasospasm
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 this
hospitalization. You were admitted because you had been
experiencing shortness of breath and when you arrived in our ED,
there were signs on your ECG that were concerning for blockages
in the arteries that supply your heart with blood. You
underwent a cardiac catheterization which did not reveal a
blockage, but did reveal that you coronary arteries were prone
to 'spasm'. You were started on two medications to help guard
against these 'spasms'. We recommend that you obtain a stress
echo as an outpatient.
Please make the following changes to your medications:
-START: Diltiazem ER 120 mg daily
-START: Atorvastatin 40 mg daily
-START: Lisinopril 2.5mg daily
-Please continue taking your other medications as previously
directed.
Followup Instructions:
___
|
19651629-DS-21
| 19,651,629 | 23,513,822 |
DS
| 21 |
2118-02-24 00:00:00
|
2118-02-24 17:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetanus Vaccines & Toxoid
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of 2 bare metal stents to
distal RCA
History of Present Illness:
Mr. ___ is a ___ year old man with CAD who presents with
chest pain. He was at the ___ game and noted substernal
chest pain for 15 minutes after walking. He recieved 325mg ASA
at ___ and his pain resolved. No dyspnea, presyncope,
or syncope.
In the ED, initial vitals were 98.3 68 124/92 18 99% ra. His
trops rose from < 0.01 to 0.06 at 8am. He was started on a
heparin gtt.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for 2 bouts of presyncope
over the last several months with exertion that resolved
spontaneously. absence of dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations.
Past Medical History:
CAD (POBA to LAD ___ yrs ago, and RCA stent ___ yrs ago)
Javelin injury to his R neck while he was a teenager
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: ___ .O2 sat= 98-100% on RA
General: well appearing, talkative/conversant
HEENT: MMM
Neck: non-elevated JVD
CV: RRR no m/r/g
Lungs: CTAB no w/r/r
Abdomen: soft/nt/nd +BS
GU: no foley
Ext: 1+ ___ pitting edema
Neuro: normal gait
Skin: no rashes/excoriations
PULSES: 2+ ___ bilaterally
Discharge:
VS: 98.5 ___ 50-70 16 95%RA
General: well appearing, talkative/conversant
HEENT: MMM
Neck: non-elevated JVD
CV: RRR no m/r/g
Lungs: CTAB no w/r/r
Abdomen: soft/nt/nd +BS
GU: no foley
Ext: no edema. right femoral access site with mild ecchymosis.
No hematoma. No bruit.
Neuro: no focal abnormalities
Skin: no rashes/excoriations
PULSES: 2+ ___ bilaterally
Pertinent Results:
LABS:
Admission:
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD WBC-8.4 RBC-4.92 Hgb-15.4 Hct-44.5 MCV-91
MCH-31.4 MCHC-34.7 RDW-12.8 Plt ___
___ 08:30PM BLOOD Glucose-87 UreaN-21* Creat-1.2 Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
___ 08:59AM BLOOD CK(CPK)-115
___ 08:30PM BLOOD cTropnT-<0.01
Discharge:
___ 07:00AM BLOOD WBC-9.6# RBC-5.65 Hgb-18.0 Hct-51.7
MCV-92 MCH-31.9 MCHC-34.8 RDW-13.3 Plt ___
___ 07:00AM BLOOD ___ PTT-27.8 ___
___ 07:00AM BLOOD Glucose-113* UreaN-18 Creat-1.4* Na-144
K-4.8 Cl-102 HCO3-26 AnGap-21*
___ 07:00AM BLOOD CK(CPK)-337*
___ 07:00AM BLOOD CK-MB-36* MB Indx-10.7* cTropnT-0.99*
___ 07:00AM BLOOD CRP-1.7
===========================================================
IMAGING / OTHER STUDIES
CXR:
No evidence of acute cardiopulmonary process.
LHC:
Diagnostic angiography revealed a series of lesions in the
distal RCA,
the most severe of which was a 90% stenosis.
PTCA and stenting was planned under bivalirudin
thromboprophylaxis.
The RCA was selectively engaged with a ___ JR4 guiding catheter.
A
prowater wire was advance across the lesion with minimal
difficulty
allowing delivery of a 2.5*28mm MINI VISION RX bare metal stent
that was
deployed distally at 18atm. A second stent of the same kind
(2.5*18mm)
was delivered to the distal RCA, proximal to the previous stent
with
overlapping of the stents, providing complete coverage of the
lesions.
This stent was deployed at 16atm. Final angiography revealed 0%
residual
stenosis and TIMI 3 flow in all major epicaridal branches. There
was no
angiographic evidence of coronary dissection.
During the procedure, the patient experience some chest
discomfort
during balloon inflations, but was free of angina at the end of
the
procedure. The patient also experienced an important vagal
episode that
was treated successfully with 1mg of Atropine and IV fluids. By
the end
of the procedure, the patient was hypertensive (180mmHg
systolic) for
which a nitroglycerine perfusion was started. The patient was
transfered
to the floor for continued care in stable condition and free of
angina.
COMMENTS:
1. Right-dominant coronary system
2. LMCA: No obstructive disease.
3. LAD: There was ? of a lesion near D1 in the ___ cranial view,
which
was not clearly seen in other views.
4. LCX: minimal disease
5. RCA 90% serial lesions with plaque rupture.
6. Successful placement of 2 bare metal stents in the distal
LAD.
7. RFA closure with Angiseal
FINAL DIAGNOSIS:
1. Right dominant system with signle vessel disease in RCA.
2. Successful PTCA and Stenting (BMS) of the distal RCA.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of CAD who
presented with an NSTEMI.
# NSTEMI: Patient presented with typical anginal chest pain and
troponin elevation to 0.06. LHC showed a 90% distal RCA lesion,
which was treated with 2 overlapping bare metal stents. During
the procedure, patient had an episode of chest pain and
hypertension, which resolved with initiation of a nitroglycerin
gtt. There was initially concern for coronary dissection;
however, pain resolved and flow was restored with placement of
the second stent. Post-cath troponin was elevated to 0.22 ->
0.99. Nitro gtt was quickly weaned off and patient had no
furthur chest pain. Troponin elevation was thought to be
secondary to brief occlusion durring placement of first stent
during procedure. He was discharged on atorvastatin 80mg daily,
carvedilol 6.25mg BID, prasugrel 10mg daily, ASA 325mg.
As there was concern for potential coronary dissection, CRP was
obtained to help r/o vasculitis. CRP was wnl.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 180 mg PO Q24H
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Prasugrel 10 mg PO DAILY
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST Segment Myocardial Infarction
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to ___ with an NSTEMI. ___ underwent
cardiac catheterization which demonstrated a 90% in the distal
right coronary artery. This was opened using two bare metal
stents. During the procedure there may have been a small
dissection of the coronary artery, causing an elevation in your
cardiac labs and transient chest pain. Your blood pressure was
elevated, so ___ were switched to the beta-blocker, carvedilol
6.25mg BID, which can be adjusted by your outpatient
cardiologist.
It was a pleasure taking part in your care and we wish ___ a
speedy recovery!
Followup Instructions:
___
|
19651865-DS-15
| 19,651,865 | 29,314,768 |
DS
| 15 |
2175-01-04 00:00:00
|
2175-01-04 19:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diaphragmatic hernia
Major Surgical or Invasive Procedure:
1. Laparoscopic hernia repair with mesh (___)
History of Present Illness:
___ in usual state of health until acute onset
nausea/vomiting/abdominal pain 2days ago ___ pm) after eating
tuna salad for lunch. Since then has had intractable
nausea/vomiting and has not been able to keep down solids of
fluids. Abdominal pain mainly associated with bouts of vomiting
but was also occurring at rest, and along with lightheadedness
today with walking, decided to go to ED. At OSH ED, was found
to
have CT findings concerning for diaphragmatic hernia and gastric
outlet obstruction. An NGT was inserted with evacuation of 1.7L
f coffee-ground and gastric contents, with immediate relief in
abdominal pain. WBC at OSH 16.4, Hct 50.1, Cr 1.2.
Denies fevers, chills, sweats. No chest pain or difficulty
breathing.
Of note, he had a CXR in ___ with no signs of diaphragmatic
hernia, and he denies any traumatic injuries that might explain
the defect. He does, however, work in ___ with
significant heavy lifting as part of his work.
Past Medical History:
CONTACT DERMATITIS
HEALTH MAINTENANCE
L LEG FRACTURE
SYNCOPE/TIA ___
Social History:
___
Family History:
NC
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: Appears well, AAOx3
CV: RRR
Resp: Normal effort, no distress
Abdomen: Soft, nondistended, nontender, no rebound or guarding
Wound: Incision C/D/I
Tube/Drain: SS
Ext: Warm, well perfused, no edema
Pertinent Results:
___ 01:33PM PLT COUNT-246
___ 01:33PM NEUTS-84.3* LYMPHS-4.6* MONOS-10.7 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-12.89* AbsLymp-0.70* AbsMono-1.63*
AbsEos-0.00* AbsBaso-0.02
___ 01:33PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-4.5
MAGNESIUM-2.1
___ 09:44PM PLT COUNT-191
___ 09:44PM WBC-10.5* RBC-4.28* HGB-12.7* HCT-40.0 MCV-94
MCH-29.7 MCHC-31.8* RDW-14.0 RDWSD-47.6*
___ 09:44PM GLUCOSE-150* UREA N-26* CREAT-1.2 SODIUM-149*
POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-31 ANION GAP-15
___ 10:06PM freeCa-1.08*
___ 10:06PM TYPE-ART PO2-101 PCO2-51* PH-7.42 TOTAL
CO2-34* BASE XS-6
___ 10:06PM TYPE-ART PO2-101 PCO2-51* PH-7.42 TOTAL
CO2-34* BASE XS-6
Brief Hospital Course:
Mr. ___ was admitted on ___ with nausea, vomiting and a
large anterior diaphgramatic hernia on imaging. He was taken to
the operating suite for an uncomplicated laparoscopic hernia
repair with mesh. He was Extubated afterwards and arrived in
PACU in stable condition. He remained stable on post-operative
and remained in the ICU POD0 for monitoring, NPO with NGT
decompression and foley catheter for urinary monitoring. On POD1
he was doing well and was transferred to the floor. His NGT was
discontinued and he was given sips. His foley catheter was
discontinued and he voided spontaneously thereafter. On POD2 his
diet was further advanced to a regular diet and his fluids were
discontinued. He tolerated that well, he ambulated
independently, and he voided spontaneously. He was deemed ready
for discharge and he was discharged home on POD2. All questions
were answered to his satisfaction. He was instructed to avoid
heavy weight lifting for this time and will be seen in follow
up.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr:PRN Disp #*50
Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr:PRN Disp #*10
Tablet Refills:*0
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Anterior diaphragmatic hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with a diaphragmatic hernia which you had
repaired. You are now tolerating a regular diet and are ready
for discharge. It is very important to remember to avoid
exertion or straining until follow up. You should also not lift
anything heavier than 10lbs for ___ weeks and until told
otherwise. You will see us in clinic. Please expect a phone call
with a time. Otherwise it was great taking care of you and
follow the instructions below:
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting.
-Increased shortness of breath
Pain
-Take Tylenol on a standing basis to reduce opiod use.
-Take stool softners while taking narcotics
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk ___ times a day for ___ minutes increase to a Goal of
30 minutes daily
Diet:
Eat small frequent meals. Sit in chair for all meals. Remain
sitting up for ___ minutes after all meals
NO CARBONATED DRINKS
Followup Instructions:
___
|
19651885-DS-12
| 19,651,885 | 27,894,411 |
DS
| 12 |
2123-08-27 00:00:00
|
2123-08-27 16:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
VF ARREST
Major Surgical or Invasive Procedure:
VT ablation with Impella support
s/p left T1-T5 sympathectomy
History of Present Illness:
Mr. ___ is a ___ with history of coronary artery disease
status post CABG in ___ (LIMA-LAD, SVG-PDA, SVG-OM/diagonal)
and PCI to LMCA, D2, and SVG-PDA in ___, mixed
cardiomyopathy (LVEF 20%) status post ___ dual-chamber ICD
placement in ___ (atrial lead and CRT-D upgraded in ___,
and VT status post ICD shock in ___, and ___
requiring VT ablation in ___ who is now transferred from
___ after receiving ICD shocks at home. The
history is limited however he was reportedly dyspneic at home.
EMS was called and on arrival the pt was apparently pulseless in
VF arrest, shocked twice by ICD, shocked once by EMS, achieved
ROSC. He ___ have been following commands at that time. He was
taken emergently to ___.
At ___, he had multiple runs of VT and was loaded with
lidocaine bolus and drip. After this he suffered another VF
arrest, shocked externally and 2 rounds of ACLS with ROSC. He
was bolused another 80mg IV lidocaine. He was sedated with
fent/versed due to hypotension from propofol. He was transferred
to ___ for further management.
- In the ___ ED, initial vitals were: T 34.6 60 130/75 14
100% on CMV FiO2: 50 PEEP:5 RR: 14 Vt: 500
- Labs notable for Na 120, bicarb 18, Cr 1.8 (baseline 1.4-1.6),
trop-T 0.28. ALT/AST both in 200s. VBG with pH 7.24 pCO2 59
lactate 2.9.
- u/a with large blood.
- He ___ have had a brief episode of VT with hypotension which
spontaneously resolved. He was briefly on norepi but quickly
taken off due to stable hemodynamics.
- lidocaine gtt was continued
- 45 minutes off of propofol and vecuronium he was reportedly
non-responsive
- He is on the cooling protocol with goal T 34 per discussion
with post-arrest team.
- he was admitted to CCU for further management
- Access: 18x2, 20.
On arrival to the CCU, VS: T 34.2 HR 62 BP 143/87 100% on CMV,
40%FiO2 and PEEP 5.
REVIEW OF SYSTEMS:
Unable to obtain, intubated and sedated.
Past Medical History:
1) coronary artery disease s/p inferior MI and CABG in ___
(LIMA-LAD, SVG-PDA, SVG-OM/diagonal) s/p PCI to LMCA and to D2,
and to SVG PDA (with collaterals to OM/diagonals) in ___
2) mixed cardiomyopathy with LVEF 20%, inferior scar, and LV
10x7.6cm on CT scan
3) s/p ___ dual-chamber ICD for primary prevention
___, atrial lead and CRT-D upgrade ___
4) VT s/p ICD shock in ___, with recurrence despite sotalol
in ___ s/p SVG-PDA stenting, s/p recurrent VT in ___ and
subsequent VT substrate ablation via transseptal approach in
region of inferior scar on ___
5) ?right-sided peripheral vascular (femoral arterial) disease
6. Hypertension
7. Hypercholesterolemia
8. Hyperprolactinemia /pituitary adenoma- diagnosed ___ years
ago
9. Chronic kidney disease- creat 1.6
10. Gout
11. Actinic Keratosis
12. Hx of lentigo maligna s/p mohs surgery
___. Anal fissure with occasional mild bleeding
14. Polio as a child
15. tooth abscess treated with PCN 500 4x daily ___.
Social History:
___
Family History:
multiple family members with early cardiac death on his mother's
side
Physical ___:
ADMISSION EXAM:VS: T 34.2 HR 62 BP 143/87 100% on CMV, 40%FiO2
and PEEP 5.
Gen: Intubated
HEENT: Pupils 2 mm, equal and reactive to light.
NECK: Soft,supple
CV: RRR. S1 and S2.
LUNGS: Coarse breath sounds anteriorly
ABD: Hypoactive BS. Soft, non-tender, non-distended.
EXT: Cool.
PULSES: 2+ bilateral radial pulses, ___ pulses non-palpable
SKIN: Scattered excoriations over bilateral upper/lower
extremities
NEURO: non-responsive to pain/voice
DISCHARGE EXAM:
VS: T afebrile, 106-111/54-61, HR 69-70 AV paced, RR 20, 93-95%
RA
8hr: + 100
24 hr: - 1.2 Litres
NECK: Soft,supple
CV: RRR. S1 and S2.
LUNGS: Clear, diminished at bases
ABD: Hypoactive BS. Soft, non-tender, non-distended.
EXT: 1+ pitting edema bilateral shins
PULSES: 2+ bilateral radial pulses, ___ pulses non-palpable
SKIN: Scattered excoriations over bilateral upper/lower
extremities
NEURO: A/O x3 denies pain.
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD WBC-9.7# RBC-4.51* Hgb-13.6* Hct-38.8*
MCV-86 MCH-30.2 MCHC-35.1* RDW-13.5 Plt ___
___ 05:20PM BLOOD Neuts-88.4* Lymphs-7.7* Monos-3.3 Eos-0.4
Baso-0.2
___ 05:20PM BLOOD ___ PTT-25.6 ___
___ 05:20PM BLOOD Glucose-292* UreaN-17 Creat-1.8* Na-120*
K-4.6 Cl-91* HCO3-18* AnGap-16
___ 05:20PM BLOOD ALT-216* AST-222* AlkPhos-55 TotBili-0.9
___ 05:20PM BLOOD proBNP-1780*
___ 05:20PM BLOOD cTropnT-0.28*
___ 05:20PM BLOOD Albumin-3.6 Calcium-8.0* Phos-4.0 Mg-2.3
___ 05:20PM BLOOD TSH-7.2*
___ 05:31PM BLOOD Lactate-2.9*
___ 05:30PM URINE Color-PINK Appear-Hazy Sp ___
___ 05:30PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:30PM URINE RBC->182* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:30PM URINE Mucous-RARE
___ 03:00AM URINE Hours-RANDOM UreaN-145 Creat-29 Na-74
K-34 Cl-100
___ 05:35PM URINE Hours-RANDOM UreaN-704 Creat-130 Na-LESS
THAN K-55 Cl-13
___ 05:30PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS:
___ 01:59AM BLOOD Lactate-0.9 Na-125*
___ 05:20PM BLOOD cTropnT-0.28*
___ 04:45AM BLOOD CK-MB-31* cTropnT-0.47*
___ 03:16PM BLOOD cTropnT-0.46*
___ 04:40AM BLOOD ALT-35 AST-54* LD(LDH)-448* AlkPhos-39*
TotBili-0.9
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-6.7 RBC-3.19* Hgb-9.5* Hct-28.6*
MCV-90 MCH-29.9 MCHC-33.4 RDW-14.9 Plt ___
___ 04:50AM BLOOD Glucose-100 UreaN-29* Creat-1.8* Na-137
K-3.8 Cl-103 HCO3-25 AnGap-13
___ 04:50AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
MICROBIOLOGY:
___ BLOOD CULTURES: NO GROWTH
___ MRSA SCREEN: NEGATIVE
STUDIES:
___ ECG: Probable sinus and ventricular paced rhythm. On the
tracing of ___ there was probably also A-V paced rhythm
with short A-V delay. QRS complex is now wider. Otherwise, no
change.
Rate PR QRS QT/QTc P QRS T
60 ___ 0 -95 63
___ CXR: IMPRESSION:
Endotracheal tube in appropriate position.
Enteric tube courses below the diaphragm however the side port
appears in the distal esophagus/ GE junction and should be
advanced so that it is well within the stomach.
Left base opacity ___ be due to pleural effusion and
atelectasis, underlying consolidation not excluded.
___ TTE: The right atrium is markedly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe regional left
ventricular systolic dysfunction with akinesis and thinning of
the inferior, inferolateral, and basal inferoseptal walls. The
anterolateral wall is hypokinetic. There is hypokinesis of the
remaining segments (LVEF = ___. There is no ventricular
septal defect. Right ventricular chamber size is normal with
mild to moderate global free wall hypokinesis. There are three
aortic valve leaflets. The aortic valve leaflets are mild to
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. [Due to acoustic shadowing, the
severity of tricuspid regurgitation ___ be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with severe
regional systolic dysfunction c/w CAD (RCA/LCx territories).
Mild to moderate mitral regurgitation. Normal right ventricular
chamber size with mild to moderate hypokinesis. Aortic valve
sclerosis with minimal aortic stenosis and at least mild aortic
regurgitation. Mild pulmonary hypertension.
Compared with the report of the prior study from ___
in the atrius system (images unavailable for review) of
___ the findings are likley similar.
___ CTA CHEST: IMPRESSION:
1. Patent arterial vasculature, as described above, with severe
atherosclerotic calcifications in the abdominal arterial
vasculature,
including the bilateral common femoral arteries.
2. Cardiomegaly.
3. Right lower lobe low opacity, concerning for pneumonia or
large
aspiration. Trace right pleural effusion.
4. Mildly distended gallbladder with wall edema and
pericholecystic fluid. Recommend clinical correlation for
acalculous cholecystitis. This could be further evaluated with a
HIDA scan if indicated.
___ NERVE BIOPSY: Segment of benign-appearing peripheral
nerve.
___: CXR: IMPRESSION:
1. Other tubes and lines are in appropriate positions.
2. Increased left pleural effusion and left base atelectasis.
3. Possible mild mediastinal shift to the left, but finding
likely due to
obliquity of the patient. When repeating chest radiograph,
nonoblique views
is recommended.
___: IMPRESSION:
Pacemaker generator obscures a long portions of the left costal
pleural
margin. There could be a very small left pneumothorax. If there
is any left
pleural effusion is small. Postoperative widening of the cardiac
silhouette is
stable. Substantial left lower lobe atelectasis has worsened.
Subsegmental
atelectasis at the right base is also more pronounced. There is
no pulmonary
edema and no right pneumothorax.
Brief Hospital Course:
___ with history of coronary artery disease status post CABG in
___ (LIMA-LAD, SVG-PDA, SVG-OM/diagonal) and PCI to LMCA, D2,
and SVG-PDA in ___, mixed cardiomyopathy (LVEF 20%) status
post ___ dual-chamber ICD placement in ___ (atrial lead
and CRT-D upgraded in ___, and VT status post ICD shock in
___, and ___ requiring VT ablation in ___ who
presents after VT/VF arrest x2 in the setting of heart failure
exacerbation.
# CORONARIES:
SVG-OM-Diagonal: Known occluded
SVG-PDA: 50% proximal lesion. 40% touchdown disease. The
retrograde portion of the LDA makes a 180 degree turn filling a
large PL that fills the diagonal, OM2 as well. The bend has a
no significant re-stenosis compared with last procedure.
LIMA-LAD: Not injected. Known widely patent 3 months ago.
# PUMP: EF ___, ICD in place
# RHYTHM: a and v-PACED
#)VT/VF Arrest: Patient with multiple shocks both from ICD and
AED in the field for presumed VF/VT arrest. He was initially
responsive after first arrest at home but subsequently was not
rousable s/p ROSC after second round of VT/VF with shock. Could
be ___ arrhythmogenic scar from prior ischemic events. He was
admitted to ___ and continued on the cooling protocol,
however, while at 34 degrees he became responsive and was
following commands. He was rewarmed. For his VT, thoracic
surgery was consulted for sympathectomy, which was performed on
___. This was complicated by hemothorax requiring chest tube
placement. He then underwent VT ablation on ___ with impella
for support. For VT prevention, he was linitially on lidocaine
gtt, but this was transitioned to metoprolol (no amiodarone
given that he was on this at home). Despite an initially
successful ablation, he had an episode of VT arrest with ROSC
after external defibrillation and 1 mg epi on ___. He was put
back on a lidocaine gtt and then transitioned to quinidine 324
TID as an anti-arrhythmic. His metoprolol was changed to
succinate 25 mg BID. He had no further episodes prior to
discharge.
#) HEMOTHORAX: Developed during/after ablation procedure likely
from being fully anticoagulated shortly after having the
sympathectomy. Chest tube was removed after chest xrays stable
without signs of reaccumulation. Plavix (initially held) was
restarted after chest tube pulled.
#) ACUTE DECOMPENSATED HEART FAILURE: LVEF ___. Pt presented
with VT/VF arrest in the setting of increased dyspnea/weight
gain for several days prior to admission. He was diuresed with
IV lasix PRN. Patient received impella device for assistance
during ablation procedure. This was removed after. He resumed
home furosemide and lisinopril.
#) Acute on chronic kidney injury: Pre-renal secondary to heart
failure vs ATN secondary to VF arrest. Now back to baseline
around Cr 1.7.
#) CAD s/p CABG in ___: Patient with trop elevation likely in
the setting of chest compressions and shocks.
He continued home cardiac meds (aspirin, plavix). He restarted
metoprolol as above. Simvastatin was decreased to 20 mg daily.
Ranexa was not restarted and discontinued due to concern that
its anti-arrhythmogenic properties would interfere with the
quinidine.
Chronic Issues:
#) Hypertension: LisinopriI 5 mg PO daily. Restarted metoprolol
#) Hypercholesterolemia: Simvastatin as above
#) Hyperprolactinemia/pituitary adenoma: Diagnosed ___ years ago:
Continue cabergoline
#) Chronic kidney disease: creat 1.6 at baseline. On admission,
Cr 1.8
#) Gout: Stable. Not on medication.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Aldara (imiquimod) 5 % topical Twice a year
5. cabergoline 0.5 mg oral 2X/WEEK
6. Diazepam 5 mg PO ASDIR
7. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR Frequency is
Unknown
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron 4 mg PO Frequency is Unknown
10. Furosemide 40 mg PO DAILY
11. Pravastatin 40 mg PO QPM
12. Amiodarone 200 mg PO BID
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Ranexa (ranolazine) 500 mg oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. quiniDINE Gluconate E.R. 324 mg PO Q8H
7. Simvastatin 20 mg PO QPM
8. Aldara (imiquimod) 5 % topical Twice a year
9. cabergoline 0.5 mg oral 2X/WEEK
10. Diazepam 5 mg PO ASDIR
11. Hydrocortisone (Rectal) 2.5% Cream ___SDIR
12. Furosemide 40 mg PO DAILY
___ increase to 80mg daily if shortness of breath, or weight
gain
13. Outpatient Lab Work
ICD: 420.0
PLease have Chem 7 drawn on ___
Results sent to : ___ MD Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
VT/VF arrest
ACute on chronic systolic heart failure exacerbation
VT storm
VT ablation with Impella support
s/p left T1-T5 sympathectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for VT storm and a heart failure exacerbation.
You underwent a sympathetamy and a VT ablation during which your
heart was supported with an impella device. WE have made some
medication changes including increasing your diuretic dose for
the short term and stopping your Amiodarone and Ranexa in
exchange for quinidine.
You should continue to weigh yourself daily and report an
increase in weight of more than 3 ppounds in one day or 5 pounds
in two days to your cardiologist who manages your diuretic.
You are written for a script for labs to be drawn on ___ to
follow up your electrolytes and renal function on an increased
dose of diuretic.
An updated list of your meds will be included in your discharge
paperwork.
It was a pleasure taking care of you this hospitalization.
Followup Instructions:
___
|
19652084-DS-13
| 19,652,084 | 23,863,411 |
DS
| 13 |
2120-03-17 00:00:00
|
2120-04-02 20:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
pravastatin / oxycodone / lisinopril
Attending: ___
Chief Complaint:
acute onset
of visual changes and left face and arm numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of HTN, bilateral primary open
angle glaucoma, OSA not yet on CPAP who presents with acute
onset
of visual changes and left face and arm numbness, for whom Code
Stroke was called. History provided by patient.
Mr. ___ reports he was in his usual state of health
neurologically until the last ___ weeks when he began
experiencing left arm parasthesias and numbness. This is
localized to the left arm, primarily in the antecubital fossa,
radiating several inches proximally up the arm and several
inches
distally in the forearm circumferentially, not in a clear
dermatomal distribution. This sensation was present most of the
day for the last ___ weeks, and annoying but not impacting his
daily functioning.
This morning, he was last well at around 11:00am. He works at
the
___ desk and had taken several calls without difficulty
since
his arrival to work at around 9:40am. At around 11:00am, he
began developing more severe numbness and tingling in the left
arm, in the same area that was previously affected. This
persisted for about 15 minutes, when he then developed acute
onset of vision loss. He reports that "a curtain came down over
my eyes, and everything went black." He is not sure whether it
was monocular or binocular; he did not try closing either eye to
see if it resolved. After a few seconds he turned toward the
window and was able to do see "only that it was window vaguely,
nothing through it." He stood up and was able to find his way
to
his supervisor's office with great difficulty, when he told him
what was going on and was helped to a chair. Once he sat in the
chair, the vision loss began to significantly improve. He
estimates that the period of vision loss lasted a few minutes.
His supervisor called ___. As he was sitting there waiting for
EMS to arrive, the left arm numbness/tingling remained
persistent, and he began to have left face numbness/tingling as
well (which was new). No symptoms in the leg. When EMS came to
see him shortly thereafter, he reports he had difficulty
focusing. He again is not sure whether this was monocular or
binocular. There was no visual loss at this point, rather the
vision was generally blurry. He then was brought to ___ for
further evaluation.
Throughout this time, Mr. ___ denies any pain, denies any
diplopia, denies flashers, denies floaters, denies focal
weakness, denies headache,denies difficulty understanding or
expressing speech.
On arrival to ___ ED he reports that the vision is generally
blurry but significantly improved. Now, after re-examining him
after CT scan, the vision is back to normal. By the time of
arrival to the ED, the left face numbness has resolved, and the
left arm numbness is improving but not yet fully resolved. He
had
an NIHSS of 1 per ED scoring for left face numbness, but it is 0
on my exam en route to CT scanner.
Of note:
- Mr. ___ has a history of bilateral severe open angle
glaucoma. He reports that only symptoms he has at baseline from
this is that "everything seems darker" and he has some
difficulty
at times distinguishing between light and dark places. He has
never had sensation like this before. He actually saw his
Opthalmologist yesterday who did not that his glaucoma is not
well controlled and he has severe glaucomatous optic neuropathy
___, with constriction of visual field in both eyes. He is on
latanoprost and recommended continuing this for the time being.
Plan for formal binocular visual field testing for driving in
the
near future.
- Patient has had multiple ED visits recently for various
symptoms. Most recently was in ED ___ for bilateral leg
restlessness and leg tingling. He was asymptomatic on arrival
and
discharged with plans for neuro-urgent care. Patient reports the
leg tingling is present mostly at night and has been going on
for
months. Prior to that he was seen on ___ in ED for intermittent
dizziness and palpitations, found to have hypokalemia, and felt
related to chlorthalidone which was stopped. Finally he was seen
on ___ with headache, found to be hypertensive, with headache
improved as BP was normalized.
Apart from above, patient denies any recent changes to his
routine such as missed medication doses, recent illness,
fevers/chills or trauma.
On neuro ROS:
+ intermittent b/l leg tingling (chronic), left arm
numbness/tingling as above
- denies headache, loss of vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems: 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:
Bilateral severe open angle glaucoma
HTN
OSA not on CPAP (is working on having this arranged)
Social History:
___
Family History:
Denies any family history of premature CAD, stroke or
blood clots.
Physical Exam:
Admission Physical Exam:
Vitals: HR 56, BP 124/79, RR 17, O2 100% RA
Glucose 83
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Visual acuity with his glasses is ___
bilaterally. PERRL 3 to 2mm and brisk. Unable to visualized
fundi
despite attempt in busy ED hallway. EOMI without nystagmus.
Normal saccades. VFF to confrontation via finger counting.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No agraphesthesia. No extinction to DSS. Romberg
absent.
-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. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
Discharge Physical Exam:
24 HR Data (last updated ___ @ 1735)
Temp: 98.3 (Tm 98.3), BP: 143/88 (113-144/73-88), HR: 59
(44-71), RR: 18 (___), O2 sat: 97% (96-98), O2 delivery: Ra,
Wt: 223.1 lb/101.2 kg
General: middle aged man sitting comfortably in bed
HEENT: NC/AT
Pulmonary: breathing comfortably on room air
Cardiac: RRR, warm, well-perfused
Abdomen: soft, ND
Extremities: wwp, no C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-MS: awake, alert. oriented to ___, date. Able to relay
history
without difficulty. Language is fluent. No paraphasic errors.
-CN: PERRL 5-3mm b/l. VFF to confrontation. EOMI, no nystagmus.
Facial sensation equal b/l. No facial asymmetry. Symmetric
palate
elevation. Tongue midline. ___ trapezius b/l.
-Motor
[Delt] [Bic] [Tri] [ECR] [FEx] [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; intact to pinprick throughout
-Reflexes: 2+ biceps, 2+ patellar.
-Coordination: Intact FNF, no dysmetria. Intact finger tapping.
-Gait: Deferred.
Pertinent Results:
___ 12:12PM BLOOD WBC-6.4 RBC-5.14 Hgb-15.3 Hct-45.1 MCV-88
MCH-29.8 MCHC-33.9 RDW-12.3 RDWSD-39.7 Plt ___
___ 12:12PM BLOOD Neuts-37.9 ___ Monos-8.8 Eos-3.0
Baso-1.3* Im ___ AbsNeut-2.44 AbsLymp-3.12 AbsMono-0.56
AbsEos-0.19 AbsBaso-0.08
___ 12:12PM BLOOD Glucose-89 UreaN-12 Creat-1.1 Na-140
K-4.2 Cl-99 HCO3-26 AnGap-15
___ 12:12PM BLOOD ALT-30 AST-27 AlkPhos-69 TotBili-0.5
___ 12:12PM BLOOD cTropnT-<0.01
___ 12:12PM BLOOD Albumin-4.6 Calcium-9.8 Phos-3.3 Mg-2.1
Cholest-178
___ 12:12PM BLOOD %HbA1c-6.2* eAG-131*
___ 12:12PM BLOOD Triglyc-127 HDL-44 CHOL/HD-4.0
LDLcalc-109
Non-Contrast CT of Head: No acute process per my read. Mild
periventricular white matter disease c/w small vessel ischemic
changes.
CTA head/neck: ___ and d/w stroke fellow there is a
possible plaque just distal to right carotid bifurcation in the
right ICA. Pending reformats. Otherwise no large vessel
occlusion, no significant intracranial disease.
MRI Head ___
FINDINGS:
No evidence of acute intracranial hemorrhage.
No diffusion restriction with corresponding ADC signal to
suggest new infarct.No mass or subsequent mass effect. The
ventricle and sulci are unremarkable.
The intracranial flow voids are preserved.
The paranasal sinuses, middle ear cavities are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large
territorial infarct.
Carotid Duplex ___ FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous
atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is
59 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
right internal
carotid artery are 28, 35, and 50 a cm/sec, respectively. The
peak end
diastolic velocity in the right internal carotid artery is 22
cm/sec.
The ICA/CCA ratio is 0.98.
The external carotid artery has peak systolic velocity of 49
cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is
82 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 33, 47, and 58 cm/sec, respectively. The
peak end
diastolic velocity in the left internal carotid artery is 25
cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 73
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No evidence of significant stenosis in the internal carotid
arteries
bilaterally.
Brief Hospital Course:
___ year old man with history of HTN, bilateral primary open
angle glaucoma, OSA not yet on CPAP who presents with acute
onset of visual changes and left face and arm numbness, for whom
Code Stroke was called. History is notable for ___ week history
of intermittent patchy left arm sensory changes, and more
acutely this morning developed acute onset of left arm
numbness/tingling followed shortly thereafter with acute onset
of visual loss lasting a few minutes (unclear if monocular or
binocular), and left face/arm tingling. Visual loss resolved
after a few minutes, sensation improving. His neurologic
examination is normal at this stage including visual fields and
acuity.
Later, patient's history seemed more consistent with a
pre-syncopal event as patient did not lose vision fully. He had
visual dimming and felt like he was about to pass out. Patient
also had sinus bradycardia on telemetry down to ___ while
sleeping but asymptomatic.
MRI did not show acute infarct. CTA showed diffuse narrowing of
R ACA. Carotid US showed less than 40% stenosis.
Unclear etiology of event but patient has glaucoma and reports
palpitations recently. TIA is less likely given numbness is
patchy and transient on L forearm and L leg. Patient was
bradycardic to ___ overnight while sleeping but asymptomatic.
#Hypertension: Continue home antihypertensives
Transitional Issues:
[] f/u holter monitor results for arrhythmia
[] TTE as outpatient
[] follow up with cardiologist
[] follow up with PCP
[] follow up with neurology
Medications on Admission:
- Losartan/HCTZ 100mg/25mg daily
-Fish oil 415mg daily
-Latanoprost drops 0.005% ___
-Diclofenac gel 1% daily
-Naproxen 500mg PRN - has not taken recently
- Sildenafil 20mg PRN - has not taken recently
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Zolpidem Tartrate 5 mg PO ___ insomnia
RX *zolpidem 5 mg 1 tablet(s) by mouth at bedtime Disp #*15
Tablet Refills:*0
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES ___
4. losartan-hydrochlorothiazide 100-25 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pre-syncope
Secondary diagnosis:
Hypertension
Transient parasthesias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of sudden onset
decreased vision. Initially there was concern for a transient
stroke. MRI scan of the brain did not show any acute stroke.
Your sudden onset decreased vision may be caused by pre-syncope,
making you feel like you were about to pass out. Sometimes this
is caused by dehydration or an irregular heart rhythm.
You also had transient numbness in a patchy area of your left
arm and left leg. This is likely not due to TIA or stroke, but
could be caused by nerve compression.
Please follow up with your primary medical doctor for ___ referral
to an Atrius neurologist.
You should follow up with your heart doctor or primary doctor
who gave you a holter monitor test.
It is also important for your to follow up with your appointment
to have a sleep study. A CPAP machine may help you sleep better
and prevent long term health effects of obstructive sleep apnea.
Please continue to take your medications as prescribed.
Thank you for the opportunity to participate in your care.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19652762-DS-13
| 19,652,762 | 27,338,528 |
DS
| 13 |
2134-01-25 00:00:00
|
2134-01-28 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
bee pollen
Attending: ___
Chief Complaint:
Bilateral lower extremity weakness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI:
___ man with a past medical history significant for
DVT/PE after meniscal knee surgery in the left leg has
subsequently developed bilateral lower extremity weakness distal
greater than proximal with radiating pain in both legs. He says
his symptoms first started in ___ when he got off a plane
and he felt a left calf cramp. Since that time his left and
then
his right legs have become progressively weaker with radiating
pain. He now feels that his right hand has a lot of pain
although he does not feel that this week at all. He has been
seen by multiple physicians for these complaints including Dr.
___ at ___. He has been diagnosed with chronic
inflammatory demyelinating polyradiculopathy of unclear
etiology.
He has undergone 2 lumbar punctures, 2 EMGs, imaging of his
entire spine, muscle biopsy, and other than persistent elevated
ACE in the serum, workup has been unrevealing.
From previous notes "He has had multiple investigations
including
laboratory investigations which revealed normal workup for
infectious (Lyme, syphilis, hepatitis B, hepatitis C, HIV) and
inflammatory (anti-DNA antibodies, Sjogren's antibodies, ANCA,
___ CRP) etiologies. He was found to have mildly elevated serum
ACE of 82 (normal: ___. He has had ongoing elevated CK levels,
which have ranged from 1800-2400. An EMG study completed in
___, revealed moderate, ongoing and chronic left
lumbosacral polyradiculopathy without evidence of a myopathic
process. An MRI of the lumbar spine, completed ___,
revealed multilevel degenerative changes with smooth enhancement
of the cauda equine nerve roots. A lumbar puncture revealed mild
elevation in CSF protein with normal cells and negative cytology
and ACE level. A CT chest was normal without any evidence of
adenopathy. A CT abdomen was normal without evidence of
underlying tumor. A PET scan completed in ___ revealed
an 8 mm thyroid nodule and diffuse muscle uptake throughout,
which may represent muscular inflammation. A muscle biopsy of
the
right gastrocnemius revealed a neurogenic process with the
presence of focal myopathic changes seen occasionally." He was
given a diagnosis of CIDP versus sarcoidosis and treated with
IVIG for 6 months with minimal improvement.
He went to see a Lyme specialist earlier this year, who
prescribed azithromycin for 2 months through ___ line and then
switched to Zithromax for presumed chronic Lyme although his
titers have never been positive. He felt initially that this
was
helping but then there was no more improvement so he stopped the
antibiotics about 6 weeks ago because they were causing him
stomach problems. He now complains of marked weakness in his
legs. He is having difficulty ambulating. His knees often feel
like they are going to buckle and he is going to collapse
although he has not had any actual falls. He continues to have
extreme muscle aches and pain in the legs both in the calves
with
cramping as well as radicular shooting pain from his hips down
to
his ankles. The pain never goes into his feet. He feels that
his calves are shrinking in size and he acknowledges that they
do
twitch and endorses fasciculations. Since ___, he states
that he has lost 30 pounds for unclear reasons. He was evaluated
by Dr. ___ today in clinic and sent for admission to
neurology for expedited workup.
On neuro ROS, bilateral lower extremity weakness, muscular pains
and cramping, radicular shooting pain, difficulty with
ambulation
and weight loss as above. Otherwise, the pt denies headache,
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies numbness
changes in sensation. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent illnesses
although he has lost 30 pounds in ___ for unclear reasons.
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:
Left meniscus repair years ago with subsequent DVT and PE for
which he was treated with Lovenox for 6 months
Gallbladder removed ___
Pericarditis ___
Social History:
___
Family History:
He has 2 children a boy and a girl ___ and ___. His
daughter has celiac disease. He has a brother who is ___ with
essential thrombocythemia. His sister is ___ and healthy. His
father is alive at ___ with hemochromatosis. His mother passed
away at ___ from liver cirrhosis she was a moderate drinker.
Physical Exam:
Discharge Physical Exam:
Vitals:
PHYSICAL EXAM ___:
- Vitals: Temp 97.3-98.3, BP 108-124/68-74, HR 65-71, RR 18,
96-99%RA
- General: Awake, cooperative, tan-appearing man in NAD
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: No increased WOB
- Cardiac: Well perfused
- Extremities: No edema
- Skin: No rashes or lesions, but notably tan throughout
NEURO EXAM:
- Mental Status: Awake, alert, oriented. Able to relate history
without difficulty. Attentive to history and exam. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric.
There was no evidence of apraxia or neglect.
- Cranial Nerves: PERRL 3 to 2mm and brisk. No facial droop.
Hearing intact to room voice.
- Motor: Atrophy in the bilateral calves, intermittent
fasciculations in b/l thighs and calves noted. Normal tone
throughout. No adventitious movements such as tremor or
asterixis noted.
Muscle RightLeftMuscle RightLeft
Shoulder Abd55Hip ___
Elbow ___
Elbow ___
Wrist ___ Dorsi4-4-
Wrist ___ Plantar44
Finger ___ Flex4+4+
Finger ___ Ext ___-
Ankle Eversion2 3
Ankle Inversion 4- 4
- Sensory: No deficits to light touch, proprioception
throughout. No paraspinal pinprick loss.
Plantar response was flexor bilaterally.
- Coordination: No dysmetria on FNF bilaterally.
- Gait: Able to walk independently. Slower than normal. Narrow
based.
Admission Physical Exam:
GENERAL EXAM:
- Vitals: Pain 5 temperature 97.6 heart rate 72 blood pressure
146/79 respiratory rate 14 100% room air
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to history and exam.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high and low frequency objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Good
knowledge of current events. There was no evidence of apraxia or
neglect.
- Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation. EOMI without
nystagmus. Facial sensation intact to light touch. No facial
droop. Hearing intact to room voice. Palate elevates
symmetrically. ___ strength in trapezii and SCM bilaterally.
Tongue protrudes in midline and to either side with no evidence
of atrophy or weakness.
- Motor: Atrophy in the bilateral calves, no fasciculations
noted. Normal tone throughout. No pronator drift bilaterally.
No adventitious movements such as tremor or asterixis noted.
Muscle RightLeftMuscle RightLeft
Shoulder Abd55Hip ___
Elbow ___
Elbow ___
Wrist ___ Dorsi4+4
Wrist ___ Planti44
Finger ___
Finger ___ Ext ___
Ulnar Intrinsic55
APB 55
- Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 1 0 1 0 0
R 1 0 2 0 0
Plantar response was flexor bilaterally.
- Coordination: No dysmetria on FNF bilaterally.
- Gait: Wide-based careful steps. Decreased arm swing, and
intention. Easily pulled backwards with multiple missteps on
pull test during Romberg.
Pertinent Results:
- ACE: 86 most recently on ___
- Cryoglobulins: Negative.
- ___ negative.
- ANCA negative
- SPEP neg.
- Celiac ab negative.
- Heavy metal screen negative.
- Sjogren's Abs neg.
- Lyme: Negative by EIA.
- CSF cytology: No malignant cells
- Urine porphobilinogen: negative.
Brief Hospital Course:
Mr. ___ is a ___ man with presumed chronic inflammatory
demyelinating polyradiculopathy of unknown etiology followed by
Dr. ___ in neurology, who was admitted for workup of his
progressive weakness and pain in his bilateral distal lower
extremities. On exam, he has bilateral weakness with ankle
dorsi/plantarflexion, toe flexion/extension, and ankle
eversion/inversion; atrophy and fasciculations in both legs;
hyporeflexia throughout; and abnormal gait. His symptoms first
presented in ___ and since then he has had extensive
work-up: CSF with pleocytosis with elevated protein, elevated CK
values, elevated ACE, enhancement of the lumbar roots on MRI,
severe chronic and ongoing left lumbosacral polyradiculopathy on
EMG, and muscle biopsy with focal findings suggestive of
neurogenic disease. He was initially diagnosed with sarcoid
(never proven) vs. CIDP vs. other autoimmune process.
Differential for polyradiculopathy also includes hereditary
disorders (CMT, HNPP), infection (HCC, HTLV, Lyme,
mycobacterial, VZV), and exposure-related/toxic-metabolic. He
was admitted to the general service for further workup given
worsening symptoms.
Given his hand-stiffness in the morning, and asymmetric weakness
and pain (left worse than right), an auto-immune condition
seemed most likely, though all testing for specific conditions
came back negative so far. Mr. ___ requested to defer a
muscle biopsy during this admission, so after lots of testing
and collaboration with several other tests, we decided to pursue
IV steroids x 5 days.
Mr. ___ had pulmonary nodules on a CT scan from ___, and
when repeated, these pulmonary nodules were stable in size.
Pulmonology was consulted, and did not ultimately recommend
biopsying these nodules.
Rheumatology consulted to help consider auto-immune diagnoses,
and recommended several lab tests along with a muscle biopsy,
though Mr. ___ opted to not pursue a second muscle biopsy
at this time.
Endocrinology also consulted, given Mr. ___ known
thyroid nodule. They recommended that he continue his plan with
his outpatient endocrinologist of having this biopsied in their
office, and the endocrinology team had no further
recommendations for Mr. ___ as an inpatient.
An LP was performed on Mr. ___ second hospital day, and
showed 8 WBC, 39 RBC, and a lymphocytic predominance of 95%.
Total protein in the CSF was 104. From the CSF, a paraneoplastic
panel and multiple sclerosis panel was sent, as was an ACE
level, all which remain pending.
Further workup for the etiology of his polyradiculopathy was
performed. Mr. ___ ACE was 86 on re-testing, and had
been previously similarly high.
- Cryoglobulins: Negative.
- ___ negative.
- ANCA negative
- SPEP neg.
- Celiac ab negative.
- Heavy metal screen negative.
- Sjogren's Abs neg.
- Lyme: Negative by EIA.
- CSF cytology: No malignant cells
- Urine porphobilinogen: negative.
He had IV methylprednisolone 1000mg daily for 5 days, from
___ through ___.
In discussion with his primary neurologist, it was decided that
rituximab would be tried as the next step in trying to combat
Mr. ___ unknown, but probable auto-immune
polyneuropathy, and this was set-up as an outpatient. He was
started on cellcept upon discharge, per his primary
neurologist's recommendations.
Mr. ___ agreed with plans for discharge and follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
Discharge Medications:
1. melatonin 3 mg oral QHS
2. Mycophenolate Mofetil 500 mg PO BID
Take 500mg BID x 1 week, then 1000mg BID.
RX *mycophenolate mofetil [CellCept] 500 mg 1 tablet(s) by mouth
twice a day Disp #*120 Tablet Refills:*3
3. PredniSONE 60 mg PO DAILY Duration: 7 Doses
Start: ___, First Dose: First Routine Administration Time
This is dose # 1 of 7 tapered doses
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
4. PredniSONE 50 mg PO DAILY Duration: 7 Doses
Start: After 60 mg DAILY tapered dose
This is dose # 2 of 7 tapered doses
RX *prednisone 50 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
5. PredniSONE 40 mg PO DAILY Duration: 7 Doses
Start: After 50 mg DAILY tapered dose
This is dose # 3 of 7 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. PredniSONE 30 mg PO DAILY Duration: 7 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 4 of 7 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
7. PredniSONE 20 mg PO DAILY Duration: 7 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 5 of 7 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
8. PredniSONE 10 mg PO DAILY Duration: 7 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 6 of 7 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
9. PredniSONE 5 mg PO DAILY Duration: 7 Doses
Start: After 10 mg DAILY tapered dose
This is dose # 7 of 7 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
10. Gabapentin 600 mg PO TID
Take 500mg in the morning & afternoon, 600mg at night x 3d, then
___ x3d, then 600mg 3x/d.
RX *gabapentin 400 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*11
RX *gabapentin 100 mg 5 capsule(s) by mouth three times a day
Disp #*540 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Autoimmune polyradiculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for extensive workup of your lower
extremity weakness and pain. You have symptoms of a
polyneuropathy, but the diagnosis has remained unclear.
While you were admitted, you were taken care of by the neurology
team, but several other doctors ___, including:
Rheumatology, Endocrinology, and Pulmonology.
You had a chest CT, which showed stable size of previously known
lung nodules nodules. The pulmonologists did not think that
these lung nodules were significant, and did not recommend
biopsying them.
The thyroid nodule was stable in size on this CT compared to
your prior chest CT in ___.
You had a spinal tap, which showed elevated protein, a
non-specific sign of inflammation in your spinal fluid, which
has been present on prior lumbar punctures. You had a high
number of lymphocytes in your spinal fluid, and the final result
of all of the spinal fluid tests is pending.
You had a repeat Lumbar Spine MRI, which showed similar results
to your prior MRI, with lumbar spondylosis looking the same as
it did before (the nerve roots are slightly compressed by
narrowing of your spinal canal there).
A muscle biopsy was recommended, to help guide us toward the
correct diagnosis, by looking for signs of inflammation in your
muscle tissue, but this tests was deferred based on your
request.
It was decided to pursue immune-modulating therapy, and to start
high dose steroids, IV methylprednisolone for 5 days. This
therapy will be arranged for you as an outpatient, per your
request.
Followup Instructions:
___
|
19653430-DS-5
| 19,653,430 | 29,512,330 |
DS
| 5 |
2176-03-02 00:00:00
|
2176-03-02 18:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
oxybutynin / trazodone / Aleve
Attending: ___.
Chief Complaint:
rigors vs seizure
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
___ Stroke Scale (performed within 6 hours of presentation)-
Total [20]
Date: ___
Time: 1735
1a. Level of Consciousness -2
1b. LOC Questions -1 (intubated)
1c. LOC Commands -2
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -0
5a. Motor arm, left -3
5b. Motor arm, right -3
6a. Motor leg, left -3
6b. Motor leg, right -3
7. Limb Ataxia -0 (cannot understand commands)
8. Sensory -0
9. Language -3
10. Dysarthria -UN
11. Extinction and Neglect -UN
HPI:
Pt is a ___ yr F w/ hx of frontal dementia, HTN, HLD, and
depression who presents due to concern for breakthrough seizure.
Hx obtained from son at bedside.
This afternoon around 1500, son was driving with pt to
sister-in-law's house when he noticed she was less interactive
than normal, responding with one word answers at best. Upon
arriving to house pt was seen to develop acute onset of shaking
while sitting on the couch. Of note, shaking described as
tonic-clonic by EMS while son displayed as more rigorous in
nature. Pt was laid on her side and EMS was called who upon
arrival gave 5mg Versed intranasally. EMS report that pt
displayed R head/gaze deviation, with shaking lasting for at
most
a few minutes before resolution. Pt was brought to BI ED where
Code Stroke was called.
Son denies any recent f/c or infectious sx. No recent head
trauma
or substance abuse. Of note, pt has had prior "drop attacks"
evaluated in ED, generally attributed to presyncope. Son is
unsure if she had any similar shaking during those episodes. On
one occasion in ___ pt was admitted to BI after being found
down
in her bathroom, with subsequent cardiac w/u negative.
Past Medical History:
Hypercholesterolemia
Hypertension, essential, benign
Primary hypothyroidism
osteoporosis, s/p alendronate ___, last DEXA ___
History of SCC (squamous cell carcinoma) - right jawline
___
Fibrothecoma s/p BSO ___
Generalized anxiety disorder
Osteoarthritis of both hands
PMR (polymyalgia rheumatica)
Urge incontinence of urine
Hemorrhoids
Frontal lobe dementia
Diverticulosis of large intestine without hemorrhage
GERD (gastroesophageal reflux disease)
Chronic bilateral low back pain without sciatica
Chronic constipation
Degenerative joint disease (DJD) of lumbar spine
Spondylolisthesis, lumbosacral region
Social History:
___
Family History:
Brother - MI at age ___
Brother - HTN
Mother - Heart disease
Father - HTN
Daughter - atrial fibrillation, HTN
Physical Exam:
Exam on admission:
==============
Vitals: T: HR: BP: RR: SaO2:
General: NAD, intubated and sedated
HEENT: NCAT, no oropharyngeal lesions, neck supple, ETT in
place
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination (off Propofol):
MS: Somnolent, opens eyes briefly to voice w/o regard/tracking.
Does not follow commands.
CN: PERRL 3->2mm, +VORs, corneals. BTT. Grimaces appropriately
to
noxious.
Sensorimotor: Intact bulk and tone b/l. Withdraws briskly to
tactile stimuli in all extremities b/l. Intermittent generalized
rigors noted.
DTRS:
___ and symmetric throughout. Plantar response flexor b/l.
Coordination/Gait: Deferred
DISCHARGE EXAM:
General: appears well, in no distress
HEENT: NC/AT
___: WWP
Pulmonary: Breathing comfortably on room air.
Extremities: Warm, no edema
Neurologic Examination
Neuro:
MS- Oriented to self, month, year, not date. Generally
appropriate but a times tangential.
CN- Pupils 2->1.5 mm, slight left nasolabial fold flattening
with
symmetric activation and left ptosis with strong eye closure
Sensory/Motor- Diffuse paratonia. Moves all extremities
symmetrically and anti-gravity. intact to light touch
throughout.
Pertinent Results:
___ 11:50PM BLOOD WBC-16.2* RBC-4.21 Hgb-12.7 Hct-40.7
MCV-97 MCH-30.2 MCHC-31.2* RDW-12.9 RDWSD-46.0 Plt ___
___ 12:13PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-4 Polys-4
___ Macroph-7
___ 12:13PM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-73
IMAGING:
CT/CTA/CTP:
CT HEAD WITHOUT CONTRAST: No acute intracranial process.
CT PERFUSION: Symmetric mismatch in the bilateral occipital
lobes
is felt to be artifactual in nature. No definite evidence of
perfusional abnormality.
CTA HEAD: Patent circle of ___. No acute vascular occlusion.
CTA NECK: There is a short segment of caliber change in the
distal V2 segment of the right vertebral artery at the level of
C3 which may be due to noncalcified atherosclerotic plaque or a
focal dissection (04:127). MRA neck could be obtained for
further
evaluation. The more distal V3 and V4 segments of the right
vertebral artery, as well as the basilar artery, are normal in
caliber.
OTHER: There is a large consolidation in the posterior left
upper
lobe which may represent pneumonia or aspiration in the setting
of altered mental status.
EEG:
IMPRESSION: This continuous video-EEG monitoring study was
abnormal due to:
1) Occasional rhythmic delta activity in the left temporal
region, consistent
with LRDA and is associated with increased risk for seizures;
2) Intermittent polymorphic delta slowing over the left temporal
region,
indicative of left temporal focal cerebral dysfunction;
3) Diffuse background slowing and disorganization, indicative of
mild diffuse
cerebral dysfunction, which is nonspecific as to etiology.
There were no clinical events. There were no electrographic
seizures or
epileptiform discharges. Compared to prior day's recording,
there was no
significant change.
Brief Hospital Course:
___ is a ___ year old woman with PMH of frontal dementia,
HTN, HLD, and depression who was admitted to the neuro ICU due
to
concern for seizure s/p intubation. CT/CTA/CTP only revealing
for potential PNA. MRI wuthout stroke.
Per discussion with daughter and review of EMS records,
patient's presentation could be consistent with a secondary
generalized seizure, but this is questionable as other "drop
attacks" reportedly may have been worked-up to be syncopal in
nature. LP reassuringly bland. She is now at neurological
baseline. Impression is seizure vs rigors provoked by community
acquired pneumonia vs progression of frontotemporal dementia.
Given the fact that she is certainly at risk for seizures, opt
to continue treatment with keppra indefinitely.
# Neuro:
- EEG IMPRESSION: Occasional rhythmic delta activity in the left
temporal region, consistent with LRDA. Intermittent polymorphic
delta slowing over the left temporal region, indicative of left
temporal focal cerebral dysfunction. Diffuse background slowing
and disorganization, indicative of mild diffuse cerebral
dysfunction. No electrographic seizures or epileptiform
discharges.
- Continue Keppra 1g PO BID
- She was continued on home Donepezil
- Memantine was held and in conjunction with OP neurologist,
plan to discontinue this medication as it has not been hepful.
# CV/Pulm:
- Continued on home ASA and statin
# ID:
- treated with CTX and azithromycin for community acquired PNA.
- She completed 5d of azithromycin in the hospital
- CTX was transitioned to cefpodoxime while inpatient, she has 2
days left to complete 7 day course.
TRANSITIONAL ISSUES:
- continue keppra 1g BID indefinitely
- continue cefpodoxime for 2 more days to complete 7d course for
PNA
- outpatient f/u with Dr. ___ neurology)
- hold memantine indefinitely per Dr. ___ helpful as
outpatient)
Medications on Admission:
Aspirin 81 mg PO DAILY
Donepezil 10 mg PO QHS
Levothyroxine Sodium 100 mcg PO DAILY
Omeprazole 40 mg PO DAILY
Simvastatin 40 mg PO QPM
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H pneumonia
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
2. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*5
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure
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 for seizure. You were started on a new
anti-seizure medication called Keppra. You should continue
taking this everyday to help prevent seizure.
You were also found to have a pneumonia while you were in the
hospital. You will take 2 more days of antibiotics at home to
complete your treatment course.
Memantine was stopped during this hospitalization due to
ineffectiveness.
There were no other changes to your medications. You should
follow up with your neurologist, Dr. ___.
It was a pleasure caring for you.
Sincerely,
___ Neurology
Followup Instructions:
___
|
19653575-DS-16
| 19,653,575 | 21,817,298 |
DS
| 16 |
2128-09-22 00:00:00
|
2128-09-23 13:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atenolol
Attending: ___
Chief Complaint:
fever and body ache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history of myasthenia ___ and
a recent OSH admission for acute prostatis who presented to the
ED with weakness, chills, dysuria and fever to 102.5. The
patient was in his usual state of health until a prostate biopsy
on ___. On ___ he presented to the ___ with
generalized weakness, fever, chills, and dysuria. He was
diagnosed with a UTI and acute prostatitis thought to be
secondary to his recent biopsy and was treated with a course of
IV ceftriaxone. After one day of clinical improvement, he
insisted on being discharged to be able to make an
opthalmologist appointment for a recent dx of glaucoma and was
switched to an 8 day course of Bactrim on discharge, but it is
not clear if he finished the course. Blood and urine cx obtained
from that admission had no growth. Since discharge 16 days ago
he had been feeling well until this morning when he woke up with
weakness and chills. He described this as a lesser version of
his earlier episode of fever and chills over two weeks prior.
His wife measured his temperature at home to 102.5F. He also
reported mild discomfort while urinating and some trouble
starting his stream. He has BPH but only rarely has trouble
initiating a stream. He denied having any cough, SOB, or chest
pain. He also denied having any new rashes or recent exposures
to ticks. No nausea, vomiting, diarrhea or abdominal pain.
Past Medical History:
POAG/severe glaucoma
High grade prostatic intraepithelial hyperplasia (new dx)
BPH
myasthenia ___
colonic polyps
essential HTN
gout
Social History:
___
Family History:
Father died of cancer (lymphoma+) at ___. Maternal uncle and
grandfather died of MI at ages ___ and ___, respectively.
Physical Exam:
On Admission:
VS in the ED: ___ 112 110/70 16 99%RA
On the floor: 99.2F, BP 126/74, HR 78, RR 18, O2-sat 98%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no carotid bruits
LUNGS - CTA bilat, no crackles or wheezes, good air movement,
resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2, no S3 or S4
ABDOMEN - NABS, soft/NT/ND, 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, DTR (patellar)
2+ and symmetric
rectal (per ED): no tenderness on palpation of the prostate
On Discharge:
Vitals (as of ___ 98.3/98.4F, BP 91-101/63-71, HR 54-59, RR
18, O2-sat 95%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - MMM, OP clear
LUNGS - CTA bilat, no crackles or wheezes, good air movement,
resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2, no S3 or S4
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
On Admission:
___ 11:45AM BLOOD WBC-17.1* RBC-4.41* Hgb-13.9* Hct-40.5
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.4 Plt ___
___ 11:45AM BLOOD Neuts-87.1* Lymphs-7.9* Monos-4.5 Eos-0.4
Baso-0.1
___ 11:45AM BLOOD ___ PTT-24.7* ___
___ 11:45AM BLOOD Glucose-87 UreaN-28* Creat-1.3* Na-141
K-4.0 Cl-99 HCO3-30 AnGap-16
___ 11:54AM BLOOD Lactate-2.2*
___ 02:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 02:30PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 02:30PM URINE RBC-4* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-0
urine and blood cultures pending.....
On Discharge
___ 06:05AM BLOOD WBC-10.5 RBC-3.53* Hgb-11.3* Hct-32.9*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.4 Plt ___
___ 06:05AM BLOOD Glucose-80 UreaN-24* Creat-1.1 Na-144
K-3.9 Cl-106 HCO3-27 AnGap-15
urine cx ___ - no growth
___ 09:25AM URINE RBC-14* WBC-30* Bacteri-FEW Yeast-NONE
Epi-0
blood cx ___ still pending but NGTD
Brief Hospital Course:
Summary:
Mr. ___ is a ___ yo man with a history of myasthenia ___ and
a recent OSH admission (___) for acute prostatis 3 days s/p
prostatic biopsy discharged on 8 days of bactrim who presented
to the ED ___ with weakness, chills, and dysuria and a temp
recorded at home of ___. In the ED he was septic with a WBC of
17k, Cr of 1.3 and was started on CTX, flagyl, and fluids for
presumed recurrent prostatitis vs complicated UTI. By the time
he arrived on the floor he was hemodynamically stable. He was
not started on cipro because of his MG (it may cause MG crises)
also not on bactrim because it was considered a failure. On the
floor he remained afebrile and was treated with IV cefepime. He
was seen by ID and urology and ultimately sent home stable on PO
Bactrim for 4 weeks.
Active Issues:
1)UTI vs. Prostatis: Given the severity of his presentation and
apparent relapse after a reasonable course of treatment for
cystitis, ID thought a prostate abscess post biopsy is possible,
however urology thought this was more likely a UTI than acute
prostatitis. ID recommended not using vancomycin as enterococci
would not have responded to trim/sulfa and MRSA was unlikely,
and given cipro is not an option they recommended trim/sulfa up
to 4 weeks for presumed prostate infection. He will need to
follow up with his PCP ___ ___ to monitor his clinical status
and follow up cultures- he will also get an US on ___ to r/o
abscess.
Chronic Issues:
# myasthenia ___: currently not active. continued on steroid
regimen, also given 100mg prednisone in the ED in case of
adrenal insufficiency. Avoid drugs known to exacerbate MG.
# POAG: new diagnosis but stable, continued on current treatment
# HTN: Antihypertensives and KCl held as an inpatient, he can
restart these as an outpatient and follow up with his PCP
___:
1)UTI vs. Prostatis
- F/u with radiology for US to r/o abscess on ___ - he should
give himself a tap water enema the morning of the ultrasound.
- F/u w/ PCP ___ days after discharge to follow up cultures,
follow up radiology US report, and also to discuss prophylaxis
for PCP pneumonia given his immunosuppressed state arising from
chronic prednisone use.
- Continue treatment with Bactrim for a total of 4 weeks unless
advised otherwise by PCP in light of US report
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Allopurinol ___ mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Amlodipine 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. PredniSONE 20 mg PO EVERY OTHER DAY
10. PredniSONE 17.5 mg PO EVERY OTHER DAY
alternate 20mg one day and 17.5 the next
___. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. PredniSONE 20 mg PO EVERY OTHER DAY
7. PredniSONE 17.5 mg PO EVERY OTHER DAY
alternate 20mg one day and 17.5 the next
8. Amlodipine 5 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Weeks
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis, resistant UTI vs. acute prostatitis, myasthenia ___,
Primary Open-Angle Glaucoma (POAG, Hypertension
Discharge Condition:
Improved, mental status at baseline, ambulatory
Discharge Instructions:
You were treated for a bacterial infection of your blood which
came from a urinary tract infection or an infection of your
prostate. You were given broad spectrum antibiotics, fluids,
and stress dose steroids and your infection improved. It is
very important that you continue taking all of your antibiotics
until they are finished so that the bacteria which caused your
life threatening infection does not develop resistance to these
antibiotics and become more difficult or impossible to treat.
You were discharged with the following new medications:
Bactrim which you should take for 4 weeks.
You should follow up with your primary care doctor within ___
day after discharge to monitor your progress, follow up your
ultrasound report, follow up on your cultures, and also to
discuss prophylaxis for PCP pneumonia given your
immunosuppressed state arising from chronic prednisone use.
Followup Instructions:
___
|
19653575-DS-17
| 19,653,575 | 22,186,972 |
DS
| 17 |
2135-06-06 00:00:00
|
2135-06-06 16:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atenolol
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PCI with DES to LCx - ___
History of Present Illness:
From admitting H&P:
___ is a ___ old man with a history of HTN, ocular
myasthenia ___, and gout presenting with chest pain.
The patient reports the pain came on last night at 6:30 while
sitting in his car. It felt like bad heartburn and initially
improved with Zantac. The pain then returned after eating a
sandwich a few hours later, and persisted despite 4 Tums. The
pain was still there when he woke up this morning, which
prompted
him to come to the ED. The pain does not radiate. He denies
chest pressure, SOB, diaphoresis.
In the ED initial vitals were T 97.6 HR 59 BP 116/72 RR 18 O2
sat
98% RA. Patient subsequently dropped BP to as low as ___
systolic. Received 2L fluid in ED with improvement in BPs to ___
systolic.
EKG: Sinus rhythm, normal axis, short PR interval and upsloping
STD in V3-V6.
Labs/studies notable for troponin 0.42->0.67, MBI 20.7, WBC
13.1,
lactate 1.1. CXR showed no acute cardiopulmonary abnormality.
Bedside TTE showed EF ~50%, with possible inferior WMA.
Patient was given 324 mg aspirin and started on a heparin gtt
prior to transfer.
On the floor, patient endorses the history above. He reports
that
he has been having worsening "heartburn" for around three
months,
but it was never this severe. His pain is currently much
improved, and there is only a "lingering shadow" of it. His
health up until yesterday has been good, though he does report
one episode of laryngitis several weeks ago.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains,
cough, hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. All of the other review of systems were
negative."
Past Medical History:
POAG/severe glaucoma
High grade prostatic intraepithelial hyperplasia (new dx)
BPH
myasthenia ___
colonic polyps
essential HTN
gout
Social History:
___
Family History:
Uncle and grandfather with MIs prior to age ___.
Physical Exam:
On day of discharge:
Vitals: Temp: 98.4 (Tm 99.7), BP: 104/69 (104-121/69-78), HR: 66
(65-84), RR: 17 (___), O2 sat: 94% (93-96), O2 delivery: RA
Telemetry: NSR
General: lying in bed, appears comfortable and in NAD
HEENT: wearing glasses. EOMI. Oral mucosa pink and moist. No JVD
CV: RRR, S1/2 audible. No m/r/g
Lungs: Rales present in LLL. Otherwise CTA throughout
Abdomen: Bowel sounds present throughout. Soft, NT, ND
Ext: No pitting edema in the bilateral lower extremities.
Pertinent Results:
On day of admission:
___ 08:19AM BLOOD WBC-13.1* RBC-3.88* Hgb-12.9* Hct-37.0*
MCV-95 MCH-33.2* MCHC-34.9 RDW-13.2 RDWSD-44.8 Plt ___
___ 08:19AM BLOOD Plt ___
___ 08:19AM BLOOD Glucose-88 UreaN-25* Creat-1.0 Na-145
K-3.4* Cl-105 HCO3-27 AnGap-13
___ 08:19AM BLOOD CK(CPK)-768*
___ 08:19AM BLOOD CK-MB-159* MB Indx-20.7* cTropnT-0.42*
___ 07:32AM BLOOD CK-MB-141* MB Indx-14.2* cTropnT-4.20*
___ 08:19AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.9
___ 07:32AM BLOOD Triglyc-92 HDL-38* CHOL/HD-3.1 LDLcalc-60
On day of discharge:
___ 07:40AM BLOOD WBC-9.0 RBC-3.27* Hgb-10.8* Hct-33.4*
MCV-102* MCH-33.0* MCHC-32.3 RDW-13.7 RDWSD-50.4* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-77 UreaN-23* Creat-1.1 Na-146
K-4.3 Cl-110* HCO3-26 AnGap-10
___ 07:40AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.0
Cardiac catheterization ___:
50-60% stenosis of proximal LAD just distal to origin of D2.
100% occlusion of LCx. 40% stenosis of proximal RCA. LCx
lesion traversed with wire and balloon angioplasty performed,
followed by placement of DES.
TTE ___:
Mild regional left ventricular systolic dysfunction (LVEF
40-45%), c/w LCx-territory myocardial infarction. Mild aortic
regurgitation. Mild pulmonary hypertension (PASP 29mmHg).
Brief Hospital Course:
___ old man with a history of HTN, ocular myasthenia ___,
and gout, presenting with chest pain.
#NSTEMI: The patient presented to the ED with atypical symptoms
and no distinct EKG changes. He was found to have elevated and
up-trending troponins consistent with type I NSTEMI. He has no
known history of CAD. He was taken for a coronary angiogram and
percutaneous coronary intervention with placement of a drug
eluting stent in the left circumflex artery. Of note, the
patient was also noted to have 50-60% stenosis of the LAD and
40% stenosis of the RCA, neither of which were intervened on. He
also had evidence of smaller vessel disease, but stents were not
placed in these vessels due to their small size. Trop peaked at
4.20. He was started on dual antiplatelet therapy with aspirin
and ticagrelor. He was also started on low dose metoprolol and
high-intensity atorvastatin. Remained chest pain free after
cath. Low dose lisinopril started prior to discharge as well.
#New HFrEF: An echocardiogram obtained after PCI showed a
decreased EF of 40-45% with focal wall motion abnormalities in
the inferior and inferolateral regions (left circumflex
territory). This may represent a permanent change due to his MI
or stunned myocardium. Patient exhibited some signs of volume
overload on exam and had initial dyspnea on exertion, and
received 10 mg IV Lasix with symptomatic improvement. Was
started on furosemide 20 mg PO daily on day of discharge.
#Hypotension: The patient was noted to have low blood pressures
in ED with systolic BPs in the ___, though these improved
somewhat after administration of IV fluids. Lactate was normal.
The patient exhibited no signs or symptoms of infection. The day
after admission, he was noted to have a decrease in his
hemoglobin, however he exhibited no other evidence of bleeding.
His blood pressures remained low but stable and repeat lab work
showed that his hemoglobin and hematocrit were stable. His home
lisinopril was decreased to 2.5 mg daily, and may be increased
on an outpatient basis if the patient's blood pressures can
tolerate it. Hydrochlorothiazide was also held until outpatient
follow-up.
#Fever: Noted overnight on ___, without localizing infectious
symptoms. CXR, UA/UCx, blood cultures without evidence of
infection. Fever was likely in the setting of myocardial
necrosis and inflammation, and did not recur.
Transitional Issues:
[] Titrate anti-hypertensive regimen as blood pressures
tolerate; discharged on 2.5 mg lisinopril with
hydrochlorothiazide held.
[] Patient was started on furosemide 20 mg. Discharge weight =
77.4 kg (170.63 lb). Discharge Cr = 1.1. Please repeat BMP ___
days after discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. netarsudil 0.02 % ophthalmic (eye) QHS
4. Allopurinol ___ mg PO DAILY
5. PredniSONE 7 mg PO DAILY
6. Pilocarpine 4% 1 DROP BOTH EYES Q8H
7. Aspirin 81 mg PO DAILY
8. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID
9. brimonidine 0.2 % ophthalmic (eye) Q8H
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Lisinopril 2.5 mg PO QPM
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. brimonidine 0.2 % ophthalmic (eye) Q8H
9. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. netarsudil 0.02 % ophthalmic (eye) QHS
12. Pilocarpine 4% 1 DROP BOTH EYES Q8H
13. PredniSONE 7 mg PO DAILY
14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until told to do so
by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
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 came to the hospital with chest pain and were admitted
because you had a heart attack
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were taken for a procedure to look for blockages in the
arteries that supply your heart muscle with blood. We found a
significant blockage in one of the main arteries of the heart
and placed a stent to restore blood flow. You tolerated the
procedure well. We started you on some new medications to help
prevent future heart attacks.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- It is very important to take your aspirin and ticagrelor
(also known as Brilinta) every day.
- These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
- If you stop these medications or miss ___ dose, you risk a
blood clot forming in your heart stents and having another heart
attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You are also on other new medications to help your heart,
such as atorvastatin, lisinopril, and metoprolol
- You should seek medical attention if you develop chest pain,
shortness of breath, inability to lay flat due to shortness of
breath, swelling in your legs, fainting, or other new or
concerning symptoms.
- Your discharge weight was 170.63 lbs. Please monitor your
weight daily and call your doctor if your weight increases by
more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19653727-DS-6
| 19,653,727 | 25,117,465 |
DS
| 6 |
2117-03-11 00:00:00
|
2117-03-15 12:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / codeine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt states that since procedure she has had lower abd pain and
heavy bleeding for 2.5 weeks, with ___ pads of blood per day
following hysteroscopic myomectomy on ___. Lower abdominal
pain ceased two weeks ago, when she began to notice new onset
epigastric pain. The pain is intermittent and sharp in nature
that lasts for ___ minutes at a time and returns every 10
minutes. She has not noticed any exacerbating factors, and the
only relieving factor is dilaudid that was prescribed following
myomectomy. Over the past week, epigastric pain has
significantly worsened, now with nausea, NBNB vomiting. She
endorses baseline constipation, with BM every ___. Is not
currently using NSAIDs, though used 220 mg aleve daily for 1.5
months prior to surgical procedure for dysmenorrhea.
She has had temps of 99 at home, and reports the max temp of 101
early last week. She has had a reduced appetite and has lost 13
pounds in 2 weeks.
Pt notes she had epigastric pain, similar in location but less
severe and less sharp, back in ___ for which she had a
non-diagnostic endoscopy. She also endorses prior EGDs that have
showed "ulcerations"
In the ED initial vitals were: 9 97.4 123 114/97 16 96% ra
- Labs were significant for WBC 17.3 (N 79.2%, L 15.4%), hgb
11.6, hct 36.6, Plt 595, Lactate 2.2
- Patient was given pantoprazole 40mg IV, 2.5mg IV dilaudid, 4mg
zofran x2, prochlorperazine 10mg, benadyrl 25mg IV, 1L NS
Vitals prior to transfer were: ___ 111/70 16 100% RA
On the floor, T97.8 115/75 8 16 98% RA, patient was resting in
bed slightly uncomfortable but in NAD.
Past Medical History:
PAST MEDICAL HISTORY:
1. Anemia.
2. Fibroids.
3. Fibromyalgia.
4. Migraine headaches.
5. Hypertension.
6. Empty sella syndrome.
7. Osteopenia.
8. Hyperlipidemia.
9. Reactive airway.
10. Peptic ulcer.
PAST SURGICAL HISTORY
1. D&C: X2.
2. Myomectomy.
3. Foot surgery.
Social History:
___
Family History:
No hx of GI cancer
Physical Exam:
ADMISSION EXAM
Vitals - T97.8 115/75 8 16 98% RA
GENERAL: NAD resting in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, upper airway wheezes
ABDOMEN: obese, nondistended, +BS, nontender with deep
auscultation pressure, but diffuse tenderness with light
palpation, no rebound/guarding,
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
Neuro: alert, conversant, able to move all extremities,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
Vitals: T 97.9 P 90 BP 110/81 R 18 O2 100% RA
General: Tired appearing, in no acute distress
HEENT: EOMI. PERRL. Sclera anicteric. Conjunctival pallor.
MMM. Oropharynx clear
Neck: supple, without lymphadenopathy
Lungs: Bilateral wheezes on inspiration and expiration, with
poor air movement bilaterally in bases. Inspiratory wheezing
appreciated in tracheal region, absent throughout thorax. No
rhonci or rales
CV: RRR, normal S1/S2 with physiologic splitting, no murmurs,
rubs, or gallops
Abdomen: Soft, non distended. No visible tenderness to deep
auscultation. Distractable tenderness epigastrically,
periumbilically and RUQ.
Ext: Warm, well perfused, with 2+ ___ pulses bilaterally
Neuro: A+O x3
Pertinent Results:
ADMISSION labs:
___ 05:25PM WBC-17.3* RBC-4.60 HGB-11.6* HCT-36.6 MCV-80*
MCH-25.1* MCHC-31.6 RDW-13.3
___ 05:25PM BLOOD ALT-24 AST-36 AlkPhos-82 TotBili-0.1
___ 05:25PM BLOOD Lipase-66*
___ 08:00AM BLOOD CRP-11.0*
___ 05:25PM BLOOD Neuts-79.2* Lymphs-15.4* Monos-4.4
Eos-0.6 Baso-0.3
___ 05:25PM BLOOD ALT-24 AST-36 AlkPhos-82 TotBili-0.1
___ 05:25PM BLOOD Albumin-4.4
___ 05:25PM BLOOD Glucose-83 UreaN-12 Creat-0.8 Na-134
K-4.2 Cl-95* HCO3-25 AnGap-18
___ 03:05PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 03:05PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0
___: BCX X2 PENDING
___: CHLAMYDIA/GONORRHEA NEGATIVE
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-19.4* RBC-4.62 Hgb-11.6* Hct-37.5
MCV-81* MCH-25.2* MCHC-31.1 RDW-13.7 Plt ___
___ 08:00AM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-135
K-3.7 Cl-95* ___ AnGap-13
IMAGING:
CXR PA/LAT:
___
IMPRESSION:
No evidence of acute cardiopulmonary disease.
___ CT ABD/PELVIS:
IMPRESSION:
1. Bulky enlarged fibroid uterus.
2. Central necrosis in the dominant 4.9 x 4.7 cm fibroid at the
fundus.
3. 5 cm right adnexal cyst is larger since recent ultrasound.
Recommend repeat ultrasound in ___ weeks to document resolution
as large cysts can act as a nidus for ovarian torsion.
Brief Hospital Course:
___ yo female with pmh of empty sella syndrome/adrenal
insufficiency, gastric ulcers, fibroid s/p hysteroscopic
myomectomy on ___ who presented with abdominal pain.
#Epigastric abdominal Pain: Three weeks of epigastric pain since
myectomy though surgical related pain distinctly different.
Evaluated by GYN in ED, felt not to be source of pain. CT
Abd/pelvis notable for fibroid w/ central necrosis, but per gyn,
normal natural hx of fibroids, and unlikely to explain
leucocytosis and thrombocytosis. Neg abd US on ___, normal
EGD, normal LFTs, biliary source deemed unlikely and likewise
presentation not concerning for pancreatitis. GI evaluated and
felt no indication for endoscopy at this time given neg
endoscopy in ___ and already on omeprazole 40mg BID. Most
likely etiology could be gastritis/PUD w/ prior hx of
PUD/gastritis.
- follow up with PCP/GI
#Leukocytosis/Thrombocytosis- Source of leucocytosis and
thrombocytosis was unclear but downtrending at time of
discharge. Infectious workup negative and no source identified.
Possibly related to her recent GYN surgery. ALso possibly
related to her steroid use.
- follow up with PCP
___ sella syndrome: She reports a diagnosis of empty sella
syndrome/adrenal insufficiency (diagnosed in ___ but no
paper documentation), but diagnosis unclear since ___
TSH, FH values were normal. Continued on home 10 mg prednisone.
Increased dosage to 30 mg prednisone on admission due to patient
fatigue/malaise but reduced to home dose as no change in
symptoms and no further signs of infection.
- follow up with outpatient endocrinologist Dr. ___.
#Lower abdominal pain: Lower abdominal cramping intermittently
throughout hospitalization consistent with post-surgical pain
(recent myomectomy). She was continued on post-op pain
medication and instructed to decrease doses as tolerated.
- follow up with GYN/PCP
___ vaginitis: During hospitalization, had vaginal pruritis
and thick discharge. Prior vaginal swab from earlier on
admission positive for yeast. Treated with fluconazole 150mg X1
with good effect.
CHRONIC ISSUES:
#Reactive airway disease: Patient has a hx of reactive airway
disease, never had PFTs. Inspiratory wheezes on exam, localized
to upper airway. Continued on home albuterol with relief of
symptoms.
- follow up with PCP, recommend outpatient PFTs
#Migraine
- Continued on home Topamax 100 mg
#Hypertension
- continued on home chlorthalidone
#Fibromyalgia
-Continued on home Cyclobenzaprine
#Allergies
-Continued on home Fluticasone Propionate
-Continued on home Cetirizine
#Eczema
- Continued on home Clobetasol Propionate 0.05% Soln 10 for head
- Continued on home Betamethasone Valerate 0.1% Cream for body
#Acne
-Continued on home Clindamycin 1% Solution
=================================================
Transitional Issues
=================================================
- 5 cm right adnexal cyst is larger since recent ultrasound.
Recommend repeat ultrasound in ___ weeks to document resolution
as large cysts can act as a nidus for ovarian torsion.
- Patient carries a diagnosis of empty sella syndrome/adrenal
insufficiency, but ___ TSH, FH were normal. Continue to
follow with endocrinology as an outpatient (Dr. ___.
- upper airway wheezing on chest exam without documented PFTs
and unreliable response to nebs though uses albuterol at home
with reported result. recommend outpatient PFTs
- CODE:FULL CODE
- Contact: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection prn
anaphylaxis
2. Goodys Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral unknown
3. ___ Biotin (biotin) 10,000 mcg oral daily
4. Nucynta (tapentadol) 75 mg oral Q4-6H pain
5. TAB A VITE (multivitamin;<br>multivitamin-Ca-iron-minerals)
___ mg oral daily
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob, wheeze
8. Vitamin D 5000 UNIT PO DAILY
9. Levalbuterol Neb 0.63 mg NEB Frequency is Unknown sob
10. Ranitidine 300 mg PO DAILY
11. Betamethasone Valerate 0.1% Cream 1 Appl TP DAILY: PRN
itching
12. Cetirizine 10 mg PO DAILY
13. Chlorthalidone 25 mg PO DAILY
14. Clindamycin 1% Solution 1 Appl TP DAILY
15. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
16. Cyclobenzaprine 10 mg PO BID:PRN pain
17. Docusate Sodium 100 mg PO BID
18. Fluticasone Propionate NASAL 2 SPRY NU DAILY
19. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
20. Omeprazole 40 mg PO BID
21. PredniSONE 10 mg PO DAILY
22. Promethazine 25 mg PO Q4H:PRN nausea
23. Topiramate (Topamax) 100 mg PO QHS
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob, wheeze
2. Betamethasone Valerate 0.1% Cream 1 Appl TP DAILY: PRN
itching
3. Cetirizine 10 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. Clindamycin 1% Solution 1 Appl TP DAILY
6. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
7. Cyclobenzaprine 10 mg PO BID:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
11. PredniSONE 10 mg PO DAILY
12. Promethazine 25 mg PO Q4H:PRN nausea
RX *promethazine 25 mg 1 tablet by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
13. Ranitidine 300 mg PO DAILY
14. Topiramate (Topamax) 100 mg PO QHS
15. Omeprazole 40 mg PO BID
16. Vitamin D 5000 UNIT PO DAILY
17. TAB A VITE (multivitamin;<br>multivitamin-Ca-iron-minerals)
___ mg oral daily
18. Nucynta (tapentadol) 75 mg ORAL Q4-6H pain
19. ___ Biotin (biotin) 10,000 mcg oral daily
20. Goodys Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral unknown
21. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection prn
anaphylaxis
22. Levalbuterol Neb 0.63 mg NEB Q6H:PRN sob
23. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal Pain
Secondary Diagnosis:
Anemia.
Fibroids.
Fibromyalgia.
Migraine headaches.
Hypertension.
Empty sella syndrome.
Osteopenia.
Hyperlipidemia.
Reactive airway.
Peptic ulcer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with abdominal pain and some lab
abnormalities. You had blood tests and imaging of your abdomen,
which did not reveal a source of your abdominal pain. The
gastroenterology team saw you while you were here and did not
think you needed to have another procedure.
You were also feeling very fatigued, and despite the testing
done we did not find a source. The details of your admission
were relayed to your outpatient providers and you should
continue to be monitored closely until you are feeling better.
You were discharged with a follow up appointment with your
primary care physician(PCP) and endocrinologist for further
monitoring and evaluation.
During your hospitalization, you reported some wheezing. Please
continue to use your home inhaler as needed for wheezing and/or
shortness of breath and discuss further testing with your PCP.
Please call your doctor or 911 if your abdominal pain worsens,
you develop fevers or chills, or any new symptoms that concern
you.
Followup Instructions:
___
|
19654136-DS-12
| 19,654,136 | 28,905,287 |
DS
| 12 |
2135-01-06 00:00:00
|
2135-01-06 19:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
carboplatin
Attending: ___
Chief Complaint:
abdominal pain in setting of recurrent ovary cancer, s/p
small bowel resection
Major Surgical or Invasive Procedure:
Drainage of abdominal ascites
History of Present Illness:
Ms. ___ is a ___ G2P2 with a history of stage IIIC
serous ovarian cancer s/p suboptimal tumor debulking in ___
with recurrence in ___ s/p multiple cycles of chemotherapy at
___. She was found to have a small bowel obstruction
while in ___. There she underwent a small bowel resection and
ostomy creation and has been receiving TPN. She was admitted to
___ on
___ after her return from ___ for nutrition management. She
was discharged on ___.
She was doing well until ___ when she started to develop some
upper abdominal discomfort, nausea, and back pain. She was seen
in the office that day where exam was reassuring. She was
started on Zofran for nausea. She reports that since that time
her symptoms have worsened. Her pain is now ___ in the
epigastrum and in her back. She reports nausea, no emesis. She
has gas and stool in her ostomy. She does not pass gas from
below. She reports decreased appetite, but has been tolerating
small amounts of PO. She is on TPN. She denies HA, fevers,
chills, CP. She reports that she has baseline SOB. Given her
worsening discomfort, she presented to the ___ ED.
Regarding her cancer history, she was diagnosed with ovarian
cancer in ___ and following her surgery Tumor Board recommended
chemotherapy and Lynch syndrome testing, which per ___
records was positive for Lynch syndrome. Her course since
surgery has included ___ ___ -> recurrence in
___ s/p 6 cycles ___ ___. In ___ niraparib
vs placebo trial ___. Started weekly taxol ___.
Progression of
disease ___ involving axillary nodes, switched to
___ ___. CT scan ___ with worsening
carcinomatosis. Started topotecan ___ and continued for four
weeks. Then she traveled to ___ in the end of ___ to visit
her ill mother.
While in ___ she developed a small bowel obstruction and
underwent an exploratory laparotomy with resection of "greater
than 100cm" of small bowel due to small bowel obstruction caused
by peritoneal carcinomatosis according to email communication
with her surgeon Dr. ___ in ___. According to
Dr. ___ has approximately 120cm of small bowel
remaining ending in an end ileostomy. Upon review of her
records, which she brought from ___, the surgery was
complicated by "several perforations on the small bowel" and the
proximal and distal end of the small bowel were sutured as
separate stomas. She received 10 days of antibiotics
post-operatively. She received TPN in ___ due to her short
bowel and carcinomatosis.
Past Medical History:
PMH:
- Lynch syndrome
PSH:
- ___ appendectomy
- ___ hysterectomy
- ___ ex-lap, BSO, omentectomy, suboptimal tumor debulking
POBGYN:
- ___ s/p SVD x2
- ?h/o abnl pap prior to hysterectomy
Meds: (per ___ records from ___
- Aspirin 81mg
- multivitamin
- docusate
- senna
- Compazine prn
- Zofran prn
- Neupogen x5d after each chemo cycle
Social History:
___
Family History:
Family History: She does report that her mother may have had
uterine cancer and her mother had colon cancer as did her
brother.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress, comfortable
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, non-tender, mildly distended much improved since
admission, no rebound/guarding, right sided ostomy with liquid
brown stool and left sided dressing over paracentesis, which was
clean, dry, and intact
___: nontender, nonedematous
Pertinent Results:
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 9:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 07:10AM BLOOD WBC-5.0 RBC-3.13* Hgb-8.5* Hct-28.1*
MCV-90 MCH-27.2 MCHC-30.2* RDW-15.5 RDWSD-50.0* Plt ___
___ 05:06AM BLOOD WBC-5.5 RBC-3.03* Hgb-8.3* Hct-27.2*
MCV-90 MCH-27.4 MCHC-30.5* RDW-15.6* RDWSD-51.4* Plt ___
___ 09:30AM BLOOD WBC-7.0 RBC-3.47* Hgb-9.4* Hct-30.5*
MCV-88 MCH-27.1 MCHC-30.8* RDW-15.5 RDWSD-49.9* Plt ___
___ 09:30AM BLOOD Neuts-72.5* Lymphs-17.2* Monos-8.3
Eos-1.1 Baso-0.3 Im ___ AbsNeut-5.10 AbsLymp-1.21
AbsMono-0.58 AbsEos-0.08 AbsBaso-0.02
___ 07:10AM BLOOD Plt ___
___ 05:06AM BLOOD Plt ___
___ 10:24AM BLOOD ___ PTT-34.1 ___
___ 07:10AM BLOOD Glucose-158* UreaN-16 Creat-0.5 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 05:06AM BLOOD Glucose-92 UreaN-19 Creat-0.5 Na-136
K-3.5 Cl-100 HCO3-27 AnGap-13
___ 09:30AM BLOOD Glucose-95 UreaN-28* Creat-0.5 Na-136
K-3.6 Cl-99 HCO3-24 AnGap-17
___ 09:30AM BLOOD ALT-34 AST-30 AlkPhos-97 TotBili-0.3
___ 09:30AM BLOOD Lipase-30
___ 07:10AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.7
___ 09:30AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.4 Mg-1.8
___ 01:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:05PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 01:05PM URINE RBC-0 WBC-13* Bacteri-MOD Yeast-NONE
Epi-<1
___ 01:05PM URINE Mucous-MANY
Brief Hospital Course:
Ms. ___ is a ___ with history of recurrent ovarian cancer who
was admitted from the emergency room to the gynecologic oncology
service with abdominal pain and ascites noted on abdominal CT
scan.
Her hospital course is detailed as follows. On hospital day 2,
she underwent ___ assisted paracenteses of 1.5 Liters of fluid.
Following procedure, her pain was controlled without any
medications and her symptoms were much improved. Her diet was
continued on her home TPN with coordination with nutrition.
Given her likely short bowel syndrome, she was put on an H2
blocker and given small frequent feeds, which she tolerated
without any nausea or vomiting in her hospital stay.
Patient was voiding spontaneously and ambulating independently
during hospital stay. Palliative Care consult was placed and
patient was seen to discuss future symptom control. She was
discharged on hospital day 3 as she had achieved symptomatic
relief with outpatient follow up scheduled. She was discharged
with a prescription of Macrobid for UTI.
Medications on Admission:
Fentanyl patch, Tylenol PRN
Discharge Medications:
1. Acetaminophen 650 mg PO TID
Do not exceed 4,000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6 h Disp #*60
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
Please take all pills
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*13 Capsule Refills:*0
4. Psyllium Wafer 1 WAF PO DAILY
5. Ranitidine 75 mg PO BID
6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
Do not drive while taking medication
RX *oxycodone 5 mg ___ to 1 tablet(s) by mouth Q6 h Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent ovarian cancer
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the gynecologic oncology service after
undergoing the procedures listed below. ___ have recovered well
after your operation, and the team feels that ___ are safe to be
discharged home. ___ were also found to have a urinary tract
infection. Please take full course of antibiotics. Please follow
these instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* ___ may eat a regular diet.
* It is safe to walk up stairs.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19654137-DS-15
| 19,654,137 | 22,953,678 |
DS
| 15 |
2128-11-13 00:00:00
|
2128-11-13 14:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
___ ercp with sphincterotomy/stent placement
___ cholangiogram with biliary brushings, forceps biopsy of
hilar biliary stricture and placement of 10 ___ right
___ biliary drain and 8 ___ left
___ biliary drain.
History of Present Illness:
___ M with history of prostate cancer, HTN presents with
jaundice. He is not sure how long he has been jaundiced and says
his color was noticed incidentally at his annual health
maintenance visit by his PCP.
He denies fever, chills, abdominal pain, cough, N/V/D or other
symptoms.
Because of his jaundice, his PCP ordered LFTs which were
markedly abnormal with pronounced hyperbillirubinemia, so he was
referred to the ___ ED for evaluation and ERCP.
In the ED initial vitals were: 0 98.4 66 116/60 20 99%
- Labs were significant for normal ___, ALT 91, AST 300, AP
996, ___ 19.0, albumin 3.1, WBC 11.1, Hgb 10.5, INR 1.3
- Imaging from ___ reportedly showed
U/S --> dilated ducts
CT --> 2cm hepatic lesion next to duct bifurcation, suspicious
for malignancy; 2cm cystitic lesion in unicinate process of
pancrease, 1.7cm mass adrenal concerning primary.
Vitals prior to transfer were: 98.2 76 112/62 16 97% RA
On the floor he reports feeling well. He understands he may have
cancer with a dismal prognosis, but is hopeful that his jaundice
may be due to a benign etiology. He has no complaints currently.
Past Medical History:
- Dyslipidemia
- "Suspected" coronary artery disease per PCP notes
- ___: Admitted to ___ ___, negative ___
- Prostate cancer tx with XRT in ___
- Hypertension
- Colonic adenoma
- Macular degeneration
- Osteopenia
- Iron deficiency anemia
Social History:
___
Family History:
- No history of pancreatic/GI cancer
- Brother CAD/PVD - Early
- Father ___ Other[Other] [OTHER]
- Mother ___
Physical Exam:
Admission Physical Exam:
Vitals - T 98 BP 118/67 HR 72 RR 20 SaO2 98% on RA
GENERAL: Jaundiced
HEENT: Icteric sclerae, EOMI
CARDIAC: RRR, no m/r/g
LUNG: CTAB
ABDOMEN: Umbilical hernia present, nontender in all areas on
deep palpation. No ___ Sign.
EXTREMITIES: WWP, nonedematous
SKIN: Scattered AKs on neck, face, back, chest may represent
___
LYMPH: Bilateral cervical LAD, no axillary LAD, bilateral
inguinal LAD. No appreciable periumbilical LAD or
supraclavicular LAD.
Discharge:
A&O, NAD, jaundiced
___ drains capped, insertion sites clean and dry with
DSD dressings.
Pertinent Results:
Admission labs:
___ 01:30AM BLOOD ___
___ Plt ___
___ 01:30AM BLOOD ___ ___
___ 01:30AM BLOOD ___
___
___ 01:30AM BLOOD ___
___
___ 01:30AM BLOOD ___
___ 06:58AM BLOOD ___
Studies:
___ COMMON BILE DUCT BRUSHINGS, HILAR STRICTURE: NEGATIVE
FOR MALIGNANT CELLS. Unremarkable ductal cells.
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___ ___
___ 07:20AM BLOOD ___
___ 06:58AM BLOOD ___
___ 06:58
CA ___
Test Result Reference
Range/Units
CA ___ 874 H <34 U/mL
___ 1:40 am BLOOD CULTURE
**FINAL REPORT ___ Culture, Routine (Final
___: NO GROWTH.
___ 3:48 pm SWAB Site: RECTAL Source: Rectal swab.
**FINAL REPORT ___ VANCOMYCIN RESISTANT ENTEROCOCCUS
(Final ___: No VRE isolated.
Brief Hospital Course:
___ year old man with HTN who presented with asymptomatic
jaundice and found to have hepatic mass causing obstructive
jaundice.
Hepatic Mass c/b obstructive jaundice: Per imaging from ___,
concerning for cholangiocarcinoma. No hx of cirrhosis or liver
disease by imaging, hx, or labs. S/p ERCP stenting of L hepatic
duct, unable to stent R duct which was opacified. On ___, a
cholangiogram was performed with successful placement of right
___ and left ___ F ___ biliary drains for a very
tight hilar stricture. Biliary brushings and forceps biopsies
were obtained at the right hilar stricture. Overnight, vital
signs were stable. The left drain had a small amount of blood
drainage with small clots which did not increase. The drains
were flushed. An abdominal CT was done to assess the colon for
signs of perforation of the transverse colon given blood in left
drain. Abdominal CT demonstrated improved intrahepatic biliary
ductal dilatation status post placement of bilateral internal
and external biliary drains, both of which were appropriately
positioned. The left biliary drain did not traverse the
transverse colon. Biliary drains were then capped on ___ with
decrease in LFTs:
Alt 41 from 45, ast 121 from 138, alk phos 490 from 582, t.bili
7.0 from 8.5 the prior day when drains open to gravity drainage.
Drain insertion sites without redness or drainage.
CEA was elevated at 8.8, CA ___ 874. ERCP common bile duct
brushings were negative for malignancy. Biopsy was pending. He
was being evaluated for surgical resection. A TTE and Chest CT
were done for surgical w/u. TTE demonstrated ?ASD; interatrial
septum; EF 70%, mild AR, grade I Diastolic Dysfunction, and CT
chest showed no evidence of metastatic disease within the
thorax. There were two round subpleural millimeteric ground
glass nodules which may represent ground glass nodules or lymph
nodes which do not have the typical appearance of metastasis
(per chest ct report).
On hospital day 7, he was feeling well with stable vital signs.
He was eating well and taking Ensure supplements. He was ready
for discharge home with follow up labs set up for ___ and ___
at his ___ office at ___. PCPs office RN was
contacted and updated. He will f/u with Dr. ___ on ___ to
review path results and plan.
# Code: DNR/DNI (confirmed w/patient)
# Emergency Contact: Girlfriend ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. colestipol 1 gram oral QD
7. Cialis (tadalafil) 10 mg oral PRN sexual activity
Discharge Medications:
1. Outpatient Lab Work
Stat labs on ___ and ___ : CBC with diff, chem
7 and AST, alt, alk phos , t.bili
Fax results to ___ ___ RN coordinator
2. Cyanocobalamin 50 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Tablet Refills:*3
8. Calcium Carbonate 500 mg PO DAILY
9. Cialis (tadalafil) 10 mg oral PRN sexual activity
10. Docusate Sodium 100 mg PO BID constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
painless jaundice
biliary stricture
liver mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ Visiting Nurse ___ arrange to see you at home.
Please call Dr. ___ office ___ if you have
any of the following: fever (temperature of 101 or greater),
chills, nausea, vomiting, worsening jaundice, increased
abdominal pain, increased size of abdomen/bloating, biliary
drain sites have redness/bleeding/drainage, constipation,
diarrhea
Please get blood work drawn on ___ and ___ at
___
Keep biliary drains capped.
Change dry gauze dressing to biliary drain sites daily and as
needed.
You may shower with soap and water, rinse, pat dry. No
scrubbing. Avoid direct shower/water spray to drain sites. Do
not apply powder/lotion/ointment to drain sites.
No tub baths or swimming
No driving while taking pain medication
Do not drink alcohol
Followup Instructions:
___
|
19654137-DS-18
| 19,654,137 | 23,162,587 |
DS
| 18 |
2129-01-20 00:00:00
|
2129-01-20 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___ Reductase Inhibitors / simvastatin
Attending: ___.
Chief Complaint:
Small bowel obstruction s/p CBD excision, left/caudate
hepatectomy and hepaticojejunostomy
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
Mr. ___ is a ___ y/o male who presented with small bowel
obstruction, who presented on POD #___ile duct
excision, left/caudate hepatectomy and hepaticojejunostomy, who
was ___ for a small bowel obstruction.
Past Medical History:
- Dyslipidemia
- "Suspected" coronary artery disease per PCP notes
- ___: Admitted to ___ ___, negative ___
- Prostate cancer tx with XRT in ___
- Hypertension
- Colonic adenoma
- Macular degeneration
- Osteopenia
- Iron deficiency anemia
Social History:
___
Family History:
- No history of pancreatic/GI cancer
- Brother CAD/PVD - Early
- Father ___
- Mother ___
Physical Exam:
Vital signs - Temp: 97.7 HR: 73 BP: 128/61 Resp: 20 O(2)Sat: 97
Constitutional - No acute distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs. Lungs are
clear to auscultation bilaterally
Abdomen - Right subcostal incision with SteriStrips in place,
healing nicely, no surrounding erythema. ___ drain with
___ insertion site, bilious output. PTBD with
___ insertion site, bilious output. ___ appears
intact. Abdomen soft, ___.
Extremities - Atraumatic. No cyanosis or edema
Neurologic - Grossly intact. Alert and oriented x 3
Pertinent Results:
___ 07:00AM BLOOD ___
___ Plt ___
___ 10:30AM BLOOD ___
___ Plt ___
___ 10:30AM BLOOD ___
___
___ 06:50AM BLOOD ___ ___
___ 10:30AM BLOOD ___ ___
___ 07:00AM BLOOD ___
___
___ 07:00AM BLOOD ___
___ 06:16AM BLOOD ___
___ 07:00AM BLOOD ___
___ 06:16AM BLOOD ___
Brief Hospital Course:
Mr. ___ was recently discharged s/p CBD excision,
left/caudate hepatectomy, and hepaticojejunostomy, and was
___ for SBO. He presented to ___ on
___ for an acute SBO. He was subsequently transferred here for
further management. An NGT was placed, and he was treated with
conservative management. Upon admission, patient's abscess drain
had significant malodorous output and was purulent as opposed to
bilious. Drain was stripped BID and flushed appropriately. He
was continued on his Ciprofloxacin therapy which had been
started the previous admission. On ___, patient's NGT was
removed. On ___, Mr. ___ developed chest and abdominal
pain. Vital signs were stable, and EKG was within normal limits.
The episode was attributed to anxiety. Patient did have one
additional dyspneic episode, which was ___ by a CXR;
read suggested atelectatic changes bilaterally in the bases, but
no acute interval findings. Patient was started on tube feeds
tube feeds (___) with Jevity 1.5, up to a goal of 55cc/hr.
Metoprolol 12.5 mg PO BID was started for blood pressure
control, in addition to his Amiodarone which had previously been
given for his recent history (previous admission) of ___ with
RVR. Patient's abscess drain as well as PTBD continued to have
increased output over the next ___ days, and ___ was concerned
for an abnormal communication. Another dyspneic episode resulted
in a CXR read as atelectasis vs. superimposed pneunonia;
however, patients stable vital signs and normal laboratory
values pointed away from pneumonia. A cholangiogram was obtained
to assess the PTBC clog, which demonstrated a bile leak
communicating with the abscess cavity. No drain changes or
upsizing were performed. Patient was stable to be discharged
back to rehab after the cholangiogram, and outpatient ___
will be arranged to stop up the bile ducts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Ipratropium Bromide Neb 1 NEB IH Q6H
4. Senna 8.6 mg PO BID
5. Amiodarone 200 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN pain
7. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
8. Calcium Carbonate 500 mg PO DAILY
9. Cyanocobalamin 50 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
13. Bisacodyl 10 mg PR HS:PRN constipation
14. Ciprofloxacin HCl 500 mg PO Q12H
15. Metoprolol Tartrate 25 mg PO TID
16. Pantoprazole 40 mg PO Q12H
17. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel obstruction; resolved
Malnutrition; continues on tube feeds via J tube
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:
Please call Dr ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by pain medication, swelling
of the abdomen or ankles, yellowing of the skin or eyes,
inability to tolerate food, fluids or medications, incisional
redness, drainage or bleeding, Abscess JP drain or PTBD output
increases by more than 100 cc from the previous day, abscess
drain output becomes bloody, green or develops a foul odor, the
drain insertion sites have redness, drainage or bleeding, or any
other concerning symptoms.
You may shower. Allow water to run over the incision. Pat the
area dry, do not apply lotions or powders to the incision area.
Do not allow the JP drain or PTBD to hang freely at any time.
Please place a new drain sponge around each of the drain sites
after your shower or daily. Do NOT tuck drain dressing under the
blue drain as this can cause the drain to dislodge.
The PTB drain (to gravity drainage) should by gently flushed
with 10 cc sterile normal saline twice daily. Report any
resistance to flushing or drainage around the insertion site.
The abscess drain to a JP bulb must be stripped at least BID
No lifting more than 10 pounds
No driving if taking narcotic pain medication
Please drain and record the JP drain and PTB drain output twice
daily and as needed. Send copy of the drain output with patient
clinic appointment
Continue tube feedings via J tube. Monitor insertion site for
redness, drainage or bleeding
Followup Instructions:
___
|
19654137-DS-22
| 19,654,137 | 23,547,089 |
DS
| 22 |
2129-05-25 00:00:00
|
2129-05-25 12:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / simvastatin
Attending: ___.
Chief Complaint:
J-tube receeding
Major Surgical or Invasive Procedure:
___: J-tube exchange
History of Present Illness:
___ year old male with a history of cholangiocarcinoma s/p common
bile duct excision, left caudate hepatectomy and
hepaticojejunostomy on ___ by Dr ___. He
presented with 7 days of receding J tube associated with RLQ
pain.
He first noted the J tube receding about a week ago, at that
time
he was asymptomatic. He reports that the surrounding area had
become increasingly painful and discolored; noting redness and
seepage of blackish material around the J tube site over the
last
several days. This morning he presented to the ED at ___ but was immediately transferred to ___ for
managament
of his condition. He had been receiving tube feeds through the
tube until 4 days ago when stopped because he claimed that he
could no longer tolerate the pain. He took oxycodone which
improved his symptoms. Since that time he has only been flushing
it once daily. Of note, he does take PO with the tube feeds used
as a means of supplementing his diet. He reports that he has
actually gained 16 lbs since his surgery. Patient denies nausea,
vomiting, change in bowel habit; has his last bowel movement
yesterday, and continues to pass flatus. Denies fever, chills.
Past Medical History:
- Dyslipidemia
- HTN
- Possible CAD
- Hx of syncope, unknown etiology
- Prostate cancer s/p XRT
- Hx of colonic adenoma
- Macular degeneration
- Osteopenia
- Anemia ___ iron deficiency
PSH:
S/p common bile duct excision, L/caudate hepatectomy,
hepaticojejunostomy
Social History:
___
Family History:
- No history of pancreatic/GI cancer
- Brother CAD/PVD - Early
- Father ___
- Mother ___
Physical Exam:
At discharge:
Pertinent Results:
___ 03:03PM LACTATE-1.0
___ 03:00PM GLUCOSE-90 UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
___ 03:00PM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-3.3
MAGNESIUM-2.1
___ 03:00PM URINE UHOLD-HOLD
___ 03:00PM URINE GR HOLD-HOLD
___ 03:00PM WBC-7.7 RBC-3.90* HGB-11.8* HCT-35.4* MCV-91
MCH-30.2 MCHC-33.3 RDW-18.0*
___ 03:00PM NEUTS-64.8 ___ MONOS-7.4 EOS-2.2
BASOS-0.8
___ 03:00PM PLT COUNT-262
Brief Hospital Course:
Mr. ___ was admitted on ___ for a J-tube that was
slowly receding. A hemostat was placed on the end. He was
continued on his regular diet and interventional radiology was
consulted for possible exchange of the tube. He went to ___ for a
H-tube exchange on ___. The procedure went without any
complications. He was advanced to a regular diet after the
procedure, which he tolerated well. He was also restarted on his
nocturnal tube feeds which he tolerated. The patient was managed
with oral pain medications and continued on all home
medications. He was ambulating, pain was controlled, and he was
stable for discharge on ___ with instructions to continue
cycled tube feeds at night along with his regular diet and with
follow-up in the transplant clinic with Dr. ___ in the next
___ weeks
Medications on Admission:
Acetaminophen 500mg BID prn pain, Colace 100 mg BID, Calcium 500
+ D 500 mg (1,250 mg)-400 unit tablet BID, Miralax 17 gram oral
powder packet 1 powder daily, Vitamin B-12 1,000 mcg tablet
daily, albuterol sulfate HFA 90 mcg/actuation aerosol inhaler 2
puffs q6h prn SOB/wheeze, amiodarone 200 mg tablet daily,
aspirin 81 mg daily, ferrous sulfate 325 mg daily, gabapentin
100 mg qHS prn, ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3
mL nebulization soln q6h, oxycodone 5mg q4h prn pain,
pantoprazole 40 mg BID, senna 8.6 mg BID prn constipation,
metoprolol succinate 50mg daily, Jevity 1.5 Cal 0.06 gram-1.5
kcal/mL oral liquid 90 ml/hr via J Tube 18 hours daily 90 ml/hr
x 18 hrs (Jevity 1.5) = 2430 kcals and 103 g protein.
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 200 mg PO QHS:PRN pain
9. Metoprolol Tartrate 25 mg PO TID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Pantoprazole 40 mg PO Q12H
12. Senna 8.6 mg PO BID:PRN constipation
13. Vitamin D 1000 UNIT PO DAILY
14. Amiodarone 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cholangiocarcinoma, retracted J tube
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for exchange of your feeding
tube. You undwerwent an ___ procedure to have the J-tube
replaced. You can now resume a regular diet. We do recommend
that you continue tube feeds through the J-tube at night with
your usual formula and rate. Please call the clinic if you have
high fevers, notice any redness or discharge from the J-tube
site.
Followup Instructions:
___
|
19654967-DS-21
| 19,654,967 | 29,223,690 |
DS
| 21 |
2184-06-26 00:00:00
|
2184-06-28 19:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia, extensive lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old gentleman with history of atrial
fibrillation, CHF (unknown EF), Alzheimer's dementia presenting
with new onset hypoxia and lower extremity edema to waist.
Patient has advanced dementia and was not able to provide
significant history. He was sent in from his skilled nursing
facility for new hypoxia. Per discussion with staff at ___
___, patient was ambulating with cane but over the past week
has been progressively short of breath with increase in ___ edema
which is normally limited to edema to the knee.
Past Medical History:
Alzheimer's,
atrial fibrillation, paroxysmal
peripheral edema
question of head injury
anemia
glaucoma
latent syphilis
microhematuria
incontinence
venous stasis
cellulitis, lower extremities
Social History:
___
Family History:
Anemias, coronary artery disease, hypertension,
colitis, ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs:
97.5 PO 124 / 80 70 18 100 RA
General: Alert, not oriented, very pleasant and comfortable
appearing speaking in full sentences, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: crackles at bilateral bases, no wheezes, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place with 1L yellow urine; penile edema without
erythema
Ext: Warm, well perfused, 2+ pulses, 4+ edema to hips
bilaterally; bilateral venous stasis changes to mid shin, no
overlying erythema or purulent drainage
Neuro: axoxo, moving all 4 extremities without deficit
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs:
T97.8 BP 130/74 (107-130/52-77) HR 63 (60-78) RR 18 98% RA
I/O= 1480/3325 (-1.6L) yesterday, ___ (-960) since MN
Weight: 99.1->96.1
General: Alert, not oriented, very pleasant and comfortable
appearing speaking in full sentences, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops, JVD to midneck
Lungs: crackles on the left bases, decreased breath sounds at
right base, no wheezes, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place with yellow urine; penile edema without
erythema
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to hips
bilaterally; bilateral venous stasis changes to mid shin, no
overlying erythema or purulent drainage
Neuro: AOx1, moving all 4 extremities without deficit
Pertinent Results:
ADMISSION LABS:
==============
___ 12:10AM BLOOD WBC-9.7 RBC-3.47* Hgb-11.0* Hct-34.3*
MCV-99* MCH-31.7 MCHC-32.1 RDW-16.7* RDWSD-60.2* Plt ___
___ 12:10AM BLOOD Neuts-68.3 Lymphs-16.5* Monos-13.2*
Eos-1.3 Baso-0.4 Im ___ AbsNeut-6.64* AbsLymp-1.61
AbsMono-1.29* AbsEos-0.13 AbsBaso-0.04
___ 12:10AM BLOOD ___ PTT-33.9 ___
___ 12:10AM BLOOD Glucose-100 UreaN-21* Creat-1.0 Na-140
K-3.7 Cl-101 HCO3-25 AnGap-18
___ 12:10AM BLOOD ALT-10 AST-22 LD(LDH)-265* CK(CPK)-51
AlkPhos-101 TotBili-1.9* DirBili-0.5* IndBili-1.4
___ 12:10AM BLOOD CK-MB-3 proBNP-4569*
___ 12:10AM BLOOD cTropnT-0.03*
___ 07:00AM BLOOD CK-MB-2 cTropnT-0.03*
___ 12:10AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.3 Mg-2.1
___ 12:10AM BLOOD Hapto-174
___ 12:10AM BLOOD TSH-5.9*
DISCHARGE LABS:
==============
___ 07:25AM BLOOD WBC-6.6 RBC-3.30* Hgb-10.4* Hct-32.9*
MCV-100* MCH-31.5 MCHC-31.6* RDW-16.5* RDWSD-60.3* Plt ___
___ 07:15AM BLOOD Neuts-57.6 ___ Monos-15.9*
Eos-3.7 Baso-0.5 Im ___ AbsNeut-3.79 AbsLymp-1.45
AbsMono-1.04* AbsEos-0.24 AbsBaso-0.03
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-31.5 ___
___ 07:25AM BLOOD Glucose-78 UreaN-20 Creat-1.0 Na-139
K-3.7 Cl-100 HCO3-28 AnGap-15
___ 07:15AM BLOOD ALT-8 AST-20 LD(LDH)-224 AlkPhos-82
TotBili-1.5
___ 07:25AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
___ 12:10AM BLOOD TSH-5.9*
MICROBIOLOGY:
Cdiff negative
URINE CULTURE (Final ___:
___. 10,000-100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING & STUDIES:
ECHO ___:
The left atrium is markedly dilated. The right atrium is
markedly dilated. 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 ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild to moderate mitral regurgitation. Moderate
tricuspid regurgitation. Pleural effusions.
___ CXR: volume overload/heart failure
Admission ECG: afib, rate 80, NA, NI, t wave flattening in
lateral leads
Brief Hospital Course:
Mr. ___ is an ___ year old gentleman with history of atrial
fibrillation, CHF, Alzheimer's dementia who presents with
hypoxia and lower extremity edema found to be grossly volume
overloaded on exam and CXR with elevated BNP consistent with
acute on chronic heart failure exacerbation.
# Acute on Chronic Heart Failure Exacerbation: On admission,
patient was found to be grossly volume overloaded with 4+
pitting edema to the sacrum. Patients CXR was notable for volume
overload/heart failure. Concern on admission was for an acute
exacerbation, with possible etiologies including exacerbation
due to arrhythmia with known atrial fibrillation, ischemia (with
mildly elevated troponin of 0.03, stable x 2) and infection with
possible UTI. Other less common contributing factors would be
dietary indiscretion and medication non compliance. Patient was
started on IV Lasix 40mg x2 in the ED, and was diuresed with
Lasix IV 40mg x2 on the floor, with good output of >-5L while on
the floor. Patient was transitioned to Torsemide 40mg daily
which he tolerated well with good urine output. ECHO was
obtained on this admission which was notable for mild to
moderate MR, moderate TR, pleural effusions but otherwise normal
global and regional biventricular systolic function with no wall
motion abnormalities and preserved EF of 55%. Patient was
aggressively diuresed with IV Lasix 80 and then transitioned to
po torsemide 40 BID, but was hypotensive on ___ with concern
for SIRS/sepsis vs over-diuresis. Patients diuresis was held in
this setting, and was also held due to BRBPR and hematuria (see
below). Following resolution of these episodes (per below),
patient was monitored on tele and he was diuresed with torsemide
20mg BID, which he tolerated well, with active diuresis but no
further episodes of hypotension. Plan was made for pt to be
discharged on torsemide 20mg BID and to continue diuresis at his
___ facility, with plan to monitor daily weights and decrease
torsemide dosage as appropriate. Patient was started on
Lisinopril 2.5mg daily while, which he did NOT tolerate well due
to hypotension. Beta blocker was not initiated on this admission
due to preserved EF and absence of tachycardia. Patient will be
continued to have weights monitored at ___ with
titration of his diuretics as necessary.
#UTI: On admission, patient did not have clear urinary symptoms.
UA was notable with few bacteria though no nitrates and no
blood. Patient received 1 dose ceftriaxone in ED, and urine
culture with ___ GNRs noted on UA. Urine culture grew
MORGANELLA MORGANII, which sensitivities above. Patient was
started on Levofloxaxin 500 daily for 7 days (___). At
the time of discharge, patient had completed his full course.
#Atrial Fibrillation: On admission, patient was not on
medications for rate control. He was monitored on telemetry to
ensure rate adequately controlled without medications, and
patient remained in Afib but with rate well below <110. Patients
CHADS2 = was at least 2 for CHF and age >___. However, due to
patients BRBPR and continued hematuria (microscopic hematuria as
outpatient, macroscopic this admission), patients rivaroxaban
was discontinued on this admission.
#BRBPR, resolved: during this admission, patient had 1x episode
of gross blood per rectum staining found mixed with stool.
Likely a lower GI bleed, in setting of coagulopathy evidenced by
patients elevated INR of 2.0 while also on rivaroxaban, aspirin
and had with low platelets. Patients bleeding was likely due to
anti-platelet, anticoagulation agents and underlying
coagulopathy potentially causing bleeding. Patient had Negative
DIC workup, and his rivaroxaban and aspiring was held, and he
was given Vitamin K 2.5mg po with improvement in INR. Patients
Hgb was trended,and remained stable between 9.8-10.3. After
holding aspirin and rivaroxaban and improving pts INR, patient
had no further episodes of blood per rectum. At the time of
discharge, Hgb improved to 10.4.
# Hematuria, resolved: patient had episode of gross hematuria
after starting aspirin, while on rivaroxaban, in setting of
elevated INR and low platelets. Per above, patient may have
underlying coagulopathy exacerbated by medication intervention.
Other etiologies noted by urology is prostate bleeding. Patient
was seen by urology, who noted that patient had a full workup
for hematuria within the last 2 weeks with negative cytology,
negative renal ultrasound
and negative cystoscopy. A 20fr 3-way foley was placed, with
small amount of blood but mostly clear urine. Patient had
episode of clots in urine which required manual flush. Foley
remained in place for 3 days to tamponade likely prostatic
bleeding. Patient self d/c'ed foley, which was replaced by
urology, and CBI was held. After resolution of hematuria,
patients foley was discontinued, and he underwent a voiding
trial in which he was able to void ___ while retaining 250cc.
#Tropinemia, resolved: During this admission, patient had EKG
with T wave inversions in the lateral leads. In setting of
possible PNA vs aspiration pneumonitis, possible etiologies
include demand ischemia. Troponin peaked to 0.11, now
downtrending to 0.9 Pts troponin bump may also be influenced by
decreased renal function in setting of diuresis. Troponin
downtrending. Patient was started on atorvastatin 40mg. Due to
bleeding risk, aspirin was held on this admission. Pts
betablocker was held due to concern for hypotension.
#Anemia: On admission, patient had macrocytic anemia with H/H of
___. Patient recently underwent workup for microhematuria
which may be the source of his blood loss, although patient is
s/p 2 urine cytology specimens negative for malignancy, with
normal cystoscopy. Patients differential included B12
deficiency, hypothyroidism, malignancy, alcohol use.
Alternatively patient has elevated bilirubin with indirect
predominance raising concern for hemolysis. Retic count, LDH,
haptoglobin all within normal limits. Pts TSH elevated although
unclear in the setting of acute illness, will need to followup
free T3/free T4 (can be done as outpatient).
#Hyperbilirubimemia: Patient had persistently mildly elevated
bilirubin with indirect predominance. Differential included CHF
exacerbation with impaired hepatic bilirubin uptake, as well as
hemolysis. Patients retic count was normal on this admission,
with no hemolysis. Patients daily labs were trended during this
admission.
#BPH: On this admission, patient was s/p benign cystoscopy on
___. Patient was not initiated on new therapy this admission,
but plan was made to consider alpha blocker or finasteride per
Dr. ___ note as an outpatient.
#CAD: On this admission, unclear if patient has known CAD due to
lack of records and lack of information from family who had just
moved him from a long term care facility in ___ to ___. Baby
Aspirin, statin was deferred pending followup documentation from
previous providers if in keeping with family's wishes (currently
DNR/DNI).
# CODE: MOLST with patient on arrival, DNR/DNI
# CONTACT: sister ___ ___
TRANSITIONAL ISSUES:
====================
- Please obtain serum electrolytes (chem 10 panel) on ___
___ as patients was started on Toresmide 20mg BID and is
diuresing currently. Please fax these results to: Dr. ___
___ at fax: ___
- Please obtain daily weights, and reduce torsemide 20mg BID as
appropriate. Patient was discharged with improved edema, and
will require gentle diuresis over the next few weeks with his
current dose of oral torsemide
- He will likely require titration of diuretics to lower dose
once closer to dry weight (follow up labs weekly)
- Patient was not started on a betablocker on this admission for
his Afib, as he had good HR control without medication. Can
consider low dose betablocker in the future for rate control
<110 if needed
- Please continue to hold aspirin and rivaroxaban due to
bleeding on this admission and after discussion in patients
family. If anticoagulation is necessary, patients family has
noted that pt has tolerated Aspirin 81mg daily in the past
without issue
- Can consider tamsulosin 0.4mg as an outpatient if patient has
urinary retention
- Consider finasteride if patient does not have resolution of
hematuria
- Please consider checking TSH and free T3/free T4 as
outpatient. Pt had elevated TSH on this admission, unclear if
due to acute illness.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Rivaroxaban 15 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Torsemide 20 mg PO BID
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Cyanocobalamin 1000 mcg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. TraZODone 25 mg PO QHS:PRN insomnia
6. Vitamin D 1000 UNIT PO DAILY
7. HELD- Rivaroxaban 15 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until seeing your doctor. It was
stopped in the hospital because you had blood in your urine and
stool. Your doctor and family should discuss if and when to
restart this medication.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mitral Regurgitation with (diastolic) Congestive heart failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission at
___.
You were admitted due to swelling in your legs and pelvis, which
had made it difficult for you to walk as well as shortness of
breath. When you presented to the hospital, you had evidence of
large volume of fluid in your legs, likely due to uncontrolled
heart failure. You were given medication for you to remove this
fluid from your body by urinating. You did well on this
medication, and the lower extremity swelling in your legs
decreased. Furthermore, you had less shortness of breath while
you were ambulating.
Furthermore, on this admission, you had bleeding in your stool
and bleeding in your urine. Your home rivaroxaban and the
aspirin you had been given was stopped on this admission, and
you were given Vitamin K to help with your ability to form
clots. You tolerated this regimen well, and had no further
episodes of bleeding in your urine or stool during this
admission. You will require close followup with a cardiologist,
and appointments have been arranged on your behalf below.
Lastly, you were treated for a urinary tract infection with IV
and oral antibiotics. You tolerated this therapy well, and you
had no evidence of bacteria in your urine on repeat urine
cultures. You completed your antibiotic regimen prior to leaving
the hospital.
Please followup at the appointments that have been arranged on
your behalf below.
Once again, it was a pleasure taking care of you during your
stay. We wish you the best of luck!
Your ___ care team
Followup Instructions:
___
|
19654967-DS-23
| 19,654,967 | 22,051,723 |
DS
| 23 |
2185-11-24 00:00:00
|
2185-11-24 14:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worsening confusion, fluid overload
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history of HFpEF (last LVEF 50% to
55%), atrial fibrillation, and Alzehimer's dementia presenting
for altered mental status and volume overload.
Per assisted living, patient has been more confused and agitated
recently. On routine labs was found to have leukocytosis to 17.1
and concern for volume overload, hence was given additional
bumetanide (2 mg qd to 2 mg bid)
In the ED, patient was oriented to self only, and was unsure why
he was brought in from assisted living. He denied any chest
pain, shortness of breath, nausea, vomiting, diarrhea, urinary
symptoms.
In the ED, initial VS were: 97.0 82 115/48 99% RA
Exam notable for: AO x 1 (self), unable to recite days of week
backwards, +JVD ~ 9 cm, bibasilar crackles with
diffuse/scattered rhonchi. SpO2 intermittently drops to 89%. No
focal neurological deficits.
Labs showed:
WBC 13.4 Hgb 10.4 Plt 114, 67.8% neutrophils
Na 144 K 4.0 Cl 109 CO2 21 BUN 30 Cr 1.2 Aniion gap = 14
Troponin 0.05
Lactate 2.1
BNP 8744
U/A w/ 32 WBC, large leuk, neg nitrite
Flu A/B negative
Imaging showed:
- CXR: Probable multifocal pneumonia, pulmonary vascular
congestion with severe cardiomegaly.
- CT head without contrast:
1. No acute intracranial abnormalities.
2. Hypodensities in the left frontoparietal region, bifrontal
lobes, and right
temporal lobe likely represent prior infarct.
3. Chronic microangiopathy and age related global atrophy.
Patient received: ceftriaxone 1gm, vancomycin 1000 mg, pip/tazo
4.5g, aspirin 324 mg
At time of interview patient knows he is in a hospital in ___
but not why he was here and is surprised to hear that he has
pneumonia. He denies any fevers, chills, shortness of breath,
orthopnea, ___ edema, PND, cough. He notes he is ambulatory with
walker at baseline and has not noticed any change in functional
status recently although unable to tell me how far he is able to
walk. He notes that he lives with friends, and that he is close
to his sister ___ who is his HCP.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Alzheimer's dementia
- Atrial fibrillation, paroxysmal
- HFpEF (LVH + EF 55% severe TR and dilated/hypokinetic RV)
- Anemia
- Glaucoma
- Treated latent syphilis (per family report, was treated 2x:
one at age ___ in ___, once in his ___ by PCP in ___)
- Microhematuria
- Incontinence
- Venous stasis
Social History:
Occupation: ___
Living situation: ___, in a memory unit
Children: none
HCP: ___, sister, ___
Smoking: Remote (2 ppd in ___ and ___, quit in his ___
ETOH: occasional
Illicits: none
Durable medical equipment: ___
FUNCTIONAL STATUS:
ADLs:
- Bathing: A
- Grooming: A
- Dressing: A
- Eating: I
- Toilet Hygiene: I
- Functional Mobility (walking, transfers): with walker
IADLs: (I=independent, A=needs assist, D=dependent)
- Driving: D
- Medication management: D
- Food preparation: D
- Grocery shopping: D
- Cleaning/laundry: D
- Finances: D
- Telephone: A
Family History:
Anemias, coronary artery disease, hypertension, colitis,
___
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM:
==========================
VS: ___ ___ Temp: 98.1 PO BP: 134/65 L Lying HR: 66 RR: 18
O2 sat: 92% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD to 5 cm above base of neck at 60
degrees with + hepatojugular reflux
HEART: Irregular irregular, prominent S2, ___ holosystolic
murmur at ___
LUNGS: Crackles in RUL and bilateral bases without egophony,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ edema to level of
bilateral knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused
==========================
DISCHARGE PHYSICAL EXAM:
==========================
VS: ___ 0802 Temp: 97.9 PO BP: 107/54 HR: 51 RR: 18 O2 sat:
93% O2 delivery: Ra
GENERAL: NAD alert to self and hospital
NECK: supple, no LAD, enjorged EJ, +TR murmur
HEART: Irregular irregular ___ holosystolic murmur ___
LUNGS: bibasilar insp crackles; breathing comfortably on room
air
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, soft
EXTREMITIES: wwp, no lower extremity edema, right lateral hip
with 2cm x 2cm ulceration, no fluctuance or purulence or
surrounding erythema, but there is induration
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused
Pertinent Results:
============================
LABS ON ADMISSION
============================
___ 07:05PM BLOOD WBC-13.4*# RBC-3.16* Hgb-10.4* Hct-32.7*
MCV-104* MCH-32.9* MCHC-31.8* RDW-15.6* RDWSD-59.3* Plt ___
___ 07:05PM BLOOD Neuts-67.8 ___ Monos-9.1 Eos-1.8
Baso-0.2 Im ___ AbsNeut-9.07*# AbsLymp-2.77 AbsMono-1.21*
AbsEos-0.24 AbsBaso-0.03
___ 07:22AM BLOOD ___ PTT-29.6 ___
___ 07:05PM BLOOD Glucose-105* UreaN-30* Creat-1.2 Na-144
K-4.0 Cl-109* HCO3-21* AnGap-14
___ 07:05PM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.9 Mg-2.4
___ 07:05PM BLOOD ALT-12 AST-22 AlkPhos-99 TotBili-1.5
___ 07:05PM BLOOD proBNP-8744*
___ 07:05PM BLOOD cTropnT-0.04*
============================
INTERVAL PERTINENT LABS
============================
___ 07:05PM BLOOD cTropnT-0.04*
___ 12:10AM BLOOD cTropnT-0.04*
___ 07:22AM BLOOD CK-MB-3 cTropnT-0.04*
___ 07:22AM BLOOD VitB12-369 Folate-10
============================
LABS ON DISCHARGE
============================
___ 06:10AM BLOOD Glucose-91 UreaN-27* Creat-1.2 Na-144
K-3.7 Cl-104 HCO3-27 AnGap-13
___ 06:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3
============================
MICROBIOLOGY
============================
- ___ urine legionella - negative
- ___ urine culture - no growth
- ___ blood cultures x2 - no growth at time of discharge
___ 7:10 am SEROLOGY/BLOOD
RPR w/check for Prozone (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:2.
Reference Range: Non-Reactive.
TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE.
============================
IMAGING
============================
___ CXR
AP upright and lateral views of the chest provided. Severe
cardiomegaly is again seen. There is airspace consolidation in
the right upper lobe concerning for pneumonia. Additional less
confluent areas of opacity in the lower lobes left greater than
right may also represent foci of pneumonia.
Pulmonary vascular congestion is noted without frank edema. No
large effusion or pneumothorax. Mediastinal contour stable.
Imaged bony structures are intact.
___ CTH W/O CON
1. No acute intracranial abnormalities.
2. Hypodensities in the left frontoparietal region, bifrontal
lobes, and right temporal lobe likely represent prior infarct.
3. Chronic microangiopathy and age related global atrophy
___ ULTRASOUND SOFT TISSUE
Transverse and sagittal images were obtained of the superficial
tissues of the right posterior thigh. There is induration of
the skin and mild subcutaneous fat edema. There are no
loculated fluid collection, or masses or nodules seen.
Brief Hospital Course:
___ year old gentleman with history of HFpEF (last LVEF 50% to
55%), atrial fibrillation, and Alzehimer's dementia presenting
for altered mental status and volume overload, found to have
multifocal pneumonia & non healing right thigh ulceration.
======================================
HOSPITAL COURSE BY PROBLEM LIST
======================================
# Community acquired pneumonia, treated
Patient admitted with cough and leukocytosis, with CXR
concerning for multifocal pneumonia. Initially covered on
vanc/zosyn, but narrowed to levaquin given low risk for
resistant agents and clinical stability. Urine legionella
negative. Remained afebrile and on room air during
hospitalization, and finished a 5 day course in hospital on
___.
# Acute diastolic heart failure exacerbation, resolving
Per cardiology clinic note ideal weight of 170 to 175 pounds,
admitted at 195 lbs (although this is bed weight). BNP 8744, at
last admission for HF was in 6000s. JVD clearly elevated,
although difficult to interpret in setting of TR. At home on
bumetanide 2 mg daily, recently increased to BID. He was
diuresed with lasix 80mg IV and then restarted on home
bumetanide prior to discharge. He was 183 lbs on discharge. He
has close cardiology follow up.
# Acute metabolic encephalopathy, resolving
# Chronic Alzheimer's Dementia
Per collateral, patient more confused than at baseline. Likely
secondary infection as above. Improved during hospitalization,
discharged at baseline.
# Chronic non healing ulceration right thigh
# History of latent syphilis
U/S right thigh ___ revealed induration of the skin and mild
subcutaneous fat edema. No focal mass or fluid collection. No
evidence to suggest skin or soft tissue infection. ACS evaluated
patient and this does not need debridement. Recommend keeping
the patient off of the right hip possible. Patient should follow
up with General Surgery Dr. ___ as needed. The possibility
of syphilitic gumma was invoked this admission, however, do not
suspect tertiary syphilis. RPR titer was 1:2 likely indicative
of serofast state given patient has been treated for syphilis x
2 (most recently in ___ ___ years ago according to family).
Unable to obtain records from ___ this admission due to holiday.
Likely right thigh ulceration is secondary to pressure of
subcutaneous benign nodule (per prior biopsy results).
# ___
Cr 1.3 peak from baseline 1.0, pre-renal versus cardiorenal in
the setting of infection and heart failure exacerbation.
Returned near baseline at time of discharge. Should repeat as
outpatient at cardiology follow up.
# Demand ischemia
TNT 0.04 x 3. No EKG changes or angina symptoms. Likely demand
ischemia in setting of infection and heart failure exacerbation.
Not on aspirin, statin, or beta-blocker, presumably due to prior
risk/benefit discussions.
# Atrial fibrillation
CHADS-2-Vasc 4, not on rate control as outpatient and not on
anticoagulation due to prior history of BRBPR and goals of care
discussions. Rates remained in ___.
# Macrocytic anemia
Chronic, close to baseline.
======================================
TRANSITIONAL ISSUES
======================================
[] Please recheck lytes at next appointment to monitor Cr
[] Please ensure patient follows with cardiology outpatient as
scheduled
[] Please follow up on treponemal antibody (sent to state lab)
given quantitative RPR reactive at titer 1:2 (this likely
represents serofast state). Please obtain repeat RPR in 6 months
to ensure stability in this titer. Consider referral to
Infectious Diseases.
[] Unable to retrieve department of public health records this
admission regarding prior courses of syphilis treatment. He was
treated in his ___ in the ___ per family and again in his ___
for reactive RPR in the ___. His last treatment was reportedly
per family by Dr. ___ - ___
___ Care ___.
[] Wound care recs:
1. Commercial wound cleanser or normal saline to cleanse wounds.
2. Pat the tissue dry with dry gauze.
3. Apply No Sting barrier to ___ wound skin.
4. Apply nickel thick layer of Santyl to yellow necrotic tissue.
5. Cover with barely moistened saline gauze. Then cover with ___
ABD pad. Secure with medipore tape. Change daily.
6. Try to offload weight from right hip.
[] If chronic non healing wound persists, patient should follow
up with General Surgery Dr. ___ (has seen
outpatient before)
[] Discharged with Rx for home ___ given unsteadiness on feet
#CODE: DNR/DNI (MOLST, confirmed with sister ___
#CONTACT: ___ - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 250 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Bumetanide 2 mg PO BID
4. Lactulose 15 mL PO BID
5. Acetaminophen 650 mg PO BID
6. Potassium Chloride 20 mEq PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Collagenase Ointment 1 Appl TP DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. AcetaZOLamide 250 mg PO DAILY
3. Bumetanide 2 mg PO BID
4. Collagenase Ointment 1 Appl TP DAILY
5. Lactulose 15 mL PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Community acquired pneumonia
Secondary Diagnoses:
- Acute on chronic diastolic heart failure
- Acute metabolic encephalopathy
- Alzheimers dementia
- Non healing right thigh ulceration
- Serofast state (history of latent syphilis)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear. Mr. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital with
a cough and signs of an infection. You were treated with
antibiotics and started to get better. You were able to be
discharged home.
Please see below for your follow up appointments and
medications.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19654967-DS-24
| 19,654,967 | 28,979,703 |
DS
| 24 |
2186-01-31 00:00:00
|
2186-01-31 14:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man PMH HFpEF (LVEF 50%-55%), atrial fibrillation,
and Alzehimer's dementia presents as a transfer from his nursing
home for chest pain. In the ED, patient was unable to answer
questions appropriately. He intermittently agreed to having pain
prior. He was found to be hypoxic and febrile in triage. His
MOLST form states he is DNR/DNI, do not hospitalize, do not
transfer.
After discussion with his HCP/sister (___), he would not
want any kind of invasive procedure or therapy, including
pressors, CVL, IVF, antibiotics. He is OK for for IV access. He
became hypotensive in the ED (SBP ___ prior to transfer to
medicine floor. Per discussion with family, transitioned to CMO
and started on IV morphine gtt.
Patient was accepted to hospice, however current insurance
program is negotiating ___. Cannot go back to original
facility as it does not have round-the-clock care. Although
patient has a bed per case management, he will need legal
proceedings to ensure placement. The appropriate form has been
signed, but as this has to go through the court system there is
no guarantee that the necessary steps will be completed, and
therefore decision was made to admit the patient to medicine
service for continued pain control as there is no definitive
endpoint for his care in the emergency department. Please see
case management note for more details.
In the ED:
Initial vital signs were notable for:
T: 101.3 HR: 95 BP: 130/98 RR: 22 O2 sat: 99% on 4L NC
Exam notable for:
Diffuse rhonchi
Labs were notable for:
WBC: 15 H/H: 9.8/29.8 Plt: 140
Lactate: 2.3
Studies performed include:
CXR ___
FINDINGS:
There are multifocal parenchymal opacities superimposed over
mild interstitial edema opacities, overlying the right upper
lobe in bilateral lower lobes. There is moderate cardiomegaly.
There is no large pleural effusion pneumothorax.
IMPRESSION:
Multifocal pneumonia superimposed over mild interstitial edema.
Patient was given:
IV vancomycin 1000 mg (discontinued)
IV Zosyn 4.5 g (discontinued)
IV NS 500 cc
Acetaminophen IV 100mg
Morphine gtt
Consults: none
Vitals on transfer: 98.5 52 71/46 99% 6L NC
Upon arrival to the floor, the patient is AAOx2 (person,
place), appeared comfortable, and did not want to answer
questions. HCP called, CMO status confirmed.
Past Medical History:
- Alzheimer's dementia
- Atrial fibrillation, paroxysmal
- HFpEF (LVH + EF 55% severe TR and dilated/hypokinetic RV)
- Anemia
- Glaucoma
- Treated latent syphilis (per family report, was treated 2x:
one at age ___ in ___, once in his ___ by PCP in ___)
- Microhematuria
- Incontinence
- Venous stasis
Social History:
Occupation: ___
Living situation: ___, in a memory unit
Children: none
HCP: ___, sister, ___
Smoking: Remote (2 ppd in ___ and ___, quit in his ___
ETOH: occasional
Illicits: none
Durable medical equipment: ___
FUNCTIONAL STATUS:
ADLs:
- Bathing: A
- Grooming: A
- Dressing: A
- Eating: I
- Toilet Hygiene: I
- Functional Mobility (walking, transfers): with walker
IADLs: (I=independent, A=needs assist, D=dependent)
- Driving: D
- Medication management: D
- Food preparation: D
- Grocery shopping: D
- Cleaning/laundry: D
- Finances: D
- Telephone: A
Family History:
Anemias, coronary artery disease, hypertension, colitis,
___
Physical Exam:
ADMISSION:
VITALS: N/A
GENERAL: elderly ill appearing man resting on his side in bed,
NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD
HEART: Irregular irregular, ___ holosystolic murmur at ___
LUNGS: unable to assess ___ poor inspiratory effort, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, trace edema to level of
bilateral knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2 (person, place), moving all 4 extremities with
purpose
SKIN: warm and well perfused
DISCHARGE:
RR ___
Gen: comfortable, no acute distress, responsive to voice
Pertinent Results:
LABS:
___ 06:54AM WBC-15.5* RBC-3.03* HGB-9.8* HCT-29.8* MCV-98
MCH-32.3* MCHC-32.9 RDW-15.9* RDWSD-56.4*
___ 06:54AM NEUTS-74.4* LYMPHS-11.9* MONOS-12.7 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-11.50* AbsLymp-1.84 AbsMono-1.96*
AbsEos-0.00* AbsBaso-0.03
___ 06:54AM GLUCOSE-106* UREA N-16 CREAT-1.2 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16
___ 07:00AM LACTATE-2.3*
___ 07:00AM ___ PO2-40* PCO2-33* PH-7.44 TOTAL
CO2-23 BASE XS-0 INTUBATED-NOT INTUBA
IMAGING:
CXR ___:
IMPRESSION: Multifocal pneumonia superimposed over mild
interstitial edema. Cardiomegaly
Brief Hospital Course:
___ year old man ___ HFpEF (LVEF 50%-55%), atrial fibrillation,
and Alzehimer's dementia presents as a transfer from his nursing
home for chest pain with work-up notable for likely multifocal
pneumonia. After discussion with the patient and his family,
based off of his previous goals of care discussions he was
transitioned to comfort focused measures and was initiated on a
morphine gtt for tachypnea with improvement. He was discharged
to hospice to continue his end of life care.
#Symptomatic control:
-Continue morphine gtt; titrate to comfort with PRN morphine
boluses
-Continue Ativan PRN for agitation/anxiety
#Transitional issues:
#CODE: DNR/DNI, no hospital transfer, CMO (Molst in chart)
#CONTACT/HCP: ___ (sister) ___ ___
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. AcetaZOLamide 250 mg PO DAILY
3. Bumetanide 2 mg PO BID
4. Collagenase Ointment 1 Appl TP DAILY
5. Lactulose 15 mL PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. LORazepam 0.5-2 mg IV Q2H:PRN agitation
RX *lorazepam 2 mg/mL 0.5-2 mg IV q2h Disp #*10 Vial Refills:*0
2. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q1H:PRN
pain, shortness of breath
RX *morphine 10 mg/5 mL ___ mg po q1h Refills:*0
3. Morphine Sulfate ___ mg IV Q1H:PRN Pain - Moderate
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) ___ mg
IV q1h Disp #*10 Bag Refills:*0
4. Acetaminophen 650 mg PO Q4H:PRN pain, tactile fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#PRIMARY:
Sepsis, likely due to pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You presented to the
hospital from your nursing facility due to a serious infection,
and based on you and your family's wishes we worked to treat
your symptoms related to the infection and ensuring you are
comfortable at the end of your life. You and your family will
work with the ___ facility to make sure you are comfortable.
Thank you for letting us be a part of your care.
Your ___ Team
Followup Instructions:
___
|
19655214-DS-15
| 19,655,214 | 23,906,184 |
DS
| 15 |
2167-05-28 00:00:00
|
2167-05-28 23:35:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old woman with known chronic mesenteric
ischemia but patent right common iliac to SMA bypass who
presents to ED with acute on chronic abdominal pain. Patient
reports that for the past month has had worsening of her chronic
abdominal pain. It is centrally located. She will try to ice the
area to help the pain. She feels that this is similar to the
pain she had back in ___ when she was first diagnosed with
mesenteric ischemia. She also endorses decreased appetite,
weight loss from 153lbs. to 126lbs. over 1 month. She has had
ongoing nausea, though does not feel that this is changed from
prior. Denies fever. Last BM was yesterday, but previously had
gone ___ days w/o a BM. She also notes that she is having
worsening headaches, described as a "pressure" over the top of
her head. States that this got better following having a bad
tooth removed, but then they came back. Notes that she had
family members who died of aneurisms, and believes that plan was
for her to have imaging of her head to further evaluate.
In the ED:
- VS: 99.4 134/77 79 20 100%RA
- Exam notable for: well-healed midline surgical scar, diffuse
TTP worse in RUQ with positive rebound tenderness, positive
guarding, hyperactive bowel sounds. Mildly tachycardic,
otherwise unremarkable cardiac and pulmonary exams.
- Labs notable for: WBC 13.1 w/ 67.9%N, H/H 15.2/46.9, LFTs nl,
INR 3.2, CHEM7 unremarkable, UA negative
- CTA ABD/PELVIS: no mesenteric ischemia, no acute process;
occluded celiac stent of unknown chronicity w/ filling of the
major branch vessels distally likely from collaterals; partially
occulded SMA stent
- EKG: NSR, rate 71, nl axis,
- Vascular surgery was consulted, who ultimately felt that no
acute surgical intervention was necessary. Felt that occlusion
is likely chronic, no c/f mesenteric ischemia given open distal
filling; likely developed collaterals around occluded stent.
However, patient was unable to tolerate a meal, and therefore
admission was requested to the medicine service.
- Vitals on transfer: T 97.9, HR 73, BP 133/75, RR 16, 99% RA
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Partial colectomy in ___ due to acute ischemia
- Right common iliac-SMA bypass in ___
- SMA/celiac angioplasty with stent placement
- Re-do right common iliac-SMA bypass in ___
- Goiter
- Headache (migraines)
- IBS
- nephrolithiasis
- hypercholesterolemia
- asthma
- rhinitis
- HTN
Social History:
___
Family History:
- Maternal Aunt - ___
- Mother Cancer; Cancer - Esophageal; Peripheral vascular
disease
- Also family history of: Brain aneurysms, Asthma; Cancer;
Hypertension; Thyroid Disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9, HR 72, BP 152/87, RR 16, 98% Ra
GENERAL: thin, sitting on edge of bed bent over, tearful, 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: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: normal bowel sounds, soft though with some voluntary
guarding, tenderness in epigastric and periumbilical regions,
less pain on R and L upper and lower quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact. ___ strength in upper and lower
extremities. Sensation intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 905) Temp: 97.5 (Tm 98.3),
BP: 147/77 (116-182/30-85), HR: 63(63-83), RR: 20 (___), O2
sat: 100% (95-100), O2 delivery: Ra
GENERAL: thin, gripping belly, appears in pain but very pleasant
HEENT: MMM
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB
ABDOMEN: normal bowel sounds, soft with minimal tenderness, mild
tenderness in epigastric and periumbilical regions, especially
over the incision site, less pain on R and L upper and lower
quadrants, no guarding or rebound tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact. ___ strength in upper and lower
extremities.
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
==================================
___ 07:01PM BLOOD WBC-11.0* RBC-4.94 Hgb-14.1 Hct-43.2
MCV-87 MCH-28.5 MCHC-32.6 RDW-15.5 RDWSD-49.1* Plt ___
___ 07:47PM BLOOD ___ PTT-36.5 ___
___ 07:01PM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-143
K-3.1* Cl-99 HCO3-28 AnGap-16
___ 07:50PM BLOOD ALT-9 AST-16 LD(LDH)-204 AlkPhos-93
TotBili-0.4
___ 07:01PM BLOOD Lipase-21
___ 07:01PM BLOOD cTropnT-<0.01
___ 07:50PM BLOOD Calcium-9.8 Phos-3.4 Mg-1.9
___ 06:14AM BLOOD TSH-0.50
___ 06:14AM BLOOD Free T4-1.5
___ 07:15PM BLOOD Lactate-1.2
ADMISSION LABS
(note that K was repleted prior to discharge)
==================================
___ 05:55AM BLOOD WBC-7.2 RBC-4.60 Hgb-12.9 Hct-40.7 MCV-89
MCH-28.0 MCHC-31.7* RDW-15.5 RDWSD-50.3* Plt ___
___ 05:55AM BLOOD ___ PTT-30.8 ___
___ 05:55AM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-145
K-3.2* Cl-104 HCO3-28 AnGap-13
___ 05:55AM BLOOD ALT-9 AST-15 AlkPhos-68 TotBili-0.2
___ 05:55AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.2 Mg-2.0
IMAGING:
CTA ABD&PELVIS IMPRESSION ___:
1. No evidence of mesenteric ischemia. No acute intra-abdominal
process.
2. Large cystic lesion centered in the mesentery on the left.
This could be potentially postoperative given prior surgery
though lymphangioma would be possible. Follow-up MR should be
obtained on a nonemergent basis if not already performed.
3. Occluded celiac stent of unknown chronicity with filling of
the major branch vessels distally likely from collaterals.
4. Partially occluded SMA stent with diminutive SMA that fills
distally from the ___ and patent SMA to left common iliac stent.
RECOMMENDATION(S): Recommend follow-up nonemergent MR for
further characterization of cystic lesion if not already
performed an outside institution.
MR-A BRAIN W/O CONTRAST IMPRESSION ___:
Normal MRA head. No aneurysm is identified.
MRI ABDOMEN/PELVIS W/ CONTRAST IMPRESSION ___:
1. 5.5 cm cystic retroperitoneal lesion without septations or
nodular enhancement, unchanged since ___. Findings
favor a lymphangioma, with mucinous cystadenoma a rarer common
consideration.
2. Dilated intra- and extrahepatic biliary ducts with findings
suggestive of sphincter of Oddi dysfunction. No
choledocholithiasis or obstructing mass seen.
3. Pancreatic cystic lesions, largest measuring 0.2 cm, likely
side branch intraductal papillary mucinous neoplasm (IPMN).
Consider follow up MRCP in ___ year to assess for expected
stability.
RECOMMENDATION(S): Follow up MRCP in ___ year to assess for
expected stability
of pancreatic cystic lesions.
Brief Hospital Course:
SUMMARY:
===============================
Ms ___ is a ___ year old woman with known chronic mesenteric
ischemia but patent right common iliac to SMA bypass who
presented with acute on chronic abdominal pain and poor PO
intake.
ACUTE ISSUES:
===============================
# Acute on chronic abdominal pain
Patient presented with one month of worsening abdominal pain,
located in epigastric and periumbilical areas, mainly localized
to the site of her incision, with decreased appetite, weight
loss, decrease in bowel movements. The abdominal pain is worse
immediately after she eats. Reassuringly, CTA with no acute
signs of mesenteric ischemia, showing likely collateral flow,
and lactate was normal; vascular surgery was consulted in the ED
and did not recommend further intervention at this time.
Additionally, her LFTs were normal and white count downtrended
without intervention. She was continued on her home medication
regimen including morphine 15mg BID:PRN and a fentanyl 50mcg
patch; she was also given standing Tylenol, a PPI and a
Lidocaine patch to be placed over the incision site. At time of
discharge her pain was much improved, which she attributes
mostly to the lidocaine patch.
Differential diagnosis for her acute on chronic pain is broad
and includes:
1. Superficial pain at her incision site: patient was markedly
improved with a lidocaine patch, however, unclear if this was
all that was going on.
2. Constipation/gas: strong bowel regimen and enemas led to some
improvement in symptoms. Discharged on a standing bowel regimen.
3. Gastritis: pain is worse after PO intake and she also has a
history of mild gastritis/esophagitis on prior EGD. At that time
she was negative for H. pylori. She is continued on her PPI and
a repeat EGD could be considered as an outpatient.
4. Retroperitoneal lymphangioma: CTA showed a "large cystic
lesion centered in the mesentery on the left, potentially
postoperative given prior surgery though lymphangioma would be
possible." Follow up MRI abdomen confirmed a "5.5 cm cystic
retroperitoneal lesion without septations or nodular
enhancement, unchanged since ___. Findings favor a
lymphangioma, with mucinous cystadenoma a rarer common
consideration." Given the large size of the cyst and the
location of the cyst, it is certainly possible that this is
causing or exacerbating her baseline abdominal symptoms and a
general surgery referral should be considered. However, her pain
had returned to her baseline prior to discharge, suggesting this
was not the etiology of her acute presentation.
5. Possible sphincter of oddi dysfunction: Abdominal MRI showed
findings suggestive of sphincter of oddi dysfunction. LFTs
remained normal, but if she has ongoing symptoms, ERCP with
sphincterotomy would be another possibility to consider.
# Chronic mesenteric ischemia
As noted above, patient has a history of chronic mesenteric
ischemia s/p partial colectomy and stent placement at ___
___. CT-A was not concerning for new or
worsening ischemia and vascular surgery did not recommend a need
for further intervention. She was continued on her aspirin and
warfarin in addition to her pain medication; she has not been
taking her statin due to concern that this was worsening her
abdominal pain but this was restarted at discharge upon further
discussion with the patient. She is scheduled for follow up with
her PCP for an INR check as well as with her vascular surgeon
given location of pain and concern for large cystic lesion as
noted above. Please note that her mesenteric stents are called:
RACER and RACER BE.
# Hypokalemia
Pt was intermittently hypokalemic to 3.1-3.2, likely secondary
to poor PO intake. EKG was unremarkable and she was adequately
repleted.
# Constipation/gas
Pt reports decreased bowel movements over the last month, likely
secondary to chronic opioid use. CT abdomen showed mildly
prominent loops of large bowel though no visualized focal
abnormalities and no obstruction. She was given an aggressive
bowel regimen.
# Pancreatic cysts
MRI also noted pancreatic cystic lesions, largest measuring 0.2
cm, likely side branch intraductal papillary mucinous neoplasm
(IPMN). Recommend follow up MRCP in ___ year to assess for
expected stability.
# Headache
# History of migraines
Pt reports roughly 3 months of an intermittent headache located
on the crown of her head. It is sometimes associated with nausea
and visual aura. The patient has a significant family history of
ruptured brain aneurysms and sudden death, and given the
chronicity of her headaches, she underwent a brain MR-A which
did not reveal any aneurysms. She was continued on standing
Tylenol and given heat/cold packs which helped.
# Hypertension
Elevated systolic blood pressure during majority of her stay,
ranging between 140s-160s. This may be contributing to her
headaches (see above). She was initially maintained on her
outpatient HCTZ; however, given below baseline PO intake, her
HCTZ was decreased by half and she was initiated on low dose
amlodipine at discharge.
# Chronic obstructive pulmonary disease
Advair exchanged for home symbicort while inpatient as symbicort
is non-formulary.
CHRONIC/STABLE ISSUES:
===============================
# Uterine fibroids
Imaging findings with known enlarged uterus and multiple uterine
fibroids. This may be contributing to her abdominal pain. Pt
reports that "no surgeon will address it" because of her
abnormal GI anatomy and likely multiple adhesions from prior
operations. Pt should consider following up with an OB/GYN as an
outpatient for medical and possibly surgical management.
# Homelessness
Pt reports that she has been living in her truck for ___ years.
She continues to pay rent on her apartment but does not return
to said apartment due to threats she receives from gang members
living in the area. She was seen by social work and CVPR
violence program who will follow up with her as an outpatient
for more resources and support.
TRANSITIONAL ISSUES:
===============================
Code status: Full (presumed)
- ABDOMINAL PAIN:
[ ] Follow up with outpatient primary care doctor ___ above),
assess pain control and PO intake
[ ] Would consider general surgery appointment to address the
large cyst vs lymphangioma as a possible cause of her worsening
abdominal pain; case reports have suggested that these can cause
abdominal pain and amenable to resection. On the other hand, she
is obviously a sub-optimal operative candidate given her
significant vascular disease.
[ ] F/u bowel regimen given chronic opioid use
[ ] Other pain medications to consider: bentyl, Levsin, donnatal
[ ] Consider repeat EGD to assess for worsening gastritis/PUD
lower on the differential (last EGD ___ did show gastritis).
- CHRONIC MESENTERIC ISCHEMIA:
[ ] Ensure patient is taking Atorvastatin 40mg QHS
[ ] Follow up with vascular surgery (see above)
[ ] Continue counseling re: smoking cessation
[ ] Please note that her mesenteric stents are called: RACER and
RACER BE (which are safe for MRIs)
- INR:
[ ] Please repeat INR at next outpatient appointment as it
trended down to 2.1 by discharge
- HYPERTENSION:
[ ] Follow up BP control (decreased HCTZ from 25mg to 12.5mg and
added amlodipine 5mg once daily)
- HYPOKALEMIA:
[ ] Repeat chemistry at outpatient appointment
- HEADACHES:
[ ] Consider migraine prophylaxis
- POSSIBLE SPHINCTER OF ODDI DYSFUNCTION:
[ ] Consider ERCP given MRI findings suggestive of possible
sphincter of oddi dysfunction
- PANCREATIC CYST:
[ ] Follow up MRCP in ___ year to assess for expected stability of
pancreatic cystic lesions.
- HOMELESSNESS:
[ ] Plan to follow up with CVPR violence program as an
outpatient (they met with patient while in house and will follow
up with her day after discharge).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 50 mcg/h TD Q72H
2. Morphine Sulfate ___ 15 mg PO BID:PRN Pain - Severe
3. Hydrochlorothiazide 25 mg PO DAILY
4. Warfarin 4.5 mg PO 5X/WEEK (___)
5. Warfarin 5 mg PO 2X/WEEK (MO,FR)
6. Hydrocortisone Oint 2.5% 1 Appl TP TWICE DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Esomeprazole 20 mg Other BID
9. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
11. LORazepam 0.5 mg PO TID:PRN anxiety attacks
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*30 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply 1 patch to your abdominal scar daily
Disp #*15 Patch Refills:*0
6. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily mixed in 8 ounces of water Disp #*24 Packet
Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily for
constipation. Disp #*60 Tablet Refills:*0
9. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
12. Esomeprazole 20 mg Other BID
13. Fentanyl Patch 50 mcg/h TD Q72H
14. Hydrocortisone Oint 2.5% 1 Appl TP TWICE DAILY
15. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
16. LORazepam 0.5 mg PO TID:PRN anxiety attacks
17. Morphine Sulfate ___ 15 mg PO BID:PRN Pain - Severe
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. Vitamin D 1000 UNIT PO DAILY
20. Warfarin 4.5 mg PO 5X/WEEK (___)
21. Warfarin 5 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========================
Acute on chronic abdominal pain
Chronic mesenteric ischemia
Constipation
SECONDARY:
========================
Hypokalemia
Constipation
Possible sphincter of oddi dysfunction
Incidental pancreatic cysts
Headache, history of migraines
Hypertension
Chronic obstructive pulmonary disease
Uterine fibroids
Homelessness
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 bad abdominal pain and were having
difficulty eating.
You had a cat scan of your abdomen which was not concerning for
any more blockages in the arteries, but it did show that you
have a large cyst that is stable from prior imaging. You had an
MRI to better evaluate the cyst and we recommend that you follow
up with your outpatient vascular surgeon Dr. ___ in order to
address this finding.
We treated your pain with your home medications. We also gave
you strong laxatives and a few enemas to help you move your
bowels and this seemed to help your pain.
You also had an MRI of your head because you were having
headaches; the MRI did NOT show any evidence of aneurysms. This
is great!
Finally, you were evaluated by a nutritionist who recommended
that you take a multivitamin with minerals which we have
prescribed to you.
When you leave the hospital, please follow up with your
outpatient primary care doctor and your vascular surgeon (see
below for scheduling). You may also want to go to a
gastroenterologist (belly doctor), but your primary care doctor
can help you arrange this in the future.
***Please note that your mesenteric stents are called: RACER and
RACER BE.***
If you develop significantly worsening pain or are unable to
eat, please call your doctor or return to the emergency room.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The team at ___
Followup Instructions:
___
|
19655310-DS-11
| 19,655,310 | 23,438,001 |
DS
| 11 |
2147-05-12 00:00:00
|
2147-05-12 19:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / misoprostol / Sulfa (Sulfonamide Antibiotics) /
Coumadin / cefazolin
Attending: ___
Chief Complaint:
Necrotizing pancreatitis complicated by hypotension
Major Surgical or Invasive Procedure:
-___: Central Venous Line placement
-___: PICC placement
-___: R CFA approach arteriogram with coil embolization of a
pancreatic arcade branch; angioseal device closure
-___: R EJ temporary central line placement
-___: Percutaneous ___ guided abscess drainage
-___: placement of tunneled HD line
- ___: placement of L IJ
- ___: aspiration of abdominal collection (no drain placed)
History of Present Illness:
Ms. ___ is a ___ yo W w/ SLE, class IV lupus nephritis c/b ESRD
on HD, calciphylaxis on chronic prednisone and
hydroxychloroquine
presenting as a transfer with pancreatitis.
One week ago, she developed epigastric pain radiating into the
back and left shoulder. It was gradual in onset and worsened
over
the next several days, acutely worse during her HD session on
___. She also had fevers up to T 101.7 intermittently over the
past week. She has also had constipation, with no bowel movement
in 3 days. Endorses dry cough but no dyspnea. Does not make any
urine. She has had fatigue and aches in her bilateral shoulders
and left knee but no swelling or redness. No chest pain or
dyspnea, no new rash.
She initially presented to the ___ and was transferred
from there to ___ ED.
In the ED,
- Initial Vitals: Temp 99.1 HR 110 BP 86/53 RR 18 SpO297% RA
- Exam:
General: in NAD
Chest: CTAB
Cardiac: RRR
Abd: diffusely tender, worse over RUQ, Epigastrium
Extremities: no pedal edema
- Labs: WBC 10.3, Hgb 12.0, Plts 285, Lipase 197, BUN 21, Cr
4.4,
Lactate 1.8
- Imaging: US abdomen, CT abd/pelvis, CXR
- Consults: Surgery - reviewed CT abdomen and determined no need
for acute surgical intervention
- Interventions: Zosyn, Acetaminophen, Midodrine, LR
On arrival to the FICU, she reports that she has abdominal
"ache"
but no nausea currently. The pain is about the same as it has
been for the past several days. No dizziness or lightheadedness,
she reports her BPs are routinely in the ___ at home.
Past Medical History:
- Systemic lupus c/b nephritis/ESRD, on HD
- Hyperlipidemia
- Hyperparathyroidism ___ to CKD
- fibromyalgia
- degenerative joint disease in low back
- CVA x 3
- RIJ thrombus (___)
- abdominal calciphylaxis
- chronic hypotension on midodrine
- R BKA (___) for R heel MRSA osteomyelitis
- E.faecium bacteremia w/endocarditis c/b respiratory failure
from metapneumovirus ___, s/p ___ntibx)
Social History:
___
Family History:
father - MIs in ___, CVA in ___
paternal uncle MI at ___
paternal uncle2 cancer ___
paternal aunt cancer ___
mother - osteoarthritis, CAD in ___
maternal grandmother ___ cancer
maternal grandfather peripheral vascular disease at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.7 HR 91 BP 71/52 RR 19 O2 93% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. PERRL. MMM.
NECK: JVP 8 cm. Tunneled HD line present in R upper chest,
covered with clean bandages, no surrounding erythema.
CARDIAC: Regular rhythm, normal rate. +systolic flow murmur.
Audible S1 and S2.
LUNGS: Crackles at bilateral bases. Equal air movement
bilaterally, no wheezes or rhonchi.
BACK: No CVA tenderness.
ABDOMEN: Tender to palpation in epigastric region. Normal bowels
sounds. No rebound or guarding.
EXTREMITIES: Warm, no edema. Fistula present on LUE.SKIN:
Scattered petechial rash on BUEs.
NEUROLOGIC: AOx3. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
===========================
24 HR Data (last updated ___ @ 852)
Temp: 98.4 (Tm 98.7), BP: 112/67 (94-112/61-67), HR: 104
(95-104), RR: 18 (___), O2 sat: 98% (97-100), O2 delivery: 1L
NC, Wt: 150.7 lb/68.36 kg
Drain output: 300cc on ___
GENERAL: NAD
EYES: Anicteric, PERRL
ENT: OP clear. Tunneled HD line in R upper chest C/D/I with
steri-strips over tunneling site. L IJ c/d/I. Dobhoff in place.
CV: RRR, nl S1, S2, no m/r/g, no JVD
RESP: diminished breath sounds at bases; faint bibasilar
crackles
ABD/GI: obese, + BS, soft, minimal LUQ/LLQ TTP, non-distended,
no
R/G, drain in mid-abdomen with dry occlusive dressing draining
serous fluid
GU: No suprapubic fullness or tenderness to palpation; no
vaginal
discharge on limited external exam
VASC/EXT: s/p R BKA. LUE fistula weak thrill. LLE warm to
touch. No lower ext edema.
SKIN: No rashes or lesions noted on visible skin
NEURO: AOx3, oriented to president, CN II-XII intact, ___ all
ext
(distal RLE testing deferred given BKA), sensation grossly
intact
to light touch, gait not tested
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
==================
___ 04:24AM BLOOD WBC-10.3* RBC-4.78 Hgb-12.0 Hct-41.4
MCV-87 MCH-25.1* MCHC-29.0* RDW-19.3* RDWSD-59.0* Plt ___
___ 04:24AM BLOOD Neuts-81.5* Lymphs-6.5* Monos-8.3 Eos-2.3
Baso-0.3 Im ___ AbsNeut-8.42* AbsLymp-0.67* AbsMono-0.86*
AbsEos-0.24 AbsBaso-0.03
___ 04:24AM BLOOD ALT-7 AST-21 AlkPhos-82 TotBili-0.4
___ 04:24AM BLOOD Albumin-2.8* Calcium-9.0 Phos-3.8 Mg-2.1
___ 09:53PM BLOOD ___ pO2-47* pCO2-53* pH-7.31*
calTCO2-28 Base XS-0
___ 04:37AM BLOOD Lactate-1.8
___ 09:53PM BLOOD freeCa-1.11*
INTERIM LABS:
=============
___ 05:10PM BLOOD HIT Ab-NEG HIT ___
___ 04:24AM BLOOD Lipase-197*
___ 01:50AM BLOOD Lipase-153*
___ 02:03PM BLOOD Lipase-669*
___ 02:30AM BLOOD Lipase-56
___ 03:49PM BLOOD Lipase-59
___ 05:06AM BLOOD Triglyc-105
___ 02:58AM BLOOD 25VitD-18*
___ 02:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 01:26PM BLOOD HBsAg-NEG HBsAb-NEG
___ 03:28PM BLOOD CRP-119.8*
___ 06:15PM STOOL CDIFPCR-POS* CDIFTOX-POS*
___ 07:00PM ASCITES TotPro-1.4 Glucose-74 Creat-1.0
LD(LDH)-1408 ___ TotBili-LESS THAN Albumin-0.3
___
Other:
Ferritin 2710, TIBC 190, Iron 23
Hapto 93
Trig 97
Lact 1.1 on ___
VBG 7.32/58, bicarb 31 on ___
HBsAg neg
HBsAb neg
HBcAb neg
HCVAb neg
DISCHARGE LABS:
==============
___ 06:41AM BLOOD WBC-13.6* RBC-2.86* Hgb-7.3* Hct-26.6*
MCV-93 MCH-25.5* MCHC-27.4* RDW-18.7* RDWSD-64.2* Plt ___
___ 06:41AM BLOOD Neuts-85.6* Lymphs-3.9* Monos-8.2 Eos-1.4
Baso-0.2 Im ___ AbsNeut-11.67* AbsLymp-0.53* AbsMono-1.12*
AbsEos-0.19 AbsBaso-0.03
___ 06:41AM BLOOD ___
___ 06:41AM BLOOD Glucose-150* UreaN-55* Creat-3.7* Na-138
K-6.2* Cl-94* HCO3-26 AnGap-18
___ 06:41AM BLOOD ALT-64* AST-77* AlkPhos-117* TotBili-0.2
___ 06:41AM BLOOD Calcium-10.3 Phos-6.1* Mg-2.4
MICRO:
======
C.diff (___): negative
C.diff ___: negative
C.diff (___): positive
Peritoneal fluid drainage (___):
Citrobacter freundii complex - moderate
Morganella morganii - sparse
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| MORGANELLA MORGANII
| |
AMIKACIN-------------- <=2 S 16 S
CEFEPIME-------------- R S
CEFTAZIDIME----------- =>64 R =>32 R
CEFTRIAXONE----------- 32 R 16 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- 1 S S
PIPERACILLIN/TAZO----- =>128 R 32 I
TOBRAMYCIN------------ =>16 R 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>2 R
BCx (___): pending x 1
Peritoneal fluid from bag (___): GNRs of two species,
including
Aeromonas hydrophila (sparse growth)
________________________________________________________
AEROMONAS HYDROPHILA
|
AMIKACIN-------------- S
CEFEPIME-------------- S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 2 I
LEVOFLOXACIN---------- 4 I
MEROPENEM------------- S
BCx ___, peripheral): negative x 2
BCx (___): Citrobacter freundii in 1 of 4 bottles
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
HD line swab and tip cx (___): no growth
Fungal cx (___): pending
Peripancreatic fluid x (___): negative
Peritoneal fluid (___): negative
BCx (___): negative
IMAGING/STUDIES:
================
___ CT Abd/pelvis:
1. Acute necrotizing pancreatitis as described above with non
enhancement of the pancreatic neck, significant upper abdominal
inflammatory stranding and non organized fluid.
2. While there is hyperemia and wall edema of the proximal
duodenum, these findings are likely reactive to the adjacent
pancreatic process. No free air or extraluminal enteric contrast
to suggest a perforated gastric
or duodenal ulcer. If there is continued clinical concern,
further evaluation with an EGD and direct visualization is
recommended
___ CT abd/pelvis:
1. Acute necrotizing pancreatitis which overall appears similar
to previous imaging on ___. The degree of
peripancreatic inflammatory changes including fat stranding and
surrounding non organized peripancreatic fluid
appears to have slightly improved.
2. Increasing moderate bilateral pleural effusions, right
greater
than left, with compressive atelectasis.
3. Stable small amount of intra-abdominal and intrapelvic
ascites.
4. Mild gall bladder distention with vicarious excretion of
contrast or small stones/biliary sludge.
___ Mesenteric arteriogram:
1. Celiac arteriogram showed 2 foci of active extravasation
from
a pancreatic arcade branch in the region of known peripancreatic
hemorrhage as seen on same day CT. This was confirmed by cone
beam CT.
2. No active extravasation was identified on proximal splenic
arteriogram.
3. Selective angiogram of the GDA confirmed active
extravasation
from a pancreatic arcade branch.
4. Successful Gel-Foam and coil embolization of the mid segment
of the pancreatic arcade branch across the origins of two second
order branches supplying the bleeding foci.
5. Post embolization pancreatic arcade branch angiogram showed
no evidence of residual active extravasation or pseudoaneurysm.
6. Post embolization GDA and celiac arteriogram showed no
residual extravasation.
7. Selective SMA angiogram showed no active extravasation or
collateral blood supply to the bleeding foci.
8. Failed repositioning of the right PICC line likely due to
SVC
stenosis about the existing HD line. PICC line was removed.
IMPRESSION:
1. Successful coil and Gel-Foam embolization of a pancreatic
arcade branch.
2. Removal of the right PICC line.
___ CT abd/pelvis
-Interval arterial embolization with no evidence of bleeding on
the current study.
-The main component of the hematoma adjacent to the pancreas
appears slightly smaller than prior however there are pockets
extending into the small bowel mesentery that have slightly
increased in size.
-Mild increase in the volume of ascites and mesenteric
inflammatory change.
___ TTE:
The left atrial volume index is mildly increased. There is
normal
left ventricular wall thickness with a small cavity. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
The visually estimated left ventricular ejection fraction is
>=70%. Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient with no change with Valsalva. No ventricular septal
defect is seen. The right ventricle was not well seen with mild
global free wall hypokinesis. The aortic sinus diameter is
normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets are moderately thickened with no
mitral
valve prolapse. There is moderate mitral annular calcification.
There is mild functional mitral stenosis from the prominent
mitral annular calcification (valve area normal by planimetry
but
at high HR 110/min mean gradient across the valve 12mmHg). There
is trivial mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are not well seen. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Increased transmitral
gradient at high HR ___ MAC and mitral leaflet thickening (?
valvulitis from lupus, renal function and calcium normal on
labs).
Small dynamic left ventricle. Right ventricle not well
visualized
but appears to be mildly hypokinetic. Indeterminate pulmonary
pressure. Compared with the prior TTE (images reviewed) of
___ , there has been progression of mitral
annular calcification ad mitral leaflet thickening with a
significant gradient now seen across the mitral valve at a high
heart rate on pressors.
___ ___ drainage:
Successful CT-guided placement of an ___ pigtail catheter
into the collection. Samples were sent for microbiology
evaluation. 260 cc of dark sanguinous fluid was aspirated.
Fluid did not appear purulent.
___ CT chest:
Pleural effusions with atelectasis. Mild pulmonary edema.
Possible component of pneumonia within partly atelectatic left
lower lobe, however.
___ CT abd/pelvis:
Large collection about the pancreas has mostly resolved,
although
with two probably anterior communicating peripancreatic
loculations that are newly apparent. Catheter terminates in the
fully collapsed anterior part. New small perihepatic
collection.
___ CT abd/pelvis:
1. Interval increase in size and organization of multiple
peripancreatic fluid collections, particularly adjacent to the
left hepatic lobe, posterior to the portosplenic confluence, and
adjacent to small bowel loops within the left hemiabdomen.
2. Improved pancreatic edema and peripancreatic fat stranding,
which persists.
3. Unchanged position of the anterior pigtail catheter, with the
previously visualized fluid collection completely drained.
4. Moderate bilateral pleural effusions, with interval increase
in size of the left pleural effusion.
___ RUE US:
Partially occlusive thrombus within the proximal right brachial
vein.
___ MRCP:
1. Peripancreatic fluid collections arising from/abutting the
pancreatic body and medial tail and abutting the drainage
catheter have increased in size.
2. Other peripancreatic fluid collections have decreased in
size.
3. Innumerable T2 hyperintense vertebral body lesions appear
similar to the lesions identified on cervical spine MRI
performed
___ years prior. Differential considerations continue to include
amyloidosis and brown tumors in the setting of chronic renal
insufficiency.
4. Cholelithiasis.
5. Small hiatal hernia.
___ Right upper extremity Doppler US
Interval resolution of previously seen partially occlusive
thrombus within the proximal right brachial vein. No new deep
venous thrombosis within the right upper extremity.
___ CT abd/pelvis with contrast
1. Redemonstrated changes of acute pancreatitis, with interval
development of an enlarging collection along the anterior
inferior portion of the pancreas measuring up to 5.4 cm, in
addition to multifocal peripancreatic collections, similar to
prior.
2. Moderate to large bilateral pleural effusions with
compressive
atelectasis of bilateral lower lobes.
___ EKG:
NSR at 83 bpm, PR 184, QRS 102, QTC 446, low voltages, no clear
ischemic changes
___ Central line:
Successful placement of a temporary triple lumen catheter via
the
left internal jugular venous approach. The tip of the catheter
terminates in the distal superior vena cava. The catheter is
ready for use.
___ ___ drainage
Successful CT-guided aspiration of a right abdominal
peripancreatic fluid collection. An 8 cc sample was sent for
the
requested laboratory tests.
___ KUB:
There is a Dobbhoff tube which courses down the esophagus and
past the diaphragm and terminates in the right upper quadrant.
The included imaged portion of the chest shows indistinct
pulmonary vascular markings, consistent with pulmonary edema and
likely small pleural effusions and atelectasis.
___ CT A/P w/cont
Edematous pancreatitis with persistent multifocal
peripancreatic,
perihepatic and mesenteric collections. There is a new
collection in the anterior abdomen adjacent to the anterior
percutaneous pigtail catheter.
___ CXR:
Drop of tube tip projects below the level of diaphragm and
probably within the distal stomach. Left-sided central venous
catheter tip projects within the right atrium. Right-sided
vascular access catheter tip projects within the right atrium.
Cardiomediastinal silhouette is at upper limits of normal,
unchanged from prior. Diffusely increased interstitial markings
bilaterally. Small left greater than right pleural effusions
with
compressive atelectatic changes. Additional retrocardiac
opacities may suggest developing infection. There are no
pneumothoraces.
___ EKG:
NSR at 92 bpm with 1st degree AV block, PR 212, QRS 94, QTC 420,
no ischemic changes
___ EKG:
ST at 111 bpm, borderline LAD, PR 164, QRS 98, QTC 451, Q in
III,
low voltages, no peaked T waves
Brief Hospital Course:
___ history of SLE (on chronic prednisone/hydroxychloroquine)
c/b
ESRD ___ class IV lupus nephritis on HD (___), abdominal
wall calciphylaxis, chronic hypotension (on midodrine), R BKA
(___) for R heel MRSA osteomyelitis, E.faecium bacteremia
w/endocarditis c/b respiratory failure from metapneumovirus
___, s/p ___ntibx), RIJ thrombus (___), h/o
CVA x 3 (on apixaban/clopidogrel), initially transferred from
OSH
on ___ for necrotizing pancreatitis, with course complicated by
peripancreatic hematoma s/p embolization ___ and peripancreatic
fluid collections s/p drainage and drain placement ___ and
additional drainage ___, C diff colitis s/p treatment,
hypotension requiring pressors, and RUE DVT, called out of ICU
___, with course further c/b MDR Citrobacter bacteremia from
superinfected intra-abdominal fluid collections and transient
encephalopathy. Now improved and stable for discharge to LTAC.
# Acute on chronic abdominal pain:
# Necrotizing pancreatitis:
# Peripancreatic hematoma:
# Superinfected peripancreatic fluid collections s/p
percutaneous
drainage:
Pt was admitted to the FICU initially with pancreatitis and
hypotension, treated with IVFs and dilaudid PCA (after trial of
ketamine in the ICU was too sedating). Etiology of pancreatitis
unclear, suspect gallstones given stones seen on imaging. On
___,
had worsening abdominal pain, and CT A/P significant for
peripancreatic bleed w/ hematoma. She underwent mesenteric
angiography and coil embolization of the pancreatic arcade
branch. Follow-up imaging on ___ showed multiple fluid
collections surrounding the pancreas which were drained by ___ on
___ with drain left in place. Fluid studies initially
consistent
with hematoma rather than infection, and antibx d/c'd after
treatment with Zosyn (___) and meropenem ___ - ___. Per
pancreas team, picture most c/w pancreatic duct disruption.
Repeat CT ___ for worsening pain showed drainage of collection
at drain site with increase in other ___
collections.
She underwent clamp trail with follow-up MRCP on ___ that
showed
increased size of fluid collections abutting drainage catheter
and decreased size of other peripancreatic fluid collections.
Per
pancreas team, she now likely has a fistulous connection from
her
ruptured pancreatic duct to her drainage catheter, with multiple
additional, non-contiguous collections that are not amenable to
percutaneous or endoscopic interventions at present. Not a
candidate for PD stent placement or open surgical repair at
present. CT abd/pelvis with contrast was repeated on ___ due
to
increasing leukocytosis, lethargy, and hypotension, showing
enlarging collection along the anterior inferior portion of the
pancreas. Given MDR Citrobacter bacteremia on ___, existing
drain output was cultured ___ (growing Citrobacter and
Aeromonas) and enlarging collection was aspirated by ___ ___
(growing Citrobacter, Morganella), suggestive of new pancreatic
superinfection as source. ID consulted. Treated with Zosyn
(___), transitioned to meropenem ___. Repeat CT A/P on
___ showed stable prior fluid collections and development of a
possible new collection adjacent to her existing drain. After
extensive discussions with the pancreas team, ___, and the
infectious disease team, it was decided to treat with
antibiotics
for ~4 weeks (through ___, with plan to repeat CT in
~2
weeks to guide further therapy and timing of percutaneous drain
discontinuation. Confirmed that ___ team will organize this
imaging after discharge. She will ultimately need pancreatic
duct
stent placement or surgical intervention to repair her PD and
should be considered for CCY as well if a candidate. An
appointment with the Pancreas service was requested, pending at
the time of discharge. She was discharged on standing Tylenol
(limited to 2g/d) and low-dose oxycodone with home methadone
d/c'd. She was tolerating a regular diet with supplemental
gastric TFs at discharge.
# Leukocytosis:
# Citrobacter bacteremia:
Leukocytosis was initially attributed to her pancreatitis and
C.diff (treated as above and below). On ___ she was found to
have MDR Citrobacter bacteremia ___, with likely source
polymicrobial superinfected peripancreatic fluid collections
(with Citrobacter, Morganella, and Aeromononas, see above). She
was treated with Zosyn ___, transitioned to meropenem
___ with plan for a minimum 4-week course, with final duration
to be guided by repeat imaging. Confirmed that OPAT team will
organize this imaging after discharge for approx. 2 weeks from
discharge. Please ensure this is scheduled. She will require
weekly CBC w/diff and chem 10 (with LFTs), with results to be
faxed to ___ clinic (___). Leukocytosis had improved
to
13.6 at discharge.
# Encephalopathy:
# Respiratory acidosis with compensatory metabolic alkalosis:
Triggered ___ for somnolence. Attributed to narcotics at that
time given concurrent hypercarbia and some improvement with
narcan. Low suspicion for new CNS event (including new stroke,
seizure, or bleed) or sepsis (given normal lactate).
Splinting/restrictive physiology vs OSA may be contributing to
hypercarbia; low suspicion for PE (and already anticoagulated).
Remained mildly hypercarbic on recheck with development of a
mild
metabolic alkalosis with normalization of pH and resolution of
encephalopathy. Her home methadone was discontinued, and her
pain
was reasonably well-controlled with low-dose oxycodone, without
further episodes of encephalopathy. Of note, Partner's records
suggest similar episodes at ___ ___ of unclear
etiology. ___ benefit from outpatient sleep study to evaluate
for
contribution from OSA.
# Chronic hypotension:
# Mild functional MS with elevated gradient:
Review of prior records suggests that baseline BPs run in the
___, possibly in setting of calciphylaxis. Initially
admitted
to ICU for hypotension and pancreatitis and received pressors
(levophed and then phenylephrine) for SBPs in the ___ via
femoral A-line, off pressors since ___ (remains on midodrine).
Initially thought to be mixed septic/ cardiogenic/ hemorrhagic
shock in setting of pancreatitis w/hemorrhagic fluid collections
and functional mitral stenosis (resulting in inadequate
diastolic
filling), s/p course of Zosyn and then meropenem without
significant improvement. Was on CVVH, transitioned back to iHD
___. AM cortisol was WNL (although on chronic prednisone), and
no significant improvement with stress dose steroids in ICU. BPs
stabilized with SBPs largely in the ___ with no clear
end-organ ischemia. Bacteremic ___ as above, but cultures
cleared with no e/o shock or bleeding. She was continued on
midodrine 20mg TID (in place of home 40mg TID) and was
tolerating
volume removal with HD at the time of discharge. Would benefit
from outpatient cardiology f/u for mitral stenosis with elevated
gradient, which should be scheduled after discharge.
# ESRD on HD:
# Lupus nephritis:
# Volume overload:
Patient previously on intermittent HD via LUE AVF however per pt
fistula hasn't worked for ___ year and was being dialyzed prior
to
admission via HD line. Was initially on CVVH in ICU given
hypotension, running net-even given blood pressures. Trialed
intermittent HD however she became volume overloaded with
worsening pulmonary edema. Restarted CRRT on ___ as evidence of
volume overload and eventually transitioned back to iHD on ___.
Tunneled R-sided HD line placed ___. Remains mildly volume
overloaded but is tolerating UF with HD with midodrine 20mg TID
(from home 40mg TID). Her fistula was evaluated by the vascular
surgery team as an inpatient; they will attempt revision in the
outpatient setting (appointment scheduled with Dr. ___ on
___. She is being discharged to an LTAC to continue iHD
via
tunneled line ___ at ___.
Dialysis prescription on the day of discharge (___):
Duration (hours): 1hr UF + 3hr HD; Dialyzer: F180; EDW (kg):
tbd; Blood flow (mL/min): 400; Dialysate flow: 600; Dialysate
temperature (Centigrade): 37; Sodium (meq/L): 137; Potassium:
Greater than or equal to 4.5= 2; Less than 4.5= 3; Calcium
(meq/L): 2.5; Bicarbonate (meq/L): 35; UF goal (mL): 1.5L in the
first hour - try for additional 3 after; SBP>70
- EPO 5000u
- IV iron on hold given infection
- Pre-HD weight 68.5kg
- Achieved volume off 2.0L (limited by SBPs in the ___ and sinus
tachycardia)
- Post-HD weight 66.5kg
- Dry weight TBD
# Hyperkalemia:
# Hyperphosphatemia:
K 6.2 on ___ prior to HD, without EKG changes, phos 6.1. She
underwent successful HD. Discussed with renal, who were not
concerned for inadequate HD and did not think a repeat BMP
necessary prior to discharge. Would recheck BMP with phos on
___. She is not currently on a phos binder, but may need
initiation of phos binder as outpatient.
# RUE brachial DVT:
# Hx RIJ thrombus:
# Hx of CVA x 3:
Complicated clotting/bleeding and stroke history. Per review of
outside records from ___ and ___, appears she had R cerebellar
stroke ___, started on ASA. At that time had negative
lupus
AC, anticardiolipin, beta-2-glycoprotein, normal APC, Protein C,
Protein S, ATIII. She had a elevated homocysteine level and was
given B12 replacement. ___ had L MCA and ___ stroke
for which she received TPA; cardiac testing unrevealing for
etiology. She was started on apixaban until ___ when
she
suffered a R MCA stroke, s/p thrombectomy. She was started on
warfarin at that time but developed calciphlaxis. Dr. ___ at
___ suggested Heparin + ASA, which reportedly worsened the
calciphylaxis. She was therefore transitioned in ___ to
apixaban
(renally-dosed, it seems) + Plavix. She had a RIJ thrombus
___
at ___, for which apixaban was increased to 5mg BID and Plavix
was changed to every other day given c/f bleeding. Admitted this
admission on that regimen, with apixaban lowered to 2.5mg BID in
setting of pancreatic hemorrhage after embolization and trial of
heparin. Had increased RUE swelling ___ after transitioning
from
hep gtt to apixaban on ___, found to have partially occlusive R
brachial DVT on U/S (not clearly line associated, but did have
R-sided central access in IJ and EJ). Heparin resumed ___, with
repeat RUE U/S ___ with resolution of clot. In discussion with
hematology, unlikely to represent apixaban failure as she missed
a few apixaban doses during the ___ interval;
unfortunately
Coumadin is contraindicated given calciphlyaxis, as is lovenox
given ESRD. She was treated with heparin gtt ___
and was ultimately transitioned back to apixaban 2.5mg BID per
hematology recommendations. Neurology was consulted and agreed
with apixaban 2.5mg BID from a stroke perspective. Plavix was
initially held, resumed prior to discharge per neurology
recommendations at home dose of 75mg every other day. Would
benefit from ___ Neurology f/u as outpatient, which will need
to be scheduled after discharge.
# Normocytic anemia:
Likely from pancreatic hematoma, s/p embolization, with
contribution from anemia of inflammation, ESRD, blood draws. S/p
5u pRBCs this admission, last ___, with Hgb now stable in ___.
No clear evidence of bleeding or hemolysis presently despite
therapeutic anticoagulation (drain output is non-bloody, and no
melena/hematochezia). She received Epo with HD, but IV iron with
HD was held in the setting of infection (can be resumed after
completion of antibiotics). Hgb 7.3 on discharge.
# Nutrition:
TFs initiated ___ to preserve gut mucosa and prevent bacterial
translocation with TPN initiated ___ to meet nutritional goals,
subsequently held for bacteremia (see below). ___ was
displaced and subsequently replaced. Patient declined
post-pyloric placement, but per Pancreas gastric feeding
continued. She was ultimately advanced to a regular diet by
mouth
and will continue supplemental TFs with Vital 1.5, cycled to
65cc/hr from 8p-8am. She should continue to work on advancing
her
oral feeds with weaning of TFs as tolerated.
# Hypoxia:
# Pulmonary edema:
# Bilateral pleural effusions:
Currently requiring intermittent 1L NC, likely due to b/l
pleural
effusions and mild pulmonary edema. No e/o PNA. Volume
management
per HD as above.
# Hyponatremia:
Asymptomatic. Likely secondary to hypervolemia with excessive
free water flushes with TFs. Improved with HD and adjustment of
free water flushes. Na 138 prior to HD on ___.
# Transaminitis:
Mild, with elevated alk phos but nl Tbili. MRCP this admission
without intra/extrahepatic biliary dilation. Patent vasculature
on U/S and nl liver echotexture. Hep serologies negative. Less
likely ischemic hepatitis with elevations to this degree.
Stable.
Home atorvastatin was held in hospital and on discharge; her
LFTs
should be rechecked in ___ weeks, with atorvastatin 80mg daily
resumed if improving for secondary stroke prevention.
# Diarrhea:
# C.diff:
# Hx of constipation:
Hx constipation. In setting of antibx, developed C.diff ___ w/o
e/o toxic megacolon, s/p treatment with PO Vanco/IV flagyl
through ___. Repeat C.diff testing negative. Mild diarrhea at
the time of discharge attributed to tube feeds. She was
continued
on C.diff ppx with Vancomcyin 125mg PO BID while on antibiotics
(___), to continue for duration of meropenem course. Home
linaclotide held in hospital and on discharge.
# SLE
Continued home hydroxychloroquine. Was initially treated with
stress-dose steroids, weaned back to prednisone 5mg daily. F/u
scheduled with outpatient rheumatologist (Dr. ___ on
___.
# Abdominal calciphylaxis:
No e/o active calciphylaxis this admission. Warfarin was
avoided.
Will need outpatient dermatology f/u.
# GERD:
Home omeprazole discontinued given association between
omeprazole
and pancreatitis. Famotidine initiated this admission.
# Vaginal candidiasis:
Pt complained of vaginal pruritus on the day of discharge
without
vaginal discharge on limited external exam. Miconazole vaginal
cream initiated ___ with plan for 7d course (through ___.
# Access:
# SVC stenosis:
Patient self-dc'd right EJ CVC on ___. A tunneled R IJ was
placed for HD, but without a VIP port. IV team was unable to
place PIV, and per ___ cannot place RUE PICC or R EJ due to SVC
stenosis (LUE PICC not appropriate given LUE fistula). Access
options were limited to LIJ vs femoral line. Discussed with
renal, who suggested LIJ despite presence of non-working fistula
in that arm. Triple lumen LIJ placed successfully ___ by ___.
She is being discharged with tunneled R IJ for HD and L IJ
triple
lumen in place for IV antibiotics and lab draws, which should be
evaluated daily and discontinued as soon as IV antibiotics are
completed. Of note, R tunneled line venotomy site had not yet
healed at the time of discharge. Discussed with ___, who
recommended replacement o steri-strips with tegadarm and close
monitoring for healing. Per ___, no indication to replace
tunneled line at this time.
# LINES/TUBES: tunneled HD line, LIJ
#CODE STATUS: Full (confirmed)
#CONTACT: ___ (mother) ___
#DISPOSITION: to ___ (___ on ___
** TRANSITIONAL **
[ ] repeat BMP, Phos on ___ to monitor hyperK and phos
[ ] continue IV meropenem, course and drain management to be
determine by ID and imaging (ID appointment pending at d/c; they
will schedule repeat imaging)
[ ] continue PO vancomycin while on meropenem
[ ] weekly CBC w/diff and chem 10 (including LFTs), to be faxed
to ___ (___)
[ ] follow LFTs; resume home atorvastatin if stable/improving
for
secondary stroke prevention
[ ] LIJ line care; d/c when IV antbx course complete
[ ] please monitor R tunneled line venotomy site closely to
ensure healing
[ ] wean TFs, advance POs as tolerated
[ ] miconazole vaginal cream x 7d (through ___
[ ] HD ___ consider resumption of IV iron after completion
of antibiotics and initiation of phos binder
[ ] f/u fungal BCx from ___, NGTD at discharge
[ ] Please monitor drain output daily; if any issues with drain,
please contact ___ Interventional Radiology at ___
[ ] will need Pancreas f/u for consideration of PD stent and
possible CCY; appointment requested prior to discharge (please
ensure this is scheduled ___
[ ] would benefit from outpatient cardiology f/u for mitral
stenosis; please schedule after discharge ___
[ ] will need outpatient neurology f/u; please schedule after
discharge ___
[ ] may benefit from outpatient sleep study
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO EVERY OTHER DAY
4. Midodrine 40 mg PO TID
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 20 mg PO Q6H:PRN Pain -
Moderate
7. PredniSONE 5 mg PO DAILY
8. Pregabalin 75 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
10. Hydroxychloroquine Sulfate 200 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. linaCLOtide 72 mcg oral DAILY constipation
13. Simethicone 80 mg PO QID:PRN gas
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
15. Polyethylene Glycol 17 g PO DAILY constipation
16. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
17. Vitamin D ___ UNIT PO DAILY
18. Miconazole Powder 2% 1 Appl TP BID:PRN itching
19. melatonin 5 mg oral QHS insomnia
20. Senna 17.2 mg PO QHS constipation
21. Docusate Sodium 100 mg PO BID constipation
22. Lidocaine 5% Ointment 1 Appl TP Q6H:PRN neuropathy
23. Methadone 7.5 mg PO Q6H
Discharge Medications:
1. Famotidine 10 mg PO Q24H
2. Meropenem 500 mg IV Q24H bacteremia, ESRD on HD
3. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7
Days
4. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
5. Vancomycin Oral Liquid ___ mg PO/NG BID
6. Acetaminophen 1000 mg PO Q12H
7. Apixaban 2.5 mg PO BID
8. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
Reason for PRN duplicate override: Alternating agents for
similar severity
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing,
shortness of breath
10. Miconazole Powder 2% 1 Appl TP PRN Skin irritation
11. Midodrine 20 mg PO TID
12. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
14. Senna 17.2 mg PO BID:PRN Constipation - First Line
15. Clopidogrel 75 mg PO EVERY OTHER DAY
16. Docusate Sodium 100 mg PO BID constipation
17. Hydroxychloroquine Sulfate 200 mg PO DAILY
18. Lidocaine 5% Ointment 1 Appl TP Q6H:PRN neuropathy
19. melatonin 5 mg oral QHS insomnia
20. Nephrocaps 1 CAP PO DAILY
21. PredniSONE 5 mg PO DAILY
22. Pregabalin 75 mg PO BID
23. Simethicone 80 mg PO QID:PRN gas
24. Vitamin D ___ UNIT PO DAILY
25. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until you have your liver function
tests rechecked in ___ months.
26. HELD- linaCLOtide 72 mcg oral DAILY constipation This
medication was held. Do not restart linaCLOtide until instructed
by your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Necrotizing pancreatitis
Peripancreatic hematoma
Peripancreatic fluid collections s/p percutaneous drainage
Hypotension
Right upper extremity DVT
ESRD on HD
Lupus nephritis
Hypervolemia
Acute hypoxic respiratory failure
C.diff colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for complications related to
necrotizing pancreatitis. You developed a hematoma beside the
pancreas that required embolization. You also developed
peripancreatic fluid collections that became infected and
required drainage by interventional radiology. You developed
C.diff colitis and were treated for this. You also developed a
blood clot in your right arm for which you were treated with
blood thinners.
You will need to complete a course of antibiotics. You will
finish at least a month of your antibiotics, and then receive a
CT scan to evaluate for resolution of your fluid collections.
You will also follow up with the pancreas service and the
surgery service for consideration of repair of your pancreatic
duct, and removal of your gallbladder.
With best wishes,
Your ___ Care Team
Followup Instructions:
___
|
19655310-DS-12
| 19,655,310 | 27,155,102 |
DS
| 12 |
2147-07-06 00:00:00
|
2147-07-07 03:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / misoprostol / Sulfa (Sulfonamide Antibiotics) /
Coumadin / cefazolin
Attending: ___
Major Surgical or Invasive Procedure:
Tunneled dialysis line placement ___
attach
Pertinent Results:
ADMISSION LABS:
___ 04:48PM BLOOD WBC-17.1* RBC-2.73* Hgb-6.5* Hct-24.0*
MCV-88 MCH-23.8* MCHC-27.1* RDW-20.9* RDWSD-66.4* Plt ___
___ 04:48PM BLOOD Neuts-91.9* Lymphs-2.2* Monos-4.7*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.76* AbsLymp-0.37*
AbsMono-0.80 AbsEos-0.03* AbsBaso-0.03
___ 04:48PM BLOOD ___ PTT-33.2 ___
___ 04:48PM BLOOD Glucose-122* UreaN-17 Creat-2.7* Na-140
K-4.5 Cl-102 HCO3-23 AnGap-15
___ 04:48PM BLOOD ALT-9 AST-20 AlkPhos-92 TotBili-0.3
___ 04:48PM BLOOD Lipase-123*
___ 09:56PM BLOOD CK-MB-3 cTropnT-0.29*
___ 02:10AM BLOOD CK-MB-3 cTropnT-0.28*
___ 04:48PM BLOOD Albumin-2.8* Calcium-9.3 Phos-3.8 Mg-1.8
___ 05:16PM BLOOD ___ pO2-34* pCO2-46* pH-7.36
calTCO2-27 Base XS-0
___ 04:57PM BLOOD Lactate-1.9
___ 05:16PM BLOOD O2 Sat-54
IMAGING:
___
CT abd/pel with contrast
IMPRESSION:
1. New fluid collection in the anterior gastric wall concerning
for early
abscess.
2. No residual fluid collection adjacent to the pigtail catheter
which
terminates inferior to the pancreas in the embolization coils.
Stranding is noted adjacent to the pigtail catheter tethering
cystic changes of the
pancreas as well as adjacent loop of small bowel. Agree with
prior
recommendation for pulling catheter.
3. Stable 1.6 cm pancreatic tail fluid collection and 2.3 cm
collection
adjacent to the transverse colon with interval increased density
which may
represent phlegmonous change or increased necrotizing component
given clinical history.
4. Slight interval decrease in size of subcapsular fluid
collection adjacent to the left hepatic lobe.
5. Slight interval decrease in edema of the pancreas with
persistent and
fluctuating cystic changes of the parenchyma.
6. Increased trace perihepatic and perisplenic ascites.
7. Stable bilateral large pleural effusions with compressive
atelectasis.
___ CXR:
FINDINGS:
Dual lumen right central venous catheter is again seen. Single
lumen
left-sided central line tip is also in the right atrium.
Increased opacity at
the right mid to lower lungs compatible least some component of
pleural
effusion and atelectasis, infection is not excluded. Small
right-sided
pleural effusion is suspected. There is pulmonary vascular
congestion.
IMPRESSION:
Pulmonary vascular congestion with moderate left and small right
pleural
effusions. Superimposed infection cannot be excluded.
___ CT A AND P WITH CONTRAST:
FINDINGS:
LOWER CHEST: Redemonstration of partially imaged moderate to
large volume
bilateral low-density pleural effusions and adjacent bibasilar
atelectasis.
There is no pericardial effusion. Coronary atherosclerotic
calcifications are seen.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Redemonstration of a 2.1 cm hemangioma in segment 2 of the liver
(2:17).
There is no suspicious focal lesion. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits. There is vicarious
excretion of contrast in the gallbladder. Again, there is a
low-density rounded fluid collection abutting the medial aspect
of the left hepatic lobe, measuring 4.6 x 3.4 x 4.2 cm on
current study (2:18, 601:28),
previously 4.8 x 3.5 x 4.6 cm.
PANCREAS: The pancreas is edematous with peripancreatic
stranding, similar to prior study. Embolization coils noted at
the pancreatic body. A 3.2 x 3.7 x 5.9 cm pancreatic tail
collection is again noted (2:20), similar in size to prior. In
a anterior peripancreatic collection currently measures 2.4 x
4.0 x 3.4 cm (2:33, 601:30), previously 3.9 x 5.4 x 4.4 cm. The
collection between the portal vein and IVC measures 1.5 x 2.7 cm
(2:26), previously 2.0 x 2.9 cm.
Again seen is an anteriorly placed pigtail catheter, and the
previously-seen 3.1 cm adjacent collection is no longer
visualized. The anterior pigtail catheter does not appear to
communicate with any sizable fluid collections. A collection
along the left mesentery measures 2.8 x 3.6 cm (2:38),
previously measuring 2.8 x 3.5 cm. Portal vein and SMV are
patent. Splenic vein is attenuated in the region of the
pancreatic tail though is patent, an appearance similar compared
to prior.
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 bilateral kidneys are atrophic and contain multiple
subcentimeter hypodensities, too small to characterize though
likely cysts. There is no evidence of solid renal lesions or
hydronephrosis. There is no perinephric abnormality. The
urinary bladder is decompressed.
GASTROINTESTINAL: Patient is status post sleeve gastrectomy.
There is mild wall thickening and surrounding soft tissue
stranding involving the distal stomach, pylorus, and proximal
duodenum, likely reactive. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement. there is small amount
of soft tissue stranding around the distal portion of the
transverse colon, likely reactive. Diverticulosis of the
descending and sigmoid colon is noted, without evidence of wall
thickening or fat stranding. The appendix is normal (601:34).
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are
grossly within
normal limits.
LYMPH NODES: Multiple prominent upper mesenteric lymph nodes are
seen (2:34, 37), likely reactive, however, there are not
pathologically enlarged by CT size criteria. There is no
retroperitoneal, pelvic, or inguinal lymphadenopathy.
VASCULAR: Mild atherosclerotic disease is present. There is no
abdominal
aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
L5 spondylolysis is noted without spondylolisthesis. L1
superior endplate
Schmorl's node with associated mild height loss of the vertebral
body is
chronic.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Similar appearance of previously seen pancreatitis with
persistent
multifocal peripancreatic, perihepatic, and mesenteric
collections. Overall, there has been mild interval decrease in
size of the collections, without evidence of new collections.
The anterior abdominal wall pigtail catheter does not appear to
communicate with a sizable fluid collection.
2. Redemonstration of multiple prominent upper mesenteric lymph
nodes, likely reactive.
3. Reactive changes are also seen within the adjacent bowel
loops, including the distal transverse colon, the distal
stomach, and proximal duodenum.
4. Redemonstration of partially imaged moderate to large volume
bilateral
effusions.
___ CXR
FINDINGS:
Dialysis catheter terminates in the right atrium. Left
subclavian catheter also terminates in the lower part of the
right atrium. Lung volumes remain low. Cardiac, mediastinal
and hilar contours appear stable. Persistent medium sized
pleural effusion on the left with layering affect. Small
pleural effusion on the right. No visible pneumothorax.
Pulmonary edema is mild, probably somewhat worse. Similar
retrocardiac opacity typical for atelectasis.
IMPRESSION:
Mild, worsening, pulmonary edema. Retrocardiac opacity typical
for
atelectasis; pneumonia is not excluded, however. Persistent
medium sized
left-sided pleural effusion.
___ CT A AND P WITHOUT CONTRAST
FINDINGS:
LOWER CHEST: Moderate to large nonhemorrhagic pleural effusions
bilaterally are slightly worsened compared to the study from ___ there is associated relaxation atelectasis at the
lung bases. Otherwise the partially imaged lung bases are
clear. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout. A 2.3 cm hemangioma in segment 2 is unchanged
(series 6: 19). No intrahepatic
or extrahepatic biliary dilatation. There is vicarious
excretion of contrast in the gallbladder, which appears normal
and without wall thickening or pericholecystic fluid.
Again seen is a 4.2 x 3.0 cm well-rounded fluid collection
abutting the medial aspect of the liver (series 6:19),
previously measuring 4.6 x 3.4 cm.
PANCREAS: The pancreas is again noted to be somewhat edematous,
similar to the prior study. A pigtail catheter is unchanged in
position anterior to the pancreas. The catheter is again
retracted in relation to a 2.6 x 1.9 Cm collection along the
transverse colon (series 6:27). This collection measured 2.2 x
1.5 Cm on the study from ___.
A collection in the tail the pancreas is decreased in size
measuring 3.9 x 1.7 x 1.3 cm, previously 3.2 x 3.7 x 5.9 cm.
The collection between the portal vein in the IVC measures 2.8 x
1.3 cm, previously 2.7 x 1.5 cm (series 6:25).
A collection along the left mesentery measures 3.2 x 2.6 cm,
previously 3.6 x 2.8 cm (series 6:37). No new collection within
the abdomen or pelvis.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions. Punctate calcifications are likely
related to prior
granulomatous disease.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are atrophic and contain subcentimeter
hypodensities, too small to characterize by CT. The urinary
bladder is under distended which limits evaluation.
GASTROINTESTINAL: Status post sleeve gastrectomy. Small bowel
loops
demonstrate normal caliber, wall thickness, and enhancement.
Diverticulosis of the sigmoid colon is noted, without evidence
of wall thickening or fat stranding.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy by size criteria. There is no pelvic or
inguinal lymphadenopathy.
VASCULAR: Mild atherosclerotic disease is present. There is no
abdominal
aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Degenerative changes are unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Similar appearance of an edematous pancreas. The collection
along the
transverse colon is slightly increased in size measuring 2.6 x
1.9 cm,
previously 2.2 x 1.5 cm. The pigtail catheter is retracted from
this
collection and is not located in any sizable collection. If
there is minimal output, this drain could likely be removed.
2. Interval decrease in remaining perihepatic, peripancreatic,
and mesenteric fluid collections, as above.
3. Slight increase in moderate to large nonhemorrhagic pleural
effusions.
___ CXR:
IMPRESSION:
Multiple left-sided displaced rib fractures are again seen.
Pulmonary edema is slightly worsened. Moderate left and small
to moderate right pleural effusions unchanged. Right-sided
___ catheter and left-sided central line are unchanged. No
pneumothorax.
___ LLE duplex
No evidence of deep venous thrombosis in the left lower
extremity veins.
CXR ___
No significant interval change in degree of pulmonary edema and
small
bilateral pleural effusions.
___ CT A/P WITH CONTRAST
1. New fluid collection in the anterior gastric wall concerning
for early
abscess.
2. No residual fluid collection adjacent to the pigtail catheter
which
terminates inferior to the pancreas in the embolization coils.
Stranding is
noted adjacent to the pigtail catheter tethering cystic changes
of the
pancreas as well as adjacent loop of small bowel. Agree with
prior
recommendation for pulling catheter.
3. Stable 1.6 cm pancreatic tail fluid collection and 2.3 cm
collection
adjacent to the transverse colon with interval increased density
which may
represent phlegmonous change or increased necrotizing component
given clinical
history.
4. Slight interval decrease in size of subcapsular fluid
collection adjacent
to the left hepatic lobe.
5. Slight interval decrease in edema of the pancreas with
persistent and
fluctuating cystic changes of the parenchyma.
6. Increased trace perihepatic and perisplenic ascites.
7. Stable bilateral large pleural effusions with compressive
atelectasis.
___ CT A/P WITH CONTRAST
1. Acute on chronic pancreatitis with overall stable appearance
of
peripancreatic collections as detailed above. Anterior abdominal
wall drainage
catheter terminates anteroinferior to the pancreas without
adjacent fluid
collection, similar to prior exam.
2. Interval resolution of anterior gastric wall fluid
collection. However,
there is persistent gastric wall thickening, suggestive of
gastritis.
3. Trace perihepatic and perisplenic ascites.
4. Large bilateral pleural effusions with associated compressive
atelectasis,
similar to the prior study.
MRI T/L SPINE WITHOUT CONTRAST ___
1. No evidence of infection in the thoracic or lumbar spine on
this
non-contrast study.
2. Innumerable T1 heterogeneously intense, T2/water IDEAL
hyperintense lesions
throughout the thoracic and lumbar spine are essentially
unchanged in
comparison with the abdominal MRI of ___. The
differential
diagnosis continues to include brown tumors versus amyloidosis
in the setting
of chronic renal insufficiency. Bone metastatic lesions may
have similar
appearance, however this possibility is less likely in relation
with the
clinical history.
3. Mild degenerative changes predominantly of the lumbar spine,
as described
above. No high-grade spinal canal or neural foraminal
narrowing.
4. Large bilateral pleural effusions.
5. Trace fluid in the pelvis is nonspecific, possibly related to
third
spacing.
PREVALENCE: Prevalence of lumbar degenerative disk disease in
subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal,
height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
___, et all. Spine ___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20%
of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):___
MICRO:
___ 5:41 am ABSCESS Source: pancreatic collection .
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ X ___
___ 07:00.
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
DISCHARGE LABS:
___ 04:38AM BLOOD WBC-12.3* RBC-2.89* Hgb-8.0* Hct-26.7*
MCV-92 MCH-27.7 MCHC-30.0* RDW-17.7* RDWSD-60.2* Plt ___
___ 04:38AM BLOOD Glucose-118* UreaN-21* Creat-2.4*# Na-136
K-3.8 Cl-94* HCO3-25 AnGap-17
___ 04:38AM BLOOD ALT-<5 AST-15 AlkPhos-96 TotBili-0.3
Brief Hospital Course:
SUMMARY
===========
___ is a ___ year old woman with SLE on chronic
prednisone and hydroxychloroquine, class IV lupus nephritis on
HD, remote abdominal wall calciphylaxis, chronic hypotension on
midodrine, R BKA (___) for R heel MRSA osteomyelitis, E.
faecium bacteremia w/endocarditis c/b respiratory failure from
metapneumovirus ___, s/p ___bx), RIJ thrombus
(___), CVA x3, who presented with worsening abdominal pain
and fever, likely due to persistent necrotizing pancreatitis
with polymicrobial fluid collections, course complicated by
episode of hypotension and somnolence requiring ICU transfer,
exposed tunneled line, and persistent pancreatic findings.
Following prolonged and complicated hospital course, ultimately,
she clearly voiced definitive decision not to continue with
active medical treatments, including dialysis, antibiotics, and
nutrition feeds through the NJ tube. This decision was made
following extensive discussions with patient, health care proxy,
patient's mother, ___ Care, ICU nursing and ICU
physicians. The health care proxy supported the patients
decision to discontinue medical care, and clearly voiced the
decision to discontinue medical care was most consistent with
the patient's previously expressed values and goals -- also
supported by the mother. After discussion with palliative care
and her health care proxies, she was transitioned to
comfort-focused care, and discharged to hospice care.
TRANSITIONAL ISSUES
======================
[] Mother is healthcare proxy. Friend ___ is alternative
healthcare proxy.
[] Continue Dilaudid 0.5-1mg Q3 for pain/dyspnea
[] Continue Ativan0.5-1mg Q4 for anxiety or dyspnea
ISSUES
================
# Necrotizing pancreatitis
# Peripancreatic fluid collections
# Carbapenem resistant citrobacter/pseudomonas
Patient presented with fevers, tachycardia, leukocytosis.
Peripancreatic fluid collections appear similar to prior. JP
drain in pancreatic biliary system, fluid culture polymicrobial
including carbapenem resistant citrobacter (from ___ and
pseudomonas. ___ consulted, felt that adjacent fluid collections
too small to drain. Patient declining NJ tube to reduce
pancreatic exertion. Despite carbapenem resistance, ID did not
feel patient had clearly failed meropenem. Meropenem continued
at 500 mg Q24H. End date to be determined by ID/OPAT.
Repeat CT abd/pel on ___ showed new anterior gastric
collection/inflammation. Discussed with GI-pancreas and felt to
be unclear etiology. D/w ___ surgery and no role for
surgery. Emailed outpatient rheumatologist ___ at
___ re possibility of serositis; seems unlikely.
Interventional team holding off on EGD +/- EUS for further
evaluation of new collections in anterior stomach wall until
nutritional improvement. Repeat CT obtained on ___ demonstrated
resolution of anterior gastric wall collection, and ongoing
acute on chronic pancreatitis, with fluid collections similar to
prior. JP drain was removed on ___. Repeat CT
abd/pelvis ___ showing improved size of fluid collections. Her
meropenem was discontinued upon decision to transition to
hospice care.
# Goals of care
She briefly required ICU stay for hypotension and tachycardia,
likely from her refusing her midodrine and increased anxiety.
Within a few days in the ICU, she began to express clear wishes
to refuse dialysis. Her NJ tube was clogged and she wanted it
out and not replaced. A meeting at the patient bedside was held
with patient and her mother (health care proxy) and friend
___ (alternate health care proxy), palliative care, ICU
nursing ICU physicians, and all were accepting of patient
decision to transition to hospice care. Pain is being managed
with PO oxycodone, and IV dilaudid and tylenol, anxiety and
dyspnea is being managed with IV lorazepam. Patient preferred to
continue IV pantoprazole to avoid GI discomfort.
# Malnutrition
She received tube feeds through her NJ tube placed ___.
NG tube was clogged. As patient expressed desire to have it
removed and not replaced, this was found to be according to her
goals of care. NJ tube was removed prior to discharge.
# ESRD
# Acute pulmonary edema / pleural effusions / hypoxic
respiratory failure
ESRD secondary to Lupus nephritis. CT with volume overload and
bilateral pleural effusions. She continued to receive dialysis
but upon transition to comfort care, dialysis was discontinued
per the patient's request. Her last session was ___.
# Episode of somnolence, hypotension, hypercarbia
She triggered on the floor ___ for hypotension to 68/54,
and somnolence with depressed respiratory rate (RR 8). VBG
showed 7.25/65/217, lactate normal at 1.3. She was given 500 mL
LR and Narcan 0.04 mg IV x1, with improvement in somnolence and
increase of her BP to ___ (at/above her baseline). Repeat
VBG was 7.29/58/177. The most likely trigger for her somnolence
is opioid overdose (given that she had received oxycodone 10 mg
PO x3 on ___, with improvement in her somnolence and
development of tachycardia, clamminess, and shaking after Narcan
administration), on the backdrop of likely obesity
hypoventilation and potential ?OSA. started oxycodone 5 mg PO
Q6H. Attempted Trilogy/AVAPS while in the ICU but she refused
due to claustrophobia.
# Exposed tunnel catheter
HD tunnel catheter exposed. Risk for infection, but BCx
negative. Had planned for replacement with ___ but after
extensive discussion, she declined the procedure due to the high
likelihood of requiring intubation for the procedure. After
multidisciplinary discussion decided to pursue awake temp line
placement to reduce risk of infection and provide dialysis
access. Ultimately when she went for the temp line placement she
was actually felt to be safe for tunneled line placement, and so
this was performed ___. Unfortunately, this line again became
exposed, and she was taken for replacement on LIJ tunneled line
placed ___.
# RIJ thrombus
On apixaban, but was on prolonged heparin gtt for procedures.
# Hx of CVA
Prolonged holding of home plavix while awaiting tunneled line.
# Severe malnutrition
No longer on tube feeds. Patient declining NJ tube at this time.
# C Diff s/p treatment
Continued vancomycin prophylaxis while on antibiotics (___)
# Chronic hypotension
Continue home midodrine 20mg TID
# Constipation:
Treated with bowel meds
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Acetaminophen 1000 mg PO Q12H
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing,
shortness of breath
5. Miconazole Powder 2% 1 Appl TP PRN Skin irritation
6. Midodrine 20 mg PO TID
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
9. Senna 17.2 mg PO BID:PRN Constipation - First Line
10. Clopidogrel 75 mg PO EVERY OTHER DAY
11. Hydroxychloroquine Sulfate 200 mg PO DAILY
12. Lidocaine 5% Ointment 1 Appl TP Q6H:PRN neuropathy
13. PredniSONE 5 mg PO DAILY
14. Pregabalin 75 mg PO BID
15. Simethicone 80 mg PO QID:PRN gas
16. Vitamin D ___ UNIT PO DAILY
17. Atorvastatin 80 mg PO QPM
18. Famotidine 10 mg PO Q24H
19. Meropenem 500 mg IV Q24H bacteremia, ESRD on HD
20. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all
dressing changes
21. Vancomycin Oral Liquid ___ mg PO/NG BID
22. melatonin 5 mg oral QHS insomnia
23. Nephrocaps 1 CAP PO DAILY
24. Docusate Sodium 100 mg PO BID constipation
25. linaCLOtide 72 mcg oral DAILY constipation
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H:PRN Pain - Mild Duration: 24
Hours
2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain or dyspnea
RX *hydromorphone 1 mg/mL 1 mL inj q3 Disp #*24 Syringe
Refills:*0
3. LORazepam 0.5-1 mg IV Q4H:PRN anxiety or dyspnea
RX *lorazepam 2 mg/mL 1 mL inj q4 Disp #*18 Vial Refills:*0
4. LORazepam 0.5-1 mg PO Q6H:PRN anxiety
5. Pantoprazole 40 mg IV Q24H
6. Acetaminophen 1000 mg PO Q12H
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Docusate Sodium 100 mg PO BID constipation
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing,
shortness of breath
10. Lidocaine 5% Ointment 1 Appl TP Q6H:PRN neuropathy
11. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
12. Pregabalin 75 mg PO BID
13. Senna 17.2 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Necrotizing pancreatitis
Peripancreatic fluid collection
Carbapenem resistant Enterobactericiae
Episode of somnolence and hypotension
Exposed/contaminated tunneled catheter
Troponin elevation
End-stage renal disease
Hypoxic respiratory failure
Right internal jugular DVT
Malnutrition
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
You were admitted to the hospital because of ongoing abdominal
pain and fevers, which were related to the fluid collections
around your pancreas, which initially required placement of a
drain (which we were later able to remove) as well as broad
spectrum antibiotics. You also had an episode of sleepiness and
low blood pressure, which was most likely related to your pain
medications. You also had contamination of your tunneled
dialysis catheter due to a wound over the catheter, and so this
had to be changed.
After a series of discussions with your family and friend
___, it was decided that you would transition from the
hospital to hospice care facility. The focus of your medical
care was transitioned to comfort, and several of your
medications were stopped.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19655310-DS-9
| 19,655,310 | 26,389,531 |
DS
| 9 |
2144-04-09 00:00:00
|
2144-04-09 21:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / misoprostol / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Fistulogram with fistuloplasty ___
Sclerotherapy ___
History of Present Illness:
HPI: Ms. ___ is a ___ y/o F w/ a PMHx of SLE c/b ESRD on HD,
c/b calciphylaxis recently diagnosed, CVA's on coumadin, who was
referred in by her Rheumatologist today for fevers and hypoxia.
She says was diagnosed with calciphylaxis 1.5 months ago, and
has been getting Rx (Sodium Thiosulfate) for it with HD for 3
weeks. She is in excruciating pain, and has been managed with
escalating doses of Oxycontin and Oxycodone, now 30mg BID of
oxycontin and 40mg Q4 of Oxycodone. She has noticed dozens of
lumps under her skin around her abdomen, arms, and legs that
have been present for several months, most prominent in the
lower abdomen, but she has "burning everywhere".
She reports ongoing issues with acid reflux, had a normal EGD
several weeks ago, and a recent upper GI at ___ with
results pending. She has increased her omeprazole to 40 mg TID
with some effect, but the acid reflux continues to wake her from
sleep, induce vomiting, and limit her appetite. She has lost
___ lbs in the last month due to decreased appetite from this.
She has belching and nocturnal GERD symptoms.
For the past two nights she has felt SOB ___ "choking on
mucous". This is associated with non-productive cough during the
day and low grade fevers. Denies weakness, visual changes,
cp/orthopnea/PND. She has had 3 CVA's, but carries no residual,
and has had no new changes.
She has HD on MWF. She makes no urine at baseline. She states
she manages her own diet renal-wise, and does not require any
renal modification to her diet. She has been on HD for ___ years.
She saw her Rheumatologist today, who referred her to the ED as
O2 sat was in the 70-80's.
In the ED, initial vitals were: 98.0, 94, 103/63, 18, 97% RA.
She was febrile to 100.7 during her ED course
Labs notable for: Cr 5.2
Imaging notable for: CXR w/o PNA
Patient was given: 2g Ceftriaxone, 20mg Oxycodone x2, 20mg
Oxycontin, 37.5mg Venlafaxine, 200mg Plaquenil, 40mg
Atorvastatin, 40mg Omeprazole, 60mg Cinacalcet
On the floor, pt confirms above history and has no new
complaint, but continues to feel wheezing, SOB, reflux, and
excruciating pain.
ROS:
(+) Per HPI.
(-) Denies night sweats. Denies sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria.
Past Medical History:
- Systemic lupus c/b nephritis: diagnosed at ___ years old,
treated with IV cytoxan and steroids in the past, Class IV lupus
nephritis. Cr high 2s in ___. Lost follow up due to insurance
reasons for ___ years. SLE also with significant arthralgias
- HTN
- Hyperlipidemia
- Hyperparathyroidism ___ to CKD
- fibromyalgia
- degenerative joint disease in low back
Social History:
___
Family History:
father - MIs in ___, CVA in ___
paternal uncle MI at ___
paternal uncle2 cancer ___
paternal aunt cancer ___
mother - osteoarthritis, CAD in ___
maternal grandmother ___ cancer
maternal grandfather peripheral vascular disease at ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION
============================
Vital Signs: 98.4, 120/82, HR 84, RR 18, 98% RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur
Lungs: Wheezes noted at RLL, faint crackles at LLL, not
tachypneic and no increased WOB
Abdomen: Soft, non-distended, bowel sounds present. Numerous
small, subcutaneous, tender masses appreciated throughout.
GU: deferred
Ext: Warm, well perfused, no edema. RUE AVF with good bruit.
Neuro: CNII-XII intact, ___ strength upper/lower extremities
Skin: Abdomen with erythema and bruising around area of
calciphylaxis nodules on RLQ. +malar rash.
PHYSICAL EXAM ON DISCHARGE
=============================
Vitals: Tm 98.3, Tc 97.9, BP 86-111/50-66, HR 81-91, RR ___,
O2
sat. 99-100% RA
General: no acute distress
HEENT: PERRL, EOMI, oropharynx free of exudate, aphthous ulcers
on inner lower lip
Lungs: CTAB, breathing comfortably on room air
CV: RRR, normal S1, S2, ___ early systolic blowing murmur best
heard at LUSB, ___ early diastolic murmur, no rubs or gallops
Abdomen: soft; normoactive bowel sounds. Painful RLQ and LLQ
ulcers, covered with dressing. Several small subcutaneous
nodules
distal to ulcers on panniculus bilaterally.
Ext: Warm, well-perfused, with no cyanosis, clubbing, or edema.
Scattered ecchymoses, particularly on RUE. Few small, tender
bumps on L calf.
Neuro: alert and oriented, CNII-XII grossly intact
Pertinent Results:
LABS ON ADMISSION:
___ 09:45PM BLOOD WBC-5.3# RBC-4.16 Hgb-12.1# Hct-37.5#
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.2 RDWSD-46.8* Plt ___
___ 09:45PM BLOOD ___ PTT-38.7* ___
___ 12:05AM BLOOD Glucose-80 UreaN-14 Creat-5.2*# Na-138
K-4.3 Cl-84* HCO3-29 AnGap-29*
___ 12:05AM BLOOD ALT-11 AST-23 AlkPhos-85 TotBili-0.2
DirBili-<0.2 IndBili-0.2
___ 12:05AM BLOOD Albumin-3.6 Calcium-8.9 Phos-1.4* Mg-2.0
___ 07:50AM BLOOD calTIBC-150* Ferritn-859* TRF-115*
___ 07:50AM BLOOD PTH-35
___ 07:50AM BLOOD 25VitD-66*
___ 07:50AM BLOOD CRP-60.0*
___ 07:50AM BLOOD dsDNA-NEGATIVE
___ 09:59PM BLOOD Lactate-1.4
Notable Labs:
___ 02:45PM BLOOD ProtCFn-131 ProtSFn-87
___ 08:10AM BLOOD VitB12-854 Folate-14.5
___ 10:05AM BLOOD TSH-4.2
___ 09:41AM BLOOD PTH-56
___ 08:10AM BLOOD 25VitD-68*
___ 07:05AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 07:50AM BLOOD dsDNA-NEGATIVE
___ 07:50AM BLOOD CRP-60.0*
___ 06:45AM BLOOD FreeKap-163.2* FreeLam-110.9* Fr K/L-1.47
IgG-986 IgA-170 IgM-50
___ 06:22AM BLOOD C3-142 C4-46*
___ Serum aluminum level 13
Test Result Reference
Range/Units
ZINC 70 60-130 mcg/dL
Test Result Reference
Range/Units
COPPER 135 70-175 mcg/dL
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 47 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 80 ___ mg/dL
IMMUNOGLOBULIN G, SERUM ___ mg/dL
Test Result Reference
Range/Units
SCL-70 ANTIBODY <1.0 NEG <1.0 NEG AI
Test Result Reference
Range/Units
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
Test Result Reference
Range/Units
VITAMIN K 202 80-1160 pg/mL
IMAGING AND OTHER STUDIES
===========================
EGD BIOPSY ___:
PATHOLOGIC DIAGNOSIS:
Gastroesophageal mucosal biopsies, three:
1. Distal esophagus:
- Squamous mucosa, within normal limits.
2. Gastroesophageal junction:
- Squamous and cardiofundic-type mucosa, within normal limits;
no intestinal metaplasia seen.
3. Gastric antral nodule:
- Foveolar hyperplastic polyp.
TTE ___:
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No definite structural cardiac source of embolism identified.
CT ABDOMEN PELVIS ___:
IMPRESSION:
1. No evidence for active extravasation or pancreatic mass.
2. 3.5 cm hemangioma in segment 2 of the liver is slightly
increased in size
from ___. The rate of interval growth is consistent with
hemangioma
3. Approximately 5.6 cm right lower quadrant ulcer with large
subcutaneous
veins coursing close to the ulcer base. A branch of the right
inferior
epigastric artery is seen extending to the region of the
ulceration. A small,
11 mm skin defect is also seen at the left lower quadrant.
4. 5 mm enhancing exophytic lesion along the inferior pole of
the right kidney
is concerning for a renal cell carcinoma. Followup imaging is
recommended.
5. Retroperitoneal lymph nodes are at the upper size limits of
normal.
However there are in decreased in size from ___. Attention
should be paid to
this region on follow-up imaging in 6 months
6. Apparent soft tissue fullness at the gastroesophageal
junction with
adjacent 11 mm lymph node. In conjunction with moderate fluid
within the
visualized distal esophagus, partially obstructing GE junction
mass cannot be
excluded. Differential diagnosis includes esophagitis.
This preliminary report was reviewed with Dr. ___,
___
radiologist.
RECOMMENDATION(S): 1. Right renal lesion concerning for renal
cell
carcinoma 6 month follow-up MRI is recommended to evaluate for
growth of the
lesion.
2. Consideration of endoscopy for evaluation of GE junction
lesion.
BONE SCAN ___:
IMPRESSION:
No osseous lytic lesions.
MRI Spine ___
FINDINGS:
Vertebral body alignment is preserved. Vertebral body heights
are preserved.
There are numerous T2 hyperintense, T1 hypo intense vertebral
body lesions
throughout the cervical and imaged portions of the upper
thoracic spine.
There is no evidence of a soft tissue component to these lesions
and they do not cause encroachment on the spinal canal.
Although atypical hemangiomas are possible, given the history,
concern such as amyloidosis or multiple brown tumors appear more
likely. Diffuse metastatic disease could produce this
appearance, but appears less likely, again considering the
clinical history.
The visualized portion of the spinal cord is preserved in signal
and caliber.
There is loss of T2 signal in multiple cervical intervertebral
discs. The
intervertebral disc heights are otherwise relatively well
preserved.
Within the limits of this noncontrast study there is no evidence
of infection.
There is no definite epidural collection. There is no
prevertebral soft
tissue swelling.. The visualized portion of the posterior fossa
and
cervicomedullary junction are preserved.
At C2-3 there is no significant spinal canal or neural foraminal
narrowing.
At C3-4 there is minimal disc bulging indenting the ventral
thecal sac without contacting the cord. Facet and uncovertebral
arthropathy produce mild left neural foraminal narrowing. The
right neural foramen is patent..
At C4-5 there is a small midline disc protrusion touching the
anterior surface of the cord. Facet and uncovertebral
arthropathy produce mild
left-greater-than-right neural foraminal narrowing.
At C5-6 there is central disc protrusion flattening the ventral
spinal cord without underlying signal abnormality which in
conjunction with ligamentum flavum thickening effaces the
surrounding CSF. Facet and uncovertebral arthropathy produce
mild bilateral neural foraminal narrowing.
At C6-7 there is no significant spinal canal narrowing. Facet
and
uncovertebral arthropathy produce mild bilateral neural
foraminal narrowing.
At C7-T1 there is no significant spinal canal or neural
foraminal narrowing.
Limited sagittal views of T1-T2, T2-T3 and T3-T4 levels
demonstrate no
significant spinal canal or neural foraminal narrowing.
IMPRESSION:
1. Numerous lesions throughout the visualized vertebral bodies
without
encroachment on the spinal canal. While these may represent
vertebral body atypical hemangioma, alternative diagnoses
including brown tumors or
amyloidosis are alternate possibilities. Metastatic disease
could produce a similar pattern, but appears less likely. If
these are hemangiomas, they may show typical diagnostic findings
on CT of the spine. Multilevel cervical spondylosis, as
described, most notable for disc protrusion at C5-C6 flattening
the spinal cord without underlying signal abnormality, with
effacement of the surrounding CSF without cord impingement. No
high-grade
neural foraminal narrowing.
2. No fracture or evidence of infection.
RECOMMENDATION(S): Consider spine CT for further evaluation of
numerous bone lesions.
___ CT Spine C-
IMPRESSION:
1. Numerous lytic lesions in the cervical spine vertebral bodies
corresponding to abnormality on recent cervical spine MRI do not
demonstrate typical CT appearance of hemangiomas. Differential
considerations include brown tumor, atypical hemangiomas, or
multiple myeloma.
2. Distended esophagus containing ingested material may suggest
esophageal
dysmotility disorder. If clinically indicated, further
evaluation could be a pursued with a barium esophagram.
___ CXR
No evidence of pneumonia.
___ PATHOLOGIC DIAGNOSIS: SKIN, L LOWER ABDOMEN, PUNCH
BIOPSY
Comment. The histologic findings in this biopsy are not
specifically diagnostic. The most strikingfeature is the
presence of multiple intravascular thrombi in the dermis and
subcutis suggesting a
thrombotic vasculopathy. The findings are not specifically
diagnostic of calciphylaxis although they Are compatible with
this diagnosis in the appropriate clinical setting. The sparse
neutrophils may
reflect an adjacent acute vasculitis although a specific
vasculitic process is not identified. Evolving warfarin skin
necrosis cannot be excluded. Clinical correlation is necessary
to differentiate between
these possibilities. These slides were reviewed with Dr.
___ by Dr. ___ on ___ at approximately 1430 hours.
DISCHARGE LABS
===============
___ 06:17AM BLOOD WBC-9.2 RBC-3.27* Hgb-9.1* Hct-29.3*
MCV-90 MCH-27.8 MCHC-31.1* RDW-16.9* RDWSD-54.9* Plt ___
___ 06:17AM BLOOD ___ PTT-66.8* ___
___ 06:17AM BLOOD Glucose-93 UreaN-24* Creat-6.5*# Na-136
K-4.6 Cl-88* HCO3-20* AnGap-33*
Brief Hospital Course:
___ with a h/o ESRD on HD ___ SLE nephropathy, calciphylaxis,
CVAs of unclear etiology, who presented with fever, cough and
now-resolved hypoxia. Her hospital course was complicated by
calciphylaxis eroding into arteries/veins in one of her wounds
(right lower quadrant of abdomen) which required sclerotherapy
and surgicell for stabilization. She also had recurrent
skin/soft tissue infections around the sites of her ulcers which
were treated with antibiotics and will likely need suppressive
antibiotic therapy in the future. She was therapeutically
anticoagulated with subcutaneous heparin ___ units BID and was
discharged on this regimen. She also had escalating pain with
increasing pain control requirements over the course of the
admission, discharged on fentanyl 225mcg/h patch with oxycodone
for breakthrough.
# Calciphylaxis - Originally dx w/ calciphylaxis several weeks
prior to admission, most likely ___ ESRD. Biopsy with thrombotic
vasculopathy consistent with calciphylaxis (although not
diagnostic) on abdomen this admission. She has had partial
response to STS (IV & IL). She was also treated with
pentoxifylline 400mg TID. Her wound was also complicated by
erosion into arteries/veins in the ulcer bed which was treated
with sclerotherapy and surgicell. Bleeding was stabilized with
no significant episodes for 2 weeks (last bleed ___ prior to
discharge. Exhaustive workup for other etiologies for lesions
was unrevealing. Patient was discharged on 225mcg/h fentanyl
patch with oxycodone 40mg q3h prn breakthrough. She will follow
up with dermatology at ___ and ___ clinic.
# Cellulitis - Treated previously w/ Keflex (___), had
recurrent concerns for cellulitis throughout admission w/
malodor, erythema, increased pain from RLQ lesion and purulent
discharge from LLQ biopsy site, RLQ ulcer. Culture of biopsy
site revealed mixed bacterial flora. ___ need to consider
suppressive antibiotic therapy given high risk of infection and
high mortality rate from infection in calciphylaxis. Treated
with vancomycin ___ ceftazidime post HD. Vancomycin
course completed, ceftazidime (___) to complete on ___
# H/o cryptogenic strokes - Pt w/ 3 prior CVAs ___
while on multiple prior agents (ASA/Plavix, Apixaban). On
warfarin after last CVA, which was d/c'ed i/s/o calciphylaxis.
She was therapeutically anticoagulated with ___ units SC
heparin BID for PTT 60-80, decreased to 16000U SC heparin BID at
discharge. Unclear etiology, hypercoag workup was unrevealing.
CT to work up malignancy showed distal esophageal thickening; no
endoscopic correlate, unremarkable biopsy. She should have
outpatient f/u MRI in 6 months (___) for renal lesion
seen on CT.
# Gastroesophageal reflux disease - Patient had ongoing symptoms
of reflux with early satiety. Significant esophageal dysmotility
seen on upper GI series at OSH & gastric dysmotility noted on
endoscopy here ___. Exhausted medical management with PPI BID
and ranitidine, can consider Carafate as an outpatient but make
sure to avoid aluminum containing formulation. She will follow
up with GI as outpatient.
# Nutritional deficiencies - Very poor PO intake, with hx of
sleeve gastrectomy & GI dysmotility. Reported sx of gradual hair
loss, vision changes, aphthous ulcers, & glossitis. Nutrition
recommended a feeding tube which patient considered but decided
to defer at this time. Would continue to encourage nutritional
support with dobhoff tube to help with wound healing.
# Risk of aluminum toxicity - Serum aluminum 13 (REF, Dialysis:
<40 mcg/L). Given her ESRD and increased aluminum intake over
the past several weeks (AlOH for GERD), patient is at risk for
toxicity. Symptoms may include myoclonic jerks, memory issues,
and hypoparathyroidism. Of note, excessively low PTH (<100) is
associated with worse outcomes in calciphylaxis. She should
avoid all sources of aluminum.
# Cervical spine lytic lesions: CT w/ incidental finding of
multiple small lytic lesions of unclear etiology in C-spine
vertebrae. Thought to be potentially brown tumors. No definite
etiology was determined on this admission and she may need
further work up and follow up as outpatient.
# Cervical radiculopathy - MRI w/disc protrusion at C5-C6 on
___. Per spine, she was determined not to be a surgical
candidate during this admission and would not benefit from
brace. Patient got gabapentin for neuropathic pain.
# Constipation - Secondary to opioids, had bowel movements with
aggressive bowel regimen.
# Glossitis - Likely ___ nutritional deficiencies. Poor PO
intake, & history of vitamin B12 deficiency.
# Aphthous ulcers - Intermittent throughout hospitalization.
Seemed pathologic given number and size, treated with brief
course of dexamethasone wash.
# Thrush - Had thrush during hospitalization, resolved with
nystatin, was likely ___ oral dexamethasone for aphthous ulcers.
# ___ vaginitis - Unclear diagnosis as patient refused exam
multiple times, got 4 doses of fluconazole while inpatient.
CHRONIC ISSUES:
# Systemic Lupus Erythematosus - Complicated by nephropathy.
Follows with Dr. ___ at ___. Continued home Plaquenil
200mg BID. Continued home 2mg Prednisone daily
# End stage renal disease on hemodialysis - ESRD secondary to
SLE nephrophathy, on HD MWF via AV Fistula. Held home Iron and
Vitamin D, as these can worsen calciphylaxis. Patient insisted
against renal diet, reports that she regulates on her own at
home. Patient had fistulogram and fistuloplasty while inpatient,
performed by Dr. ___.
# Hyperlipidemia - Continued home atorvastatin.
# Low vitamin B12 - Most recently on ___, B12 was within normal
range at 854. Continued home supplementation.
TRANSITIONAL ISSUES
====================
- Antibiotic course: Vancomycin (___), ceftazidime 2g post
HD (___)
- She should have outpatient f/u MRI in 6 months (___)
for ___ lesion seen on CT
- vitamin A, 1,25-Vitamin D pending at time of discharge
- Patient should take extra care to avoid aluminum containing
products and medicines in the future given risk for aluminum
toxicity
- Pain control with 225mcg/h fentanyl with oxycodone 40mg Q3H
prn breakthrough, may need uptitration in the future, will
follow up with palliative care
- Anticoagulation with 16000U SQ heparin BID, resumed on ASA 81.
Patient should have repeat PTT drawn on ___ hours after
a heparin dose. PTT MUST be drawn the day prior to dialysis.
Patient will follow up with heme-onc for further titration of
anticoagulation
- Patient should be referred to ___ clinic for
further management. Will have appointment with ___ derm on d/c
- Patient scheduled with transplant on discharge, consider
eligibility for re-listing for transplant at that time
- Continue to discuss nutrition with patient. She declined
dobhoff at time of discharge
- Multiple small lytic lesions seen on CT C-spine. Malignancy
work up as above, may need further work up as outpatient
- Warfarin is CONTRAINDICATED in the setting of calciphylaxis.
Patient should continue to avoid aluminum containing
medications.
#Name of health care proxy: ___
Relationship: Mother
Phone number: ___
# CODE: full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferric Citrate 420 mg PO TID W/MEALS
2. Cinacalcet 60 mg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
5. PredniSONE 2 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Warfarin 1 mg PO DAILY16
8. Omeprazole 40 mg PO TID
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. Cyanocobalamin 250 mcg PO DAILY
11. Venlafaxine XR 37.5 mg PO DAILY
12. Sodium Thiosulfate 50 g IV MWF WITH HD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Bisacodyl 10 mg PO DAILY constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. Caphosol 30 mL ORAL QID dry mouth
RX *saliva substitute combo no.2 [Caphosol] 30 mL four times a
day Refills:*0
5. CefTAZidime 2 g IV POST HD (___)
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 g IV POST HD Disp #*3 Intravenous Bag Refills:*0
6. Collagenase Ointment 1 Appl TP DAILY
RX *collagenase clostridium histo. [Santyl] 250 unit/gram Please
apply daily to black eschars. Daily Refills:*0
7. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Fentanyl Patch 225 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour please apply 3 75 mcg/hr transdermal
patches to skin q72H Disp #*10 Patch Refills:*0
9. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
10. ___ ___ UNIT SC BID
RX *heparin (porcine) 10,000 unit/mL ___ UNIT SQ twice a day
Disp #*120 Vial Refills:*0
11. LORazepam 0.25 mg PO TID:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tablets by mouth TID:PRN
Disp #*15 Tablet Refills:*0
12. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
13. Pentoxifylline 400 mg PO TID
RX *pentoxifylline 400 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
prn Disp #*30 Packet Refills:*0
15. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Salagen (pilocarpine HCl) 5 mg oral QID
RX *pilocarpine HCl 5 mg 1 tablet(s) by mouth four times a day
Disp #*160 Tablet Refills:*0
17. Senna 8.6 mg PO BID constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
18. syringe (disposable) (syringe with needle) 3mL 25G ___
syringe SQ BID
19. Syringe 3cc/25Gx1 (syringe with needle) 3 mL 25 gauge x 1
SQ BID
RX *syringe with needle [Monoject Syringe] 25 gauge x ___ draw
up ___ units heparin twice a day Disp #*60 Syringe Refills:*0
20. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
21. Omeprazole 40 mg PO BID
RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp
#*120 Capsule Refills:*0
22. OxyCODONE (Immediate Release) 40 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg 4 tablet(s) by mouth q3h PRN Disp #*120
Tablet Refills:*0
23. Sodium Thiosulfate 25 g IV MWF WITH HD
RX *sodium thiosulfate 12.5 gram/50 mL (250 mg/mL) 25 g IV MWF
w/ HD Disp #*5 Vial Refills:*0
24. Atorvastatin 40 mg PO QPM
25. Cyanocobalamin 250 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 250 mcg 1 lozenge(s) by mouth
daily Disp #*30 Lozenge Refills:*0
26. Hydroxychloroquine Sulfate 200 mg PO BID
27. PredniSONE 2 mg PO DAILY
28. Venlafaxine XR 37.5 mg PO DAILY
29.Outpatient Lab Work
Z79.01
Please check PTT on ___ hrs after heparin SQ dose)
Please fax results to ___. ___.
___: ___
Fax: ___
30.Outpatient Physical Therapy
Outpatient physical therapy for balance and endurance training
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Calciphylaxis
End-stage renal disease on hemodialysis
Cellulitis
Nutritional deficiencies
Potential aluminum toxicity
Cervical radiculopathy
Glossitis
Aphthous ulcers
Thrush
___ vaginitis
SECONDARY DIAGNOSIS
====================
Systemic lupus erythematosus
Hyperlipidemia
Hypovitaminosis B12
Cryptogenic strokes
Gastroesophageal reflux 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 the hospital because of a cough and
difficulty breathing. While you were here you developed
infections of your skin that were treated with antibiotics. You
also had bleeding from one of your ulcers which was treated with
sclerotherapy.
Please take your medicines as directed.
Please follow up with your doctors as directed.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19655386-DS-5
| 19,655,386 | 21,111,050 |
DS
| 5 |
2167-06-29 00:00:00
|
2167-06-29 15:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Thorazine
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___:
1. Open reduction and internal fixation right femoral shaft
fracture with cerclage wires.
2. Revision right total hip replacement, femoral component
only.
___:
Manipulation of the left hip using x-ray
intensification.
History of Present Illness:
Per OMR:
___ with history of R THR in ___ by Dr. ___ with
history of hip dislocation and revision 1 month ago presenting
with right hip and groin pain s/p fall yesterday. Patient was
reaching for his walker yesterday when he fell to the right.
Has
had worsening groin and hip pain today. Unable to bear weight
today. No headstrike. No numbness. No cold foot. No
CP/SOB/cough. No fevers/chills. No n/v/d.
Past Medical History:
LOW BACK PAIN
HIP PAIN
BENIGN PROSTATIC HYPERTROPHY
DEPRESSION
ANXIETY
Social History:
SH: No smoking, alcohol or illicit drugs
Physical Exam:
Upon ED Consultation, per notes:
PE:
GEN: Calm and comfortable
Neuro: A&O x 3.
CV: RRR, nl s1 and S2
CHEST: Clear to auscultation bilaterally.
ABD: Soft, Nontender, Nondistended.
MSK:
BUE
Skin clean and intact
Arms and forearms are soft
No pain with passive motion throughout
R M U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
RLE
Skin clean and intact
Thigh and leg is soft
TTP along medial aspect of right thigh and mild tenderness of
lateral hip
Pain with attempted straight leg raise and knee
flexion/extension, but strength ___ on plantar flexion and
dorsiflexion
DP/SP/S/S/T SITLT
___ fire
2+ ___ pulses with brisk capillary refill
Pertinent Results:
___ 02:20PM GLUCOSE-95 UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 02:20PM estGFR-Using this
___ 02:20PM WBC-7.1 RBC-4.48* HGB-14.3 HCT-41.8 MCV-93
MCH-31.9 MCHC-34.2 RDW-13.2
___ 02:20PM NEUTS-65.1 ___ MONOS-6.3 EOS-0.1
BASOS-0.9
___ 02:20PM PLT COUNT-145*
___ 02:20PM ___ PTT-42.7* ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right hip periprosthetic fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for manipulation under anesthesia,
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 for preparation for
surgery on ___. On ___, the pt returned to the OR for
Revision R hip stem & ORIF femur, 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.
After both procedures, 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 WBAT with strict posterior
precautions 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. Tamsulosin 0.4 mg PO HS
2. OLANZapine 2.5 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Clonazepam 1 mg PO Q6H:PRN Anxiety
5. Gabapentin 200 mg PO TID
6. LaMOTrigine 100 mg PO QAM
7. LaMOTrigine 200 mg PO QPM
8. Mirtazapine 15 mg PO HS
9. Simvastatin 40 mg PO DAILY
10. Aspirin 325 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Clonazepam 1 mg PO BID
3. Clonazepam 2 mg PO QHS
4. Gabapentin 200 mg PO TID
5. LaMOTrigine 100 mg PO QAM
6. LaMOTrigine 200 mg PO QPM
7. Mirtazapine 15 mg PO HS
8. OLANZapine 2.5 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Acetaminophen 650 mg PO Q6H
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 40 mg SC DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Multivitamins 1 CAP PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*60
Tablet Refills:*0
16. Pantoprazole 40 mg PO Q24H
17. Vitamin D 400 UNIT PO DAILY
18. Simvastatin 40 mg PO DAILY
19. Aspirin 325 mg PO DAILY
Discuss continuation with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip 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:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT, STRICT posterior hip precautions
Physical Therapy:
WBAT with strict posterior precautions
Treatments Frequency:
Dry sterile dressing, change daily
Followup Instructions:
___
|
19656110-DS-9
| 19,656,110 | 24,765,876 |
DS
| 9 |
2186-09-03 00:00:00
|
2186-09-06 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of MS, diverticulosis c/b perforation s/p
colostomy, chronic Foley ___ neurogenic bladder, hiatal hernia,
who presents from OSH w/ concern for gastric volvulus,
pneumonia, and UTI.
Yesterday night (___) at 7 pm, per patient and husband, she
developed ___ sharp, nonradiating abdominal pain, nausea, and
nonbilious, nonbloody vomiting. She was noted to be more
confused and reported to have had low grade temperatures, chills
and increased somnolence. She was taken to an OSH by ambulance
and noted to have an elevated WBC and lactate. She was found to
have a positive UA and was given CTX. She also had a NCHCT which
was normal and a CT A/P showing a gastric volvulus. She was then
transferred to ___ for surgical evaluation where review of CXR
was concerning for pneumonia. She was admitted to medicine for
treatment of UTI/PNA and work-up of concern for gastric
volvulus. Currently, she denies abdominal pain or nausea. She
does not recall much of her medical history or currently
presentation but she feels well. Her husband is not sure if her
ostomy output has changed. She denies fevers, chills. She has a
chronic cough for the last several years, no acute worsening,
nonproductive, no sputum, no hemoptysis, no pleuritic chest
chain, no dyspnea, no chest pain.
ROS per HPI.
In the ED, initial vital signs were: T 98.1 P 75 BP 122/51 R 20
O2sat: 100% RA
- Exam notable for:
Slightly confused
grossly normal neuro exam w/ exception of ___ foot drop.
Foley in place
Ostomy well appearing. Abd soft NTND
- Labs were notable for...
WBC: 28.2 Hgb:12.4 Plt:302 N:84.7 L:7.2 M:6.6 E:0.2 Bas:0.2
134|96|20
----------<186
5.3|25|1.0
___: 11.2 PTT: 23.5 INR: 1.0
05:18 Lactate:4.3
06:43 Lactate:3.3
U/A: large leuks, positive nitrites, 101 WBC, trace blood, 30
protein, 19 RBC, few bacteria
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
___ BLOOD CULTURE pending
___ BLOOD CULTURE pending
___ URINE CULTURE pending
- Studies performed include...
___ Ref Cr Chest
___bdomen
___ Ref Ct Head
___ Chest Pa + Lateral (Cxr)
___ Ct Head Without Iv Contrast
___ Ct Abdomen Pelvis W Contrast
- Patient was given...
___ 05:19 IVF NS
___ 05:23 IV Piperacillin-Tazobactam
___ 07:25 IVF NS (1000 mL)
- Vitals on transfer: 98.0 75 114/55 16 94% RA
Past Medical History:
multiple sclerosis, seizure disorder, diverticulitis c/b bowel
perforation and colostomy, GERD, esophagitis, neurogenic bladder
w/ chronic foley, constipation, hearing loss, cataracts, HTN,
psoriasis
PSH: colostomy
Social History:
___
Family History:
older sister with severe COPD
Mother with COPD
Father with heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 135/71 82 18 96 Ra
GENERAL: AOx3, NAD
HEENT: NCAT. MMM. No scleral icterus.
NECK: Supple, No LAD.
CARDIAC: Normal rate, regular rhythm. No murmurs.
LUNGS: Bowel sounds in left lower lung field. Clear to
auscultation upper left lung field, right lower and upper lung
fields.
ABDOMEN: Lower abdominal midline incision well healed.
Normoactive bowel sounds, soft, obese, non-tender to deep
palpation in all four quadrants. Well appearing ostomy with no
blood.
EXTREMITIES: 1+ pitting edema to knees bilaterally. No clubbing,
cyanosis. Pulses DP/Radial 2+ bilaterally.
GU: Foley in place.
NEUROLOGIC: Upper extremity strength normal. Groosly normal
sensation.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2-99.5 ___ 18 94-96RA
GENERAL: AOx3, NAD
HEENT: NCAT. MMM. No scleral icterus.
NECK: Supple, No LAD.
CARDIAC: Normal rate, regular rhythm. No murmurs.
LUNGS: Bowel sounds in left lower lung field. Clear to
auscultation upper left lung field, right lower and upper lung
fields.
ABDOMEN: Lower abdominal midline incision well healed.
Normoactive bowel sounds, soft, obese, mildly tender to deep
palpation (___) in RUQ. No rebound, no guarding. Well appearing
ostomy with no blood.
EXTREMITIES: 1+ pitting edema to knees bilaterally. No clubbing,
cyanosis. Pulses DP/Radial 2+ bilaterally.
GU: Foley in place.
NEUROLOGIC: Upper extremity strength normal. Groosly normal
sensation.
Pertinent Results:
ADMISSION LABS:
---------------
___ 05:08AM BLOOD Neuts-84.7* Lymphs-7.2* Monos-6.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-23.85* AbsLymp-2.04
AbsMono-1.85* AbsEos-0.05 AbsBaso-0.05
___ 05:08AM BLOOD WBC-28.2*# RBC-4.34 Hgb-12.4 Hct-37.1
MCV-86 MCH-28.6 MCHC-33.4 RDW-13.6 RDWSD-42.5 Plt ___
___ 05:08AM BLOOD ___ PTT-23.5* ___
___ 05:08AM BLOOD Glucose-186* UreaN-20 Creat-1.0 Na-134
K-5.3* Cl-96 HCO3-25 AnGap-18
___ 05:08AM BLOOD ALT-31 AST-40 AlkPhos-94 TotBili-0.3
___ 05:08AM BLOOD Lipase-23
___ 05:08AM BLOOD Albumin-3.5
___ 05:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:18AM BLOOD Lactate-4.3*
___ 06:43AM BLOOD Lactate-3.3*
___ 05:10AM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:10AM URINE Blood-TR Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 05:10AM URINE RBC-19* WBC-101* Bacteri-FEW Yeast-NONE
Epi-2
MICROBIOLOGY:
-------------
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ URINE CULTURE-PENDING
IMAGING:
--------
___ UGI SGL W/O KUB
FINDINGS:
ESOPHAGUS:
The esophagus was not dilated. There was no esophageal web,
ring, or
stricture.
The primary peristaltic wave was normal, with contrast passing
readily into the stomach. The lower esophageal sphincter opened
and closed normally.
There was mild spontaneous gastroesophageal reflux.
STOMACH:
There is an intrathoracic stomach oriented such that the greater
curvature is seen superiorly. No evidence of obstruction, and
barium passes freely into the duodenum.
IMPRESSION:
Intrathoracic stomach without evidence of obstruction. Mild
spontaneous
gastroesophageal reflux.
DISCHARGE & PERTINENT LABS:
___ 07:35AM BLOOD WBC-13.5*# RBC-3.70* Hgb-10.6* Hct-32.1*
MCV-87 MCH-28.6 MCHC-33.0 RDW-14.0 RDWSD-43.8 Plt ___
___ 07:35AM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-139
K-3.0* Cl-106 HCO3-20* AnGap-16
___ 07:35AM BLOOD Albumin-2.5* Calcium-7.8* Phos-2.7
Mg-1.5*
___ 09:18AM BLOOD ___ pO2-209* pCO2-35 pH-7.40
calTCO2-22 Base XS--1 Comment-GREEN TOP
___ 09:18AM BLOOD Lactate-2.1*
Brief Hospital Course:
___ with history of MS, diverticulosis c/b perforation s/p
colostomy, chronic Foley ___ neurogenic bladder, hiatal hernia,
who presented from OSH on ___ w/ concern for gastric volvulus.
#Abdominal pain/nausea/vomiting
Patient presented on ___ from an outside hospital with concern
for gastric volvulus in the setting of her large hiatal hernia
seen on CT Abd/Pelvis ___ and observed as left lower lobe
opacity on chest XR. On arrival, the patient was asymptomatic,
ostomy output unchanged, afebrile, WBC to 28.2, and lactate
4.3-->3.3. UGI series with intrathoracic stomach w/o evidence of
obstruction and otherwise significant only for mild GERD. Likely
that she had a partial bowel obstruction secondary to gastric
volvulus and hiatal hernia. She was initially given a dose of
broad spectrum antibiotics, IV fluids and was seen by the
surgical service who did not recommend surgical intervention at
that time given higher risk in the setting of lack of symptoms
and over all improvement. She had nothing to eat or drink by
mouth for 24 hours and was started on a liquid/soft diet prior
to discharge, which she tolerated well. She was discharged home
with PCP follow up and diet modification.
#UTI
Patient with chronic indwelling foley ___ neurogenic bladder
with U/A significant for lg neuks, pos nitrites, 101 WBC, and
leukocytosis on admission. She was treated with ceftriaxone 1g
daily while inpatient and discharged on cefpodoxime 100mg BID to
complete a 14 day course.
--------------
CHRONIC ISSUES
--------------
#diverticulitis c/b bowel perforation and colostomy: she was
continued on her home Mirtazapine 7.5 mg PO QHS and Dronabinol
2.5 mg PO BID.
#multiple sclerosis
#insomnia
#depression
-continued home Sertraline 100 mg PO QAM and TraZODone 50 mg PO
QHS
#seizure disorder secondary to MS: continued home LevETIRAcetam
500 mg PO BID
#GERD, esophagitis: Pantoprazole increased to 40 mg BID.
Recommended follow up with outpatient GI doctor.
#neurogenic bladder: chronic foley last changed on ___,
continued home Enablex (darifenacin) 15 mg oral QHS
#constipation: continued home Lubiprostone 24 mcg PO BID and
added daily miralax.
#HTN: continued home amLODIPine 5 mg PO DAILY and Atenolol 25 mg
PO BID
#health maintenance: continued home Vitamin D3, Calcium 600 and
STOPPED Furosemide 40 mg PO 2X/WEEK (MO,TH).
-------------------
TRANSITIONAL ISSUES
-------------------
[] the patient was discharged on oral cefpodoxime 100mg BID to
complete a 14 day course. Last dose on ___.
[] recommend follow up with PCP for ongoing symptom management
and GI for GERD in setting of large hiatal hernia
[] please repeat CBC and chem 10 to ensure resolution of mild
anemia and mild metabolic acidosis at next PCP follow up
appointment.
[] chronic indwelling foley, last changed ___
[] recommended soft/ground diet with good oral hydration to
prevent recurrent obstruction. Instructed to go to nearest ER if
symptoms recur.
[] discharged with miralax daily to prevent constipation
[] stopped furosemide twice weekly in setting of decreased oral
intake and mild dehydration on admission. Resume if appropriate
after full recovery.
[] surgery recommends only operating on hiatal hernia in setting
of emergency given high operative morbidity/mortality.
# CODE: full, confirmed
# CONTACT: Husband ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lubiprostone 24 mcg PO BID
2. Pantoprazole 40 mg PO QAM
3. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
4. amLODIPine 5 mg PO DAILY
5. Furosemide 40 mg PO 2X/WEEK (MO,TH)
6. LevETIRAcetam 500 mg PO BID
7. Mirtazapine 7.5 mg PO QHS
8. Sertraline 100 mg PO QAM
9. TraZODone 50 mg PO QHS
10. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
11. Enablex (darifenacin) 15 mg oral QHS
12. Atenolol 25 mg PO BID
13. Dronabinol 2.5 mg PO BID
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*25 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Atenolol 25 mg PO BID
5. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
6. Dronabinol 2.5 mg PO BID
7. Enablex (darifenacin) 15 mg oral QHS
8. LevETIRAcetam 500 mg PO BID
9. Lubiprostone 24 mcg PO BID
10. Mirtazapine 7.5 mg PO QHS
11. Pantoprazole 40 mg PO QAM
12. Sertraline 100 mg PO QAM
13. TraZODone 50 mg PO QHS
14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
15. HELD- Furosemide 40 mg PO 2X/WEEK (MO,TH) This medication
was held. Do not restart Furosemide until your doctor tells you
to resume it
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
-----------------
Hiatal hernia
Urinary tract infection
SECONDARY DIAGNOSIS
-------------------
Gastroesophageal reflux disease
Esophagitis
Atelectasis
Neurogenic bladder with chronic foley
Hearing loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you!
Why you were admitted:
-you had nausea, vomiting, abdominal pain on ___
What we did for you:
-we examined your stomach using several studies including a cat
scan and special x-rays
-we found no evidence of obstruction in your stomach and no
evidence of infection
-surgery saw you while you were here and did not want to do
surgery at this time since the risks outweighed the benefits and
your symptoms resolved after not eating for 24 hours.
What you should do after discharge:
-please follow-up with your primary care physician
-___ try to eat soft foods, have small frequent meals,
continue taking your Boost supplement at home, and drink water
regularly.
-please INCREASE your pantoprazole (protonix) to twice a day
instead of once a day
-please START Miralax once a day at home. Decrease to every
other day or every ___ day if stool is watery.
-please STOP your lasix (furosemide) pill.
-please START your course of antibiotics, cefpodoxime 100mg
twice daily, for a urinary tract infection. We will follow up
with the urine culture and contact you if you need to change
your antibiotic. Please take this medication twice a day. Your
last dose will be on ___.
-please go to the nearest emergency room if you develop
recurrent abdominal pain, nausea, vomiting and/or fever
Best,
Your ___ Care Team
Followup Instructions:
___
|
19656146-DS-4
| 19,656,146 | 21,209,242 |
DS
| 4 |
2157-11-04 00:00:00
|
2157-11-10 13:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cymbalta / cefuroxime / Flexeril / Penicillins / Vicodin
Attending: ___.
Chief Complaint:
Ascites
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
___ is a ___ with a history of type 2 diabetes,
hypertension, hyperlipidemia, and presumed NASH cirrhosis
decompensated by ascites who presents with worsening of his
ascites. He reports that since stopping spironolactone one month
ago (for hyperkalemia), he has had progressive worsening of his
ascites so that today he had to "roll out of bed," prompting him
to call his primary care clinic which referred him to the ED. He
also has had some L subscapular pain worse with deep breathing.
He has no chest pain, shortness of breath, or DOE.
He recently established care with hepatology (Dr. ___ in
___ but did not make his scheduled appointments for
endoscopy,
abdominal US with Doppler, or diagnostic and therapeutic
paracentesis.
Past Medical History:
- Cirrhosis, presumed NASH
- Noninsulin dependent diabetes
- HLD
- HTN
- Chronic back pain
- Asthma
- Anemia
Social History:
___
Family History:
Mother is alive ___ with palpitations. His
father died with kidney failure in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VS: 98.2 151/71 67 18 95 RA
GENERAL: well-appearing, NAD
HEENT: sclerae anicteric, conjunctivae noninjected, MMM
CARDIAC: RRR, no m/r/g
PULMONARY: CTAB, no w/r/r
ABDOMEN: distended, soft, nontender in all quadrants
EXTREMITIES: 1+ pitting edema in ___ bilaterally, L > R (chronic
per patient for years)
NEUROLOGIC: alert and oriented x3, no asterixis
DISCHARGE PHYSICAL EXAM:
======================
VS: T98.7 BP 117 / 61 HR 66 RR 16 O2 95 Ra
GENERAL: Sitting on side of bed, fully dressed in street clothes
HEENT: NCAT, MMM
HEART: RRR, no MRG,
LUNGS: CTAB, shallow breaths
ABDOMEN: Soft, large distended abdomen with fluid wave,
non-tender, no organomegaly
EXTREMITIES: Warm and well-perfused, 1+ peripheral edema
NEURO: AAOx3, CN II-XII grossly intact.
Pertinent Results:
ADMISSION LABS
================
___ 01:43PM BLOOD WBC-4.8 RBC-3.87* Hgb-13.3* Hct-41.5
MCV-107* MCH-34.4* MCHC-32.0 RDW-15.0 RDWSD-58.7* Plt Ct-51*#
___ 01:43PM BLOOD Neuts-81.0* Lymphs-8.8* Monos-6.9 Eos-2.5
Baso-0.6 Im ___ AbsNeut-3.87 AbsLymp-0.42* AbsMono-0.33
AbsEos-0.12 AbsBaso-0.03
___ 01:43PM BLOOD ___ PTT-33.0 ___
___ 12:45PM BLOOD Glucose-156* UreaN-14 Creat-0.7 Na-140
K-5.3* Cl-102 HCO3-28 AnGap-10
___ 01:43PM BLOOD ALT-18 AST-25 LD(LDH)-215 AlkPhos-90
TotBili-1.0
___ 01:43PM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.4 Mg-1.9
___ 12:45PM BLOOD D-Dimer-7585*
DISCHARGE LABS
================
___ 05:46AM BLOOD WBC-4.5 RBC-3.73* Hgb-12.8* Hct-39.4*
MCV-106* MCH-34.3* MCHC-32.5 RDW-14.7 RDWSD-57.2* Plt Ct-46*
___ 05:46AM BLOOD ___ PTT-33.4 ___
___ 05:46AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-144
K-4.9 Cl-102 HCO3-30 AnGap-12
___ 05:46AM BLOOD ALT-17 AST-30 AlkPhos-72 TotBili-1.4
___ 05:46AM BLOOD Albumin-3.5 Calcium-8.9 Phos-4.3 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of type 2
diabetes, hypertension, hyperlipidemia, and presumed NASH
cirrhosis decompensated by ascites who presented with worsening
of his ascites.
# Acute on chronic ascites:
Patient reported worsening ascites in the month after
spironolactone was stopped for hyperkalemia. He has had chronic
ascites and missed appointments for outpatient paracentesis.
Diagnostic paracentesis in ED here was negative for SBP. His
abdominal ultrasound revealed patent veins, moderate ascites,
large spleen, and coarse/irregular liver with recommended 3
month repeat ultrasound as an outpatient. Therapeutic
paracentesis was done and yielded 3L of fluid, and albumin was
given post-procedurally. His furosemide dose was increased to
120mg daily from 60mg daily, with plan for follow up labs in 1
week.
# Left moderate pleural effusion:
# Left scapular pain:
Moderate pleural effusion seen on CT associated with atelectasis
which is likely worsened by ascites and poor lung expansion.
Pain improved post-paracentesis.
# Cirrhosis:
Presumed secondary to NASH, decompensated by ascites with
unknown variceal status. MELD this admission 11. No history of
alcohol abuse and hepatitis serologies negative. Iron studies
not suggestive of hemochromatosis. Abdominal ultrasound
discussed above. Requires HAV vaccination. Will need outpatient
endoscopy screening for varices.
# Thrombocytopenia:
Plt as low as 46. Known splenomegaly, likely secondary to
cirrhosis. Per Atrius records, have ranged from ___. No
evidence of bleeding. Continue to monitor.
# Macrocytic anemia:
Chronic, Hgb above baseline. In ___, B12 and folate checked
and both were normal. Denies alcohol use. Had BMBx ___ without
abnormality. Known splenomegaly.
CHRONIC ISSUES
# Type 2 diabetes mellitus: metformin was held and ISS was used
in house.
# HLD: continued pravastatin
# HTN: continued atenolol
# Asthma: continued inhalers
# Depression: continued citalopram
# Chronic back pain: continued home oxycodone prn
====================
TRANSITIONAL ISSUES
====================
[ ] Furosemide increased from 60mg daily to 120mg daily. Plan
for 1 week follow up labs and titration of diuretics as
outpatient.
[ ] Requires HAV vaccination.
[ ] Will need outpatient endoscopy screening for varices.
[ ] Abnormal liver texture seen on ultrasound: recommended 3
month repeat ultrasound as an outpatient.
Discharge weight (done before paracentesis): 129.37kg (285.21
lb)
Discharge Hgb: 12.8
Discharge Cr: 8
# CODE: Presumed FULL
# CONTACT: did not wish to provide
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Furosemide 60 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
6. Pravastatin 40 mg PO QPM
7. Cetirizine 10 mg PO DAILY:PRN allergies
8. Vitamin D 4000 UNIT PO DAILY
9. coenzyme Q10 10 mg oral DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Diphenoxylate-Atropine ___ TAB PO Q6H:PRN diarrhea
12. Citalopram 20 mg PO DAILY
13. aMILoride 40 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN skin
rash
17. Lubricant Eye (PG-PEG 400) (peg 400-propylene glycol)
0.5-0.9% ophthalmic (eye) DAILY:PRN
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
Discharge Medications:
1. Furosemide 120 mg PO DAILY
RX *furosemide [Lasix] 40 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
3. aMILoride 40 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Cetirizine 10 mg PO DAILY:PRN allergies
6. Citalopram 20 mg PO DAILY
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN skin
rash
8. coenzyme Q10 10 mg oral DAILY
9. Diphenoxylate-Atropine ___ TAB PO Q6H:PRN diarrhea
10. Ferrous Sulfate 325 mg PO BID
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Lubricant Eye (PG-PEG 400) (peg 400-propylene glycol)
0.5-0.9% ophthalmic (eye) DAILY:PRN
14. MetFORMIN (Glucophage) 500 mg PO BID
15. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
16. Pravastatin 40 mg PO QPM
17. Tiotropium Bromide 1 CAP IH DAILY
18. Vitamin D 4000 UNIT PO DAILY
19.Outpatient Lab Work
___ NASH cirrhosis. Diuretic monitoring. Please obtain
chem-10 on ___ and fax results to ___. MD
at ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Ascites
Secondary: NASH Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
___ were admitted to ___.
Why ___ were here
--------------------
- ___ had swelling of the abdomen (ascites) and legs.
What was done for ___ while ___ were here
- ___ had a test of the fluid in your belly (ascites) which
showed ___ did not have any infection. This is good news!
- Your kidney function looked good.
- Your abdominal ultrasound showed no blood clots, but abnormal
texture of the liver. ___ will need another ultrasound in 3
months to monitor this.
- ___ had the fluid removed (paracentesis). We took out 3 L of
fluid.
What to do ___ when ___ go home
- ___ should see your doctors. ___ need follow up with a GI
doctor who can see regularly.
- ___ will need another liver ultrasound in 3 months.
- Your medications and appointments are below. We changed your
furosemide (Lasix) dose.
- ___ NEED LABS DONE NEXT WEEK! IT IS VERY IMPORTANT THAT ___
HAVE THESE DONE!
It was a pleasure taking care of ___ and we wish ___ good
health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19656279-DS-9
| 19,656,279 | 20,101,669 |
DS
| 9 |
2126-04-07 00:00:00
|
2126-04-10 06:30:00
|
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, Shortness of Breath, Sepsis
Major Surgical or Invasive Procedure:
Left PICC line placement
History of Present Illness:
___ year old woman with a history of quadriplegia status post
neck surgery ___ yr ago, trach collar dependent, who presents with
one day of fever to 103.8, increased SOB and increased
secretions. Patient's daughter states that the patient vomited
once earlier, but it may have been respiratory secretions. She
denies known sick contacts. No associated diarrhea, abd pain or
rash. Of note, patient has had recurrent UTIs and a MRSA
pneumonia ___ past. Also, is on coumadin for history of left
upper extremity DVT.
.
___ the ED, initial VS were: T 101.8 HR 119 BP 104/38 RR 22 O2
sat 100% 15L. Patient's temperature peaked at 103.8 ___ the ED.
She was placed on nonrebreather to trach for dyspnea and
secretions, and saturated 100%. On exam, patient was noted to
have rhonchi bilat. No abdominal tenderness, normal skin exam.
Patient has chronic Foley and urine was sent for UA, urine cx.
Labs were notable for WBC 25.3, Na 128, lactate 2, Hct 28 (close
to baseline). UA was positive for infection. CXR with no clear
consolidation. Pt was started on Cefepime, Vanc, Levofloxacin
for UTI and possible pneumonia. She was given about 900cc NS.
She was transferred to the MICU for respiratory status. On
transfer, VS were: Temperature 101.2 °F (38.4 °C). Pulse 117.
Respiratory Rate 21. Blood Pressure 171/70. O2 Saturation 97. O2
Flow humidified 02. Pain Level 0.
.
On arrival to the MICU, the patient was tachypneic, slightly
diaphoretic, but not ___ any distress. She was on humidified O2
via trach collar, complaining of bilateral arm pain c/w
contracture pain.
Past Medical History:
___
Chronic respiratory failure with trach
s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF
leak
Stage II pressure ulcers
MRSA/Hflu Ventilator-associated Pneumonia
Left upper extremity Deep vein thrombosis (DVT)
Neurogenic bowel
Neurogenic bladder
h/o Hypertension (HTN)
h/o Myocardia Infarction ___ ___ s/p BMS to ___
Diabetes Mellitus (diet controlled)
hypercholesterolemia
s/p TAH-BSO 1990s
hypotension, on florinef/MICU and glycopyrrelate
history of pan-sensitive respiratory pseudomonas
Social History:
___
Family History:
Hypertension
Physical Exam:
ADMISSION EXAM:
Vitals: T: 100.2 BP: 149/47 P: 104 R: 20 O2: 93% trach collar
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, increased oral secretions, EOMI, ptosis
L>R, baseline
Neck: supple, JVP not elevated, no LAD, there is a trach-collar
___ place
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, 2+ pulses throughout
Lungs: Diminished excursion, diffuse wheezes without focal
rhonchi or rales, no accessory muscle use. the patient is
tachypneic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, there is a feeding tube present
GU: foley present
Ext: Arms warm/well-perfused, legs cool, 2+ pulses ___ all
extremities, no clubbing, cyanosis or edema; there is a 22GA
peripheral IV ___ the right wrist
Neuro: Answers questions appropriately and clearly, insensate
lower extremities, normal sensation BUE, contractures present
BUE
.
DISCHARGE EXAM:
Vitals: 98.1 122/50 65 20 100% TM
General: Alert, oriented, answers appropriately, comfortable
HEENT: Sclera anicteric, EOMI
Neck: supple, JVP not elevated, no LAD, trach-collar ___ place;
left PICC line ___ place - non-erythematous, no drainage,
non-tender to palpation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, 2+ pulses
throughout
Lungs: Diminished excursion, no accessory muscle use, lungs
clear to auscultation, no crackles or rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, feeding tube ___ place, no pus draining
GU: suprapubic foley ___ place, no surrounding erythema
Ext: Warm/well-perfused, 2+ pulses ___ all extremities, 1+ edema
to ankle; no clubbing, cyanosis or edema
Neuro: Answers questions appropriately and clearly, normal
sensation BUE, decreseased but sensation present ___ BLE, cannot
move ___
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-25.3*# RBC-3.40* Hgb-8.7* Hct-28.5*
MCV-84 MCH-25.5* MCHC-30.4* RDW-13.6 Plt ___
___ 03:00PM BLOOD Neuts-90.5* Lymphs-4.7* Monos-4.0 Eos-0.5
Baso-0.3
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD Glucose-140* UreaN-16 Creat-0.4 Na-128*
K-4.5 Cl-93* HCO3-22 AnGap-18
___ 03:05PM BLOOD Lactate-2.0
.
DISCHARGE LABS ___ 07:40AM:
WBC-8.5 RBC-3.16* Hgb-8.0* Hct-26.6* MCV-84 MCH-25.2* MCHC-29.9*
RDW-15.2 Plt ___ PTT-60.6* ___
Glucose-134* UreaN-13 Creat-0.3* Na-141 K-4.2 Cl-108 HCO3-25
AnGap-12
Calcium-8.9 Phos-2.8 Mg-2.1
Vanco-24.5*
.
MICROBIOLOGY:
Urine culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.
.
Sputum culture ___:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Due to mixed bacterial types ( >= 3 colony types) an abbreviated
workup will be performed appropriate to the isolates recovered
from this site. UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS SPP. Unable to definitively determine the
presence or absence of commensal respiratory flora.
.
Blood culture ___: Negative
Urine culture ___: Negative
.
Blood culture ___ x 2: Negative
Urine culture ___: Negative
.
CATHETER TIP-IV: (Final ___: No significant growth.
.
IMAGING:
___ CXR:
SINGLE PORTABLE VIEW OF THE CHEST: Opacification of left
hemidiaphragm, downward displacement of the major fissure is
compatible with patient's known chronic left lower lobe
collapse. No new focal consolidation is seen to suggest
pneumonia. There is no pleural effusion or pneumothorax.
Anterior cervical fusion hardware, a percutaneous gastrostomy
tube and tracheostomy collar are noted. Cardiac and mediastinal
contours are unchanged.
IMPRESSION: No acute cardiopulmonary process.
.
Left ___ ultrasound ___:
IMPRESSION: No evidence of deep vein thrombosis ___ the left
arm.
.
CXR ___:
FINDINGS: There is a right-sided central venous catheter with
the distal lead tip ___ the distal SVC appropriately sited.
There are no pneumothoraces. Lungs are grossly clear. There is
some atelectasis at the left lung base. The heart size is within
normal limits.
.
CXR ___: PICC placement.
1. Placement of a double-lumen Power PICC line into the distal
superior vena cava via the left cephalic vein.
2. The line is ready to use.
Brief Hospital Course:
___ year old woman with a history of quadriplegia status post
neck surgery ___ year ago, trach collar dependent, admitted with
fever to 103.8F and increased secretions.
.
# Sepsis due to HCAP: Patient admitted to the MICU with fevers
to 103.8 and increased secretions. She was started on cefepime,
vancomycin, and Levaquin to cover for HCAP and possible UTI.
Fever resolved and the patient was transferred to the floor.
She underwent sputum cultures ___ that grew gram positive
cocci, but serial chest X-rays negative for pneumonia. Urine
culture also positive for > 3 types of bacteria ___ the setting
of chronic suprapubic catheter. Once fevers resolved and WBC
count normalized on ___, the patient was transitioned to PO
ciprofloxacin and linezolid. However, she spiked a fever to 101
and became hypotensive on ___. Subclavian line was placed and
she was resumed on vanc/cefepime (Day 1 - ___ for urinary
and respiratory sources of infection. Given decompensation with
transition from cefepime to ciprofloxacin, the patient was
thought to have a possible gram negative infection as the
culprit for her decompensation. Vancomycin was discontinued for
36 hours, and the patient again spiked a fever. The patient was
resumed on vancomycin on ___. A picc line was placed and the
subclavian was removed. The patient will complete a 14 day
course of vancomycin and cefepime as an outpatient. Cefepime
course will complete ___. Vancomycin course will complete
___.
.
# Left upper extremity DVT/history of pulmonary embolism:
Patient had DVT/PE ___ ___ off coumadin. Requires life-long
anticoagulation ___ immobility from quadriplegia. INR 2.0 on
admission. Warfarin continued. A left-upper extremity ultrasound
was negative for ongoing clot, so her left extremity can be used
for IV lines/draws. Warfarin was briefly held during admission
for central line placement. Despite promptly resuming this
medication, her INR trended down to 1.2. She was started on a
lovenox bridge. The patient should undergo daily INR checks,
and stop lovenox bridge once therapeutic on coumadin (INR >
2.0).
.
# history of CAD s/p NSTEMI with stent: Patient without chest
pain throughout admission. She was continued on home ASA,
statin, lisinopril. On ___, the patient underwent EKG that
showed inverted T waves ___ the lateral precordial leads. The
patient was asymptomatic at that time. Cardiac enzymes x 2
negative. Repeat EKG at a slower heart rate (65 rather than 95)
showed normalization of her EKG to baseline. The patient likely
has rate-related change secondary to history of CAD. She will
follow up with Dr. ___, as an outpatient.
.
# HTN: Chronic. Lisinopril briefly held on admission, then
resumed with stabilization on the floor. She remained
normotensive for much of admission.
.
# Quadriplegia with spasticity: Tizanidine initially held, but
then restarted after levofloxacin was stopped. The patient was
continued on home tramadol, morphine, baclofen, gabapentin.
=======================
TRANSITIONAL ISSUES:
-code status: Full Code
-Patient to complete 14-day courses of vancomycin and cefepime.
Cefepime course will complete ___. Vancomycin course will
complete ___.
-Please check vancomycin trough ___. Adjust dose
accordingly.
-Patient on lovenox bridge, as INR 1.6 at the time of discharge.
Monitor daily INRs. Stop lovenox when INR > 2.0 on coumadin.
Medications on Admission:
-baclofen 20mg @ 0600 and 1200, 30mg @ ___
-gabapentin 800mg @ 0800, 400mg @ 1200, 800mg @ ___
-hydroxyzine 50mg (25cc of 10mg/5cc) q4h prn anxiety
-ipratropium-albuterol [DuoNeb] q4h prn dyspnea/wheezing
-lisinopril 5 mg daily
-morphine 10 mg/5 mL Solution ___ G(s) PO q6h PRN pain
-nitroglycerin 0.4 mg SL q5-10 minutes x 3 PRN chest pain
-omeprazole magnesium [Prilosec] 20mg/5mL oral suspension daily
-simvastatin 20 mg once a day
-tizanidine ___ mg tid PRN muscle spasm
-tramadol 50-100 q4-6h PRN pain
-warfarin 2mg MF, 4mg all other days PO@1600
-acetaminophen 650mg qid PRN pain
-aspirin 81 mg once a day
-[Calcium 600 + D(3)] 600 mg-400 unit twice a day
-docusate sodium 60 mg/15 mL Syrup 25 ml G tube twice a day
-docusate sodium [Enemeez] 283 mg Enema daily PRN constipation
-inulin [Metamucil Clear-Natural (inul)] 5 gram/5.8 gram Powder
1 tsp by mouth up to three times daily
-nutritional supplement 6 cans(s) per G-Tube--once a day
Discharge Medications:
1. baclofen 10 mg Tablet Sig: Two (2) Tablet PO q6am, q12pm.
2. baclofen 10 mg Tablet Sig: Three (3) Tablet PO q8pm.
3. gabapentin 250 mg/5 mL Solution Sig: Eight Hundred (800) mg
PO q 8am and 8pm.
4. gabapentin 250 mg/5 mL Solution Sig: Four Hundred (400) mg PO
NOON (At Noon).
5. hydroxyzine HCl 10 mg/5 mL Syrup Sig: Fifty (50) mg PO every
four (4) hours as needed for anxiety.
6. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed for dyspnea/wheezing:
please give as duoneb with albuterol .
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for dyspnea/wheezing: please give as duoneb
with ipratropium .
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. morphine 10 mg/5 mL Solution Sig: ___ mg PO Q6H (every 6
hours) as needed for pain.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) SL
Sublingual q5 minutes x 3 as needed for chest pain: call your
doctor if you take this medication.
11. omeprazole magnesium 10 mg Susp,Delayed Release for Recon
Sig: Twenty (20) mg PO once a day.
12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. tizanidine 2 mg Tablet Sig: ___ mg PO TID (3 times a day) as
needed for muscle spasm.
14. tramadol 50 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
15. warfarin 2 mg Tablet Sig: One (1) Tablet PO q mon, fri.
16. warfarin 2 mg Tablet Sig: Two (2) Tablet PO q sun, tues,
wed, thurs, sat.
17. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for pain.
18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
20. docusate sodium 60 mg/15 mL Syrup Sig: ___ (25) mL
PO twice a day: per G tube.
21. docusate sodium 283 mg Enema Sig: One (1) enema Rectal once
a day as needed for constipation.
22. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours) for 5 days.
23. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO once a day.
24. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN.
25. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): discontinue when INR > 2.0.
26. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
27. vancomycin 750 mg Recon Soln Sig: Seven Hundred Fifty (750)
mg Intravenous twice a day for 9 days: please check vanco trough
after 4th dose.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: urinary tract infection, upper respiratory
infection, fever
Secondary diagnosis: history of deep vein thrombosis/pulmonary
embolism; history of coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
.
You were admitted to the hospital with fevers and increased
secretions. You underwent a thorough infectious evaluation, and
were found to have a likely upper respiratory infection and
urinary tract infection as the source of your fevers. You were
started on two antibiotics, called vancomycin and cefepime. We
attempted to transition you to antibiotics by mouth for your
infection, but you began to experience fevers again. You were
discharged to rehab with a special IV ___ place to continue
antibiotics for a total 14 day course.
.
During your admission, you were resumed on metoprolol for
optimal management of your heart disease.
.
MEDICATIONS CHANGED THIS ADMISSION
START metoprolol 12.5 mg twice a day
START cefepime 2 grams IV every 8 hours for 2 days (last day
___
START vancomycin 750 mg IV twice a day for 9 days (last day
___
START lovenox 80 mg twice a day until INR > 2.0
Followup Instructions:
___
|
19656748-DS-22
| 19,656,748 | 23,950,684 |
DS
| 22 |
2130-10-27 00:00:00
|
2130-10-27 20:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meloxicam
Attending: ___
___ Complaint:
Shortness of breath and cough for 2 weeks
Major Surgical or Invasive Procedure:
Attempted bronchoscopy ___: Aborted due to hypoxia
Successful bronchoscopy ___: "Secretions: Quantity:
copious; color: white; consistency: tenacious. These thick
secretions and mucous plugs were aspirated and cleared from
right middle lobe and both lower lobes. A bronchial lavage with
120ml of saline was performed for cytology and microbiology,
including AFB and fungal at the apical bronchus of the right
upper lobe (B1)."
History of Present Illness:
Ms. ___ is a ___ year old woman with PMH of allergic
bronchopulmonary aspergillosis, hypertension, peripheral
neuropathy, who presents with two weeks of shortness of breath,
associated with cough.
Patient reports that around 2 weeks ago she developed shortness
of breath, associated with cough. She was seen by per PCP, and
underwent a CXR which showed a lower lobe pneumonia. She was
also noted to have peripheral eosinophilia (12%). Her
pulmonologist
(Dr. ___ was contacted, and he recommended a 7-day course of
levofloxacin followed by repeat CBC with diff. She was also
restarted on omeprazole 20mg BID. However, patient reports that
she continued to feel worse, having severe shortness of breath,
worse with deep breaths, associated with cough, fatigue, and
headache. She checked her oxygen level, and noted that it was in
the ___. This felt similar to when she was diagnosed with APBA
in
the past. She was to have follow up with Dr. ___ in clinic, but
given that her symptoms continued to worsen, she was instead
referred to ___ ED.
On review of records, in ___ she was diagnosed with pneumonia,
eventually having a BAL that grew Aspergillus and
stenotrophomonas, as well as a positive BAL galactomannan and
peripheral eosinophilia. She was therefore diagnosed with
allergic bronchopulmonary aspergillosis. She was treated with
voriconazole and prednisone, and her symptoms improved. She has
also been treated for ongoing chronic sinus disease.
In the ED, initial vitals: T 97.5, HR 102, BP 185/98, RR 18, O2
91% 2L NC.
Past Medical History:
- ABPA ___ bronchoscopy), no prior history of asthma,
IgE<1000.
- History of Stenotrophomonas infection s/p Bactrim therapy.
- History of Pseudomonas.
- hypertension
- Spinal stenosis, lumbar
- Polyneuropathy in feet and legs, idiopathic, on gabapentin.
- Sinus disease (chronic).
- Question rheumatoid arthritis (positive rheumatoid factor,
negative CCP many years ago, prior treatment with prednisone and
Plaquenil, no recurrent since); possibly post-viral
Social History:
___
Family History:
- father - congenital heart disease, hyperlipidemia
- mother - hypertension
- paternal aunt - breast cancer
Physical Exam:
Gen: NAD, sitting in bed comfortably, conversant
EYES: Anicteric, EOMI
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: Heart RRR, no murmurs, no S3, no S4. 2+ radial and pedal
pulses bilaterally.
RESP: Lungs CTAB without distinct wheezes or crackles, normal
work of breathing, speaking in full sentences, on room air
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation, no Foley
MSK: Moves all extremities. No peripheral edema.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, EOMI, speech fluent,
moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ON ADMISSION:
=============
___ 12:30PM BLOOD WBC-12.3* RBC-4.59 Hgb-13.9 Hct-40.8
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.1 RDWSD-42.3 Plt ___
___ 12:30PM BLOOD Neuts-85.0* Lymphs-8.3* Monos-5.7
Eos-0.4* Baso-0.2 Im ___ AbsNeut-10.44* AbsLymp-1.02*
AbsMono-0.70 AbsEos-0.05 AbsBaso-0.03
___ 12:30PM BLOOD ___ PTT-29.5 ___
___ 12:30PM BLOOD Glucose-129* UreaN-8 Creat-0.6 Na-131*
K-4.3 Cl-93* HCO3-21* AnGap-17
___ 12:30PM BLOOD cTropnT-<0.01 proBNP-494
___ 06:40AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.7
___ 12:54PM BLOOD Lactate-1.7
___ 03:15PM URINE Color-Straw Appear-Clear Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:15PM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
___ 03:15PM URINE CastHy-1*
___ 03:15PM URINE Mucous-RARE*
.
.
ON DISCHARGE:
=============
___ 05:47AM BLOOD WBC-7.7 RBC-3.47* Hgb-10.2* Hct-31.5*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.3 RDWSD-44.3 Plt ___
___ 06:20AM BLOOD Glucose-74 UreaN-5* Creat-0.6 Na-143
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 06:20AM BLOOD Iron-36
___ 06:20AM BLOOD calTIBC-185* Ferritn-151* TRF-142*
___ 06:20AM BLOOD ALT-12 AST-17 AlkPhos-76 TotBili-0.5
.
.
MICROBIOLOGY:
============
Blood cultures x2 from ___: No growth (final)
Negative urine Strep and Legionella antigens
Negative MRSA screen
.
___ 6:03 am SPUTUM Source: Expectorated.
FUNGAL CULTURE ADDED ON PER ___ ___ 1732
___.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
ASPERGILLUS FUMIGATUS COMPLEX. SPARSE GROWTH.
REFER TO FUNGAL CULTURE FOR SUSCEPTIBILITY.
FUNGAL CULTURE (Preliminary):
ASPERGILLUS FUMIGATUS COMPLEX.
SENT TO ___ FOR SUSCEPTIBILITY TESTING
___.
Refer to sendout/miscellaneous reporting for results.
.
___ 4:31 pm BRONCHIAL WASHINGS TRACHIAL BRONCHIAL
WASH.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
MOLD. ~6000 CFU/mL.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
.
___ 4:48 pm BRONCHIAL WASHINGS RIGHT UPPER LOBE BAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
.
___ 06:17
ASPERGILLUS ANTIBODY
Test Result Reference
Range/Units
ASPERGILLUS ___ AB Negative Negative
ASPERGILLUS FUMIGATUS AB Negative Negative
ASPERGILLUS FLAVUS AB Negative Negative
.
___ 06:40
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
INDEX VALUE 0.08 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
.
___ 06:40
IGE
Test Result Reference
Range/Units
IMMUNOGLOBULIN E 378 H <OR=114 ___
B-GLUCAN
Test Result Reference
Range/Units
FUNGITELL(R) ___ <31 <60 pg/mL
GLUCAN ASSAY
INTERPRETATION Negative
.
___ 06:03AM OTHER BODY FLUID ANTIFUNGAL SUSCEPTIBILITY -
ISAVUCONAZOLE (MOULD)-PENDING
___ 06:03AM OTHER BODY FLUID ANTIFUNGAL SUSCEPTIBILITY -
POSACIBAZOLE (MOULD)-PENDING
___ 06:03AM OTHER BODY FLUID ANTIFUNGAL SUSCEPTIBILITY -
VORICONAZOLE (MOULD)-PENDING
___ 06:03AM OTHER BODY FLUID ANTIFUNGAL SUSCEPTIBILITY -
ITRACONAZOLE (MOULD)-PENDING
___ 04:48PM OTHER BODY FLUID ASPERGILLUS GALACTOMANNAN
ANTIGEN-PENDING
.
.
IMAGING:
========
CT chest ___
IMPRESSION:
1. Ground-glass opacities and consolidation in the right upper
lobe and
ground-glass opacity in the left upper lobe, likely representing
pneumonia.
2. Central and lower lobe predominant bronchiectasis with
associated mucous plugging, minimally changed as compared to
outside hospital CTA chest ___, nonspecific in
etiology but could represent allergic bronchopulmonary
aspergillosis.
3. Segmental right middle lobe collapse secondary to mucous
plugging in the segmental airways, unchanged from ___.
CXR ___:
Bandlike opacity in the right upper lung concerning for
pneumonia. Chronic atelectasis in the right middle lobe.
Portable CXR ___:
There is worsening parenchymal opacity in the right upper lobe
which could
represent a pneumonia. There is persistent complete atelectasis
of the right middle lobe. There is a small left pleural
effusion. No pneumothorax is seen.
CXR ___
IMPRESSION:
The right upper lobe parenchymal opacity most likely represents
pneumonia. The right middle lobe collapse is again noted.
Heart size is normal. There is no pleural effusion. There is
an endobronchial lesion obstructing the right middle lobe
bronchus better seen on the recent CT scan. There is no pleural
effusion. No pneumothorax is seen.
.
.
PATHOLOGY:
==========
Biopsies from bronchoscopy ___: PENDING, report not
finalized
___ 04:48PM PLEURAL TNC-___* ___ Polys-6* Lymphs-26*
Monos-3* Eos-2* Meso-1* Macro-60* Other-2*
Brief Hospital Course:
Ms. ___ is a ___ year old woman with PMH of allergic
bronchopulmonary aspergillosis, hypertension, peripheral
neuropathy, who presented with two weeks of shortness of breath,
associated with cough, with CT chest concerning for multifocal
pneumonia.
.
# Acute hypoxic respiratory failure
# Pneumonia
# Allergic bronchopulmonary aspergillosis: She was found to have
groundglass opacities concerning for multifocal pneumonia on CT
chest, with new O2 requirement. Bronchoscopy was attempted on
___, but aborted due to hypoxia. She had a successful
bronchoscopy with BAL on ___, which showed "Tenacious mucous
plugs obstructing RML and basilar segments of both lower lobes;
no endobronchial lesions seen." Bronchial washings were
collected, but cytology was pending at discharge. Sputum
culture grew Aspergillus. She had negative urine Strep and
Legionella, negative MRSA swab. IgE was high, Aspergillus
galactomannan antigen was negative. ID consulted was obtained.
She was treated with Ceftazidime (___) and
Azithromycin (___) for CAP coverage, though
bacterial pneumonia was less likely. She was more likely to
have ABPA and was started on Voriconazole. Pulmonology was
consulted. She developed new visual disturbances since starting
voriconazole, including flashing lights and seeing people that
looked like Halloween characters, but these symptoms resolved.
She was started on Prednisone 30mg daily on ___ for presumed
ABPA. She was on supplemental O2 during her hospital course but
successfully weaned off for >24 hours prior to discharge, with
improvement in dyspnea and cough. She did not require
supplemental O2 on discharge, but had an O2 tank and was
instructed to use PRN on page 1 referral. She was afebrile
without leukocytosis (WBC 7.7) on discharge. She was discharged
on Voriconazole 200mg Q12H and Prednisone 30mg daily, plus
started on prophylactic Bactrim daily, with plan for months of
treatment. She has follow up scheduled with Dr. ___ and
Dr. ___ on ___.
.
# Normocytic anemia: Hemoglobin was 13.9 on admission, then
declined to around ___ range, with lowest of 9.5. No evidence
of bleeding. Labs were most consistent with anemia of chronic
disease, with low TIBC and transferrin, normal iron (though low
end of normal).
.
# Hypertension: Her SBP increased up to 170s and was persistent,
so her Losartan was increased from 50mg to 75mg daily. In the
last 24 hours prior to discharge, her SBP ranged from 110 to
169. She was advised to have her BP rechecked several days
after discharge by ___ and follow up with her primary doctor.
.
TRANSITION OF CARE ISSUES:
- Needs weekly LFTs and chem panel for 4 weeks, then monthly
(she was given order for LFTs and chem panel to be checked week
after discharge) while on Voriconazole
- Needs ophthalmology referral if >1 month of Voriconazole
treatment
- Needs pulmonary rehab (pulm will set up)
- Needs Voriconazole level checked 1 week after discharge (given
order on discharge)
- Pending results: cytology from bronchial washings, antifungal
susceptibility (azoles), Aspergillus galactomannan antigen from
RUL pleural fluid, AFB and fungal cultures from tracheal and RUL
bronchial washings.
.
Check if applies: [X] Ms. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO QID
3. Losartan Potassium 50 mg PO DAILY
4. Alendronate Sodium 70 mg PO QSUN
5. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin [Mucus-ER MAX] 1,200 mg 1 tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*0
2. PredniSONE 30 mg PO DAILY
RX *prednisone 20 mg 1.5 tablet(s) by mouth Daily Disp #*45
Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0
4. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
5. Losartan Potassium 75 mg PO DAILY
RX *losartan [Cozaar] 50 mg 1.5 tablet(s) by mouth Daily Disp
#*45 Tablet Refills:*0
6. Alendronate Sodium 70 mg PO QSUN
7. Aspirin 81 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Gabapentin 300 mg PO QID
10.Outpatient Lab Work
AST, ALT, alkaline phosphatase, total bilirubin
Basic metabolic panel
To be drawn weekly for 4 weeks while on Voriconazole therapy,
starting week of ___.
ICD-9 code: ___.81 (ABPA) on Voriconazole therapy
CC result to: ___, MD ___
11.Outpatient Lab Work
Voriconazole level
To be drawn the week of ___
ICD-9: ___.81 (ABPA) on Voriconazole therapy
CC: ___, MD ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ABPA
Pneumonia
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pneumonia and allergic bronchopulmonary
Aspergillosis (ABPA). You were treated with antibiotics for a
pneumonia, though it's more likely that your symptoms were due
to the ABPA. You had a bronchoscopy - results are still
pending. You will need to take steroids and voriconazole as
prescribed. You'll also be on Bactrim, an antibiotic to help
prevent infection while you're on the steroids. Please make
sure to follow up with out infectious disease specialist and Dr.
___ to ensure resolution of ABPA.
Your blood pressure was high here, so your Losartan was
increased. Have your blood pressure checked in the next few
days to make sure it's not too high (top number should be 150 or
less ideally).
Infectious Disease is working on setting up follow up as an
outpatient. If you'd prefer to see your previous ID doctor at
___, that would also be fine. You have an
appointment with Dr. ___ pulm on ___. Pulm will help
with setting up pulmonary rehab.
Currently you do not need to use oxygen at home, but you can
have the oxygen as needed. ___ will be following you as well.
Followup Instructions:
___
|
19656808-DS-8
| 19,656,808 | 27,057,950 |
DS
| 8 |
2152-09-29 00:00:00
|
2152-09-29 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female who complains of MVC, abd pain. The patient
was transferred from an outside hospital. She was the
unrestrained driver in an ___. She had
a negative head and neck CT scan. On torso CT scan she had a
splenic laceration with a small amount of pelvic fluid. She also
had a question of a right pulmonary contusion. She had bilateral
knee abrasions and a right ankle x-ray that was negative.
Past Medical History:
Past Medical History: Hep C, IVDA
Past Surgical History: None
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM ON ADMISSION ___
Temp: 98.1 HR: 90 BP: 105/56 Resp: 16 O(2)Sat: 98
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Soft, left upper quadrant tenderness
Extr/Back: Right knee she has abrasions, right ankle she has
tenderness with range of motion. The left knee she is abrasions
as well. Her extremities are neurovascular intact.
Neuro: Speech fluent, nonfocal
PHYSICAL EXAM ON DISCHARGE ___
Temp: 98.6 HR: 87 BP: 107/72 Resp: 18 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Soft, non-tender, non-distended, BS active
Extr/Back: Right ankle is mildly swollen with some tenderness
with range of motion. The right and left knee abrasions are
healing appropriately. Her extremities are neurovascular intact.
Neuro: Speech fluent, nonfocal
Pertinent Results:
LAB WORKUP
___ 07:58PM WBC-11.8* RBC-4.70 HGB-13.5 HCT-42.8 MCV-91
MCH-28.8 MCHC-31.7 RDW-13.8
___ 08:10PM HGB-13.1 calcHCT-39
___ 01:53AM BLOOD Hct-36.7
___ 01:10PM BLOOD Hct-41.5
___ 07:58PM GLUCOSE-96 UREA N-8 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
___ 07:58PM ___ PTT-34.1 ___
___ 08:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:25PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
IMAGING
X-RAY B/L KNEES AP/LATERAL/OBLIQUE ___
No evidence of acute fracture or dislocation of the bilateral
knees.
X-RAY R ANKLE (3 ___
No evidence of acute fracture or dislocation. Possible ankle
joint effusion.
Brief Hospital Course:
The patient was transferred from the OSH for a Grade II splenic
laceration, pulmonary contusions and Right ankle swelling and
pain. She was admitted for observation under the Acute Care
Surgery service for her injuries.
Neuro: The patient received IV narcotics with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was started on a regular diet. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her UA was positive so
she was started on a 3 day course of PO Ciprofloxacin that she
will complete as an outpatient.
Hematology: The patient's complete blood count was examined
routinely to monitor her hematocrits; she remained stable and no
transfusions were required.
Musculoskeletal: The patient's b/l knee an R ankle X-rays were
negative but her right ankle was swollen on exam and she had
significant pain on ambulation so ortho was consulted. They
recommended aircast boot and weight-bearing as tolerated. She
was also seen by ___ who cleared her for discharge to home on
crutch-assist and outpatient physical therapy.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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 with crutches, voiding without assistance, and
her pain was well controlled. The patient received discharge
teaching and verbalized understanding of and agreement with
follow-up instructions and discharge plan. She will follow-up in
the orthopedics clinic in 2 weeks.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Duration:
14 Days
4. Docusate Sodium 100 mg PO BID Duration: 14 Days
5. Outpatient Physical Therapy
Diagnosis: Polytrauma
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with crutches
Discharge Instructions:
* You were admitted to the hospital for injury to your spleen
and your lungs. You were also found to have sprained your ankle.
You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
* Make sure you wear your aircast boot until you follow up with
Orthopedics in 2 weeks. You are also being given crutched to
help you ambulate at home and keep the weight off your right
foot.
* Avoid all contact sports or any activity that may involve a
hit to your abdomen for 3 months or until you follow up with us
in the surgery clinic in 2 weeks.
Followup Instructions:
___
|
19656995-DS-5
| 19,656,995 | 28,564,819 |
DS
| 5 |
2175-09-22 00:00:00
|
2175-10-09 10:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male who was involved in a rollover MVC on ___
and was found lying underneath the car. He was intubated in the
field and transferred to ___ where he had
bilateral chest tubes placed. Imaging there revealed multiple
facial fractures, multiple rib fractures, and a left humerus
fracture--which were all treated non-operatively.
Past Medical History:
patient unable to give detailed history due to TBI
Social History:
___
Family History:
___
Physical Exam:
Discharge Physical Exam:
VS: T: 97.5 PO BP: 131/79 HR: 77 RR: 16 O2: 98% RA
GEN: A+Ox3, forgetful at times to place and time
HEENT: MMM, no scleral icterus. PERRL
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: L dorsal aspect of ___ finger w/ bandaid c/d/I. LUE in
___ w/ ultra sling. LUE fingers w/ trace edema, no
erythema, + sensation in all extremities. Full ROM in RUE and
b/l ___
Pertinent Results:
IMAGING:
___: CXR:
Enteric tube courses below the diaphragm, with distal side port
at the GE
junction, suggest advancement so that it is well than the
stomach.
Left chest tube terminates over the medial left mid hemithorax,
may be in the mediastinum. Right chest tube courses along the
inferior right hemithorax, medially, possibly extending to or
just beyond midline. Subcutaneous emphysema is noted along the
lower right chest wall. Haziness of the bilateral lung bases may
be due to pleural effusions or atelectasis/aspiration.
Relative widening of the superior mediastinum; consider chest
CTA to assess for mediastinal injury.
Comminuted proximal left humeral fracture is seen. External
artifact obscures the right clavicle.
___: CT Head:
1. Linear streak of hyperdensity at the left lateral convexity
may represent a small subarachnoid hemorrhage or artifact.
2. Concern for early diffuse cerebral edema.
3. Multiple fractures involving the left face and bilateral
temporal bones, as detailed above. Fracture of the base of the
left pterygoid plate. See dedicated maxillofacial CT for
further assessment.
4. Small hematoma in the superior left orbit. Foci of gas seen
tracking into the inferior left orbit.
5. Subcutaneous gas involving the left face and orbit.
___: FEMUR (AP & LAT) LEFT PORT:
No acute fracture or dislocation of the left femur.
___: CXR:
Again, distal side port of enteric tube terminates at the GE
junction.
Recommend advancement so that it is well within the stomach.
Chest tubes are in stable position compared to the prior study,
projecting
over the lower chest extending to the midline on the right and
the upper
midline chest on the left, both chest tubes may be extending
into the
mediastinum.
Lung bases appear slightly better aerated, although still with
opacity, which could be due to pleural effusions, aspiration,
underlying pulmonary contusion not excluded.
Superior mediastinum appears slightly less widened as compared
to the prior study.
___: FOREARM (AP & LAT) LEFT PORT:
Obliquely oriented intra-articular fracture of the distal radius
involving the radial styloid with minimal radial displacement
which is improved following splinting.
___: HUMERUS (AP & LAT) LEFT PORT:
1. Fracture of the midshaft of the left humerus with improved
alignment
following splinting.
2. Incompletely assessed fracture of the surgical neck of the
humerus could be further evaluated with dedicated radiographs of
the shoulder.
___: HUMERUS (AP & LAT) LEFT:
1. Fracture of the midshaft of the left humerus with improved
alignment
following splinting.
2. Incompletely assessed fracture of the surgical neck of the
humerus could be further evaluated with dedicated radiographs of
the shoulder.
___: WRIST(3 + VIEWS) LEFT:
Obliquely oriented intra-articular fracture of the distal radius
involving the radial styloid with minimal radial displacement
which is improved following splinting.
___: HAND (PA,LAT & OBLIQUE) PORT LEFT:
There is a fracture through the distal radius involving the
styloid process and extending to the articular surface with
minimal displacement, unchanged compared to the prior study. No
additional fractures are seen. There is a dressing over the
left middle finger. No fracture of the middle finger is
identified. There is a tiny calcific density adjacent to the
base of the ring finger middle phalanx seen on the lateral view
only which may reflect a remote avulsion injury.
___: FOREARM (AP & LAT) LEFT PORT:
Status post reduction of a distal left radial fracture. No
additional
fractures are identified in the more proximal radius or ulna.
___: FOREARM (AP & LAT) LEFT:
Fracture of the surgical neck left humerus and middle third
humeral diaphysis. Fracture of the distal left radius.
___: HUMERUS (AP & LAT) LEFT:
Fracture of the surgical neck left humerus and middle third
humeral diaphysis. Fracture of the distal left radius.
___: CXR (___):
There remains a very tiny right apical pneumothorax, unchanged.
Cardiomediastinal silhouette is within normal limits. There is
atelectasis at the lung bases. There is no pulmonary edema,
focal consolidation, or large pleural effusions.
___: EEG:
This is an abnormal continuous ICU monitoring study because of
intermittent focal slowing and loss of faster frequency activity
over the left fronto-temporal region, as well as asymmetric
posterior dominant rhythm, indicative of focal cerebral
dysfunction broadly over the left hemisphere. There are no
pushbutton activations. There are no electrographic seizures or
epileptiform discharges.
___: CT Head:
1. No evidence of hemorrhage or infarction.
2. Extensive left maxillofacial fractures and temporal bone
fractures as
previously described on ___.
3. Interval reduction in soft tissue swelling about the left
face.
___: MRI Head:
1. Findings are most compatible with diffuse axonal injury, as
evidenced by scattered foci of T2 and FLAIR hyperintensity, as
well as an area of slow diffusion in the splenium of the corpus
callosum.
2. Several foci of microhemorrhage, as seen over the left
frontal lobe, and in the occipital horn of the right lateral
ventricle.
3. Maxillofacial fractures are better evaluated on CT from ___.
Paranasal sinus opacification is probably related to these
maxillofacial
injuries.
___: EEG:
This is an abnormal continuous ICU monitoring study because of
intermittent focal slowing and loss of faster frequency activity
over the left fronto-temporal region, as well as asymmetric
posterior dominant rhythm, indicative of focal cerebral
dysfunction broadly over the left hemisphere. There are no
pushbutton activations. There are no electrographic seizures or
epileptiform discharges. Compared to the prior day's recording,
there is no significant change.
___: HUMERUS (AP & LAT) LEFT:
Fractures of the surgical neck and mid-diaphysis of the left
humerus,
diaphyseal fracture is better aligned.
___: WRIST(3 + VIEWS) LEFT:
Distal radial fracture.
___: CT ORBIT, SELLA & IAC W/O CONTRAST:
1. Transversely oriented right temporal bone fracture through
the mastoid
portion that spares the otic capsule.
2. Fracture of the squamous portion of the left temporal bone at
the junction with the mastoid portion with 2 mm of depression.
3. Extensive maxillofacial fractures primarily involving the
left
zygomaticomaxillary complex and lamina papyracea were previously
evaluated on ___. Paranasal sinus opacification as described above.
Labs:
___ 10:07PM TYPE-ART TEMP-36.9 PO2-99 PCO2-29* PH-7.36
TOTAL CO2-17* BASE XS--7
___ 10:07PM LACTATE-1.5
___ 10:07PM freeCa-1.01*
___ 09:44PM GLUCOSE-139* UREA N-17 CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-18* ANION GAP-18
___ 09:44PM CALCIUM-8.1* PHOSPHATE-3.0 MAGNESIUM-1.7
___ 09:44PM WBC-11.3* RBC-4.72 HGB-14.2 HCT-41.7 MCV-88
MCH-30.1 MCHC-34.1 RDW-13.1 RDWSD-42.7
___ 09:44PM PLT COUNT-228
___ 09:44PM ___ PTT-23.3* ___
___ 08:07PM ___ PO2-38* PCO2-52* PH-7.28* TOTAL
CO2-25 BASE XS--2
___ 08:07PM O2 SAT-66
___ 08:06PM TYPE-ART PO2-90 PCO2-45 PH-7.31* TOTAL CO2-24
BASE XS--3 COMMENTS-ABG LINE A
___ 08:06PM O2 SAT-96
___ 08:04PM TYPE-ART PO2-32* PCO2-56* PH-7.27* TOTAL
CO2-27 BASE XS--2
___ 08:04PM LACTATE-1.9
___ 06:35PM PH-7.11*
___ 06:35PM GLUCOSE-126* LACTATE-4.7* NA+-147* K+-3.7
CL--112* TCO2-20*
___ 06:35PM HGB-16.6 calcHCT-50 O2 SAT-73 CARBOXYHB-2 MET
HGB-0
___ 06:35PM freeCa-1.01*
___ 06:25PM UREA N-18 CREAT-1.2
___ 06:25PM LIPASE-44
___ 06:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:25PM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:25PM WBC-20.0* RBC-5.23 HGB-15.9 HCT-48.3 MCV-92
MCH-30.4 MCHC-32.9 RDW-13.0 RDWSD-44.0
___ 06:25PM PLT COUNT-243
___ 06:25PM ___ PTT-21.7* ___
___ 06:25PM ___ 06:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:25PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 06:25PM URINE HYALINE-2* CELL-2*
___ 06:25PM URINE MUCOUS-RARE
___ 05:49PM TYPE-ART PO2-80* PCO2-55* PH-7.23* TOTAL
CO2-24 BASE XS--5
___ 05:49PM LACTATE-1.3
Microbiology:
___ 9:04 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ y/o M who was involved in a rollover MVC on
___. He was intubated in the field and transferred to
___ where he had bilateral chest
tubes placed. Imaging at ___ revealed multiple facial
fractures, multiple rib fractures, a left humerus fracture, and
a left radius fracture--which were all treated non-operatively.
The patient was then transferred to ___ for further care. He
was transferred to the ICU. Imaging revealed the patient to have
a left parietal SAH, C6 anterior osteophyte fracture with
concern for ALL injury, left zygomaticomaxillary fracture,
bilateral temporal bone fractures, a small right apical
pneumothorax, left humerus fracture, left distal radius fracture
and a laceration over the L dorsal aspect of middle finger.
Neurosurgery was consulted for the patient's SAH and C6
fracture. They recommended 1gm Keppra BID x 7 days, and
remaining in a hard cervical collar x 6 weeks until N.surgery
follow-up appointment. Plastic Surgery was consulted for the
patient's facial fractures. Per Plastic Surgery, there was no
evidence of extraocular muscle entrapment or septal hematoma and
there was no indication for surgical repair of the facial
fractures. It was recommended he receive Unasyn/Augmentin
875/125 mg PO BID x 7 days, Afrin nasal spray 2 puffs bid x 4
days, sudafed 60 mg PO q6h x4
days, Sinus precautions x 1 week.
Orthopedic Surgery evaluated the patient's LUE fractures and no
operative management was warranted. His LUE was reduced and
placed in a splint and sling. Hand surgery placed sutures to the
laceration on the dorsal aspect of his left ___ finger.
On ___, the patient's mental status was much improved (GCS
3->9), and there was no need for a repeat head CT. On ___,
the patient was extubated, his left chest tube was removed.
Hand surgery washed out the left middle finger laceration and
sutures were applied. Unasyn was d/c'd and Bactrim was started.
The patient's c-collar was removed. On ___, Speech &
Swallow cleared the patient for a regular diet. CXR showed small
R apical pneumothorax. The patient was then transferred to the
surgical floor.
On ___, there were no acute events. No chest tube air leak
was seen. The right CT was removed, postpull CXR showed a small
L apical PTX. On ___, CXR showed very tiny right apical
pneumothorax, unchanged. The rehab screening process began. On
___, the Bactrim course was completed (5 day course per
Hand Surgery). The patient worked with Physical Therapy who
recommended rehab. On ___, the patient had word finding
difficulty and had periods of disorientation, so Neurology was
consulted for concern for seizure activity. The patient had a
head CT w/ imaging suggestive of interval resolution of
subarachnoid hemorrhage and cerebral edema. MRI initially showed
infarction of left splenium of corpus callosum, however the
attending re-read revealed likely diffuse axonal injury.
Neurology obtained EEGs which showed generalized slowing. They
recommended that the patient f/u in ___ clinic in ___ weeks.
The patient was screened for rehab. 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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN for constipation
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
do NOT drink alcohol or drive while taking this medication
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5.Outpatient Occupational Therapy
Dx: Left humerus fracture, left distal radius fracture
Px: Good
Duration: 13 (thirteen) months
6.Outpatient Physical Therapy
Dx: Gait instability, Left humerus and left distal radius
fracture
Px: Good
Duration: 13 (thirteen) months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-MVC
-Right Temporal Subarachnoid hemorrhage
-Left zygomaticomaxillary fracture
-Bilateral temporal bone fractures
-Small right apical pneumothorax
-Left humerus fracture
-Left distal radius fracture
-Laceration over the L dorsal aspect of middle finger
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a motor
vehicle collision and were found to have a traumatic brain
injury with internal head bleeding, left and right temporal bone
skull fractures, multiple facial fractures, a right-sided lung
puncture, left arm and wrist fractures, and a cut on your left
middle finger. You were evaluated by the Neurosurgery service
for your head bleed and no surgery was necessary. You completed
a course of a medication called Keppra to prevent seizures. You
had some difficulty recalling words, so Neurology evaluated you
and recommended an EEG to evaluate for seizures and a head CAT
scan and MRI which was negative for a stroke, but the findings
were consistent with post-concussive symptoms from your known
traumatic brain injury. Ophthalmology evaluated your left and
right eyes and no surgical intervention was necessary.
Ophthalmology will call you for a follow-up appointment in
outpatient clinic.
Plastic Surgery evaluated your facial injuries and recommended a
soft consistency diet for the next 3 weeks and sinus precautions
(please see "Sinus Precautions" instructions below). You have a
follow-up appointment in the outpatient Otolaryngology (ENT)
clinic to assess your temporal bone fractures and you will have
a non-urgent outpatient audiogram to assess your hearing.
Prior to coming into the hospital, you had chest tubes placed
for concern of injury to your lungs. You had a small right lung
puncture which remained stable and both chest tubes were
removed.
For your left arm and wrist fracture, you were evaluated by
Orthopedic Surgery and no surgery was warranted. Your left arm
was placed in a splint and a sling. The Hand Surgery service
evaluated the cut on your left middle finger, cleaned the wound,
placed dissolvable sutures and you received a course of an
antibiotic called Bactrim to prevent infection.
You have worked with Physical and Occupational therapy and are
now ready to be discharged home with visiting nurse services,
home physical and occupational therapy. Please note the
following discharge instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms
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.
Sinus Precautions:
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:
___
|
19657723-DS-5
| 19,657,723 | 29,503,445 |
DS
| 5 |
2121-09-11 00:00:00
|
2121-09-08 17:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right acute SDH, IPH, SAH
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a mild TBI. Patient with hx of atrial
fibrillation,
hypertension transferred from ___ s/p fall ___
yesterday. Patient reports that yesterday morning around 1030am
he went to change carbon monoxide detector and he fell over and
hit his head on a stationary bike. Later in evening at 630pm he
fell backwards and hit his head on the floor. The wife reports
he
was not responding to her for a few minutes but was awake with
his eyes open. He reports there is no electricity at his house
and he was holding flashlight for his wife to see where she was
going. Patient does not remember falling. Denies dizziness prior
to falling. Per his wife, he is usually unsteady on his feet and
ambulates with walker and cane. He currently reports headache,
nausea and vomited x1. Denies dizziness, blurry vision,
parasthesias. CT scan showed acute Right SDH, bilateral IPH, and
bilateral foci SAH. Neurosurgery was consulted for further
evaluation.
Mechanism of trauma: mechanical fall
Past Medical History:
PMHx:
R groin blood clot
Atrial fibrillation
hypertension
BPH
Hyperlipidemia
sciatica
Depression
GERD
Social History:
___
Family History:
Family Hx:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T:99.1 BP:147/82 HR:100 RR:18 O2 Sat:97% 2L
GCS at the scene: __unknown __
GCS upon Neurosurgery Evaluation: 15
Time of evaluation:0130
Airway: [ ]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
Exam:
Gen: elderly , comfortable, NAD.
Extrem: warm and well perfused
Integ: lacerations to Right forearm, laceration to right ear
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
TrapDeltoidBicepTricepGrip
Right 5 5 5 5 5
Left 4+ 5 4+ 4+ 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left4 5 4 5 5 5
Left upper extremity drift
Sensation: Intact to light touch
PHYSICAL EXAMINATION ON DISCAHRGE:
Opens eyes: [x ]spontaneous [ ]to voice [ ]to noxious
Orientation: [x ]Person [x ]Place [x ]Time
Follows commands: [ ]Simple [x ]Complex [ ]None
Pupils: Right 4-3mm Left 4-3mm
EOM: [x ]Full [ ]Restricted
Face Symmetric: [x ]Yes [ ]NoTongue Midline: [x ]Yes [ ]No
Pronator Drift [ ]Yes [x ]No Speech Fluent: [x ]Yes [ ]No
Comprehension intact [x ]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right 5 5 5 5 5
Left 5 5 5 5 5
IPQuadHamATEHLGast
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
#Acute SDH, IPH, SAH
On ___, the patient was admitted to the Neuro ICU for close
neurologic checks in the setting of the acute SDH, IPH and SAH.
He received a transfusion of FFP while in the ED. A repeat
non-contrast head CT was performed and showed expected evolution
of the right frontal contusion, decrease in size of SDH. Patient
remained neurologically intact. He was transferred to the floor
in good condition. He was evaluated by ___ and OT who recommended
rehab. He was discharged to rehab on ___ in good condition with
instructions for follow up.
#Elevated BUN/Cr
Patient noted to have mildly elevated BUN/Cr. Outside records
were obtained which revealed patient's baseline Cr is 1.3-1.5.
He was gently hydrated. Recommend patient follow up with PCP
after discharge for ongoing monitoring.
#R ear laceration
Ear laceration repaired by plastic surgery. Bacitracin topical
BID x 5 days (until ___, Non-weightbearing to right face x 1
week, HOB elevation x1 week . Please have patient follow up with
Dr. ___ discharge in ~1 weeks in clinic ___
to schedule appointment.)
#R arm wound
Evlauated by plastics. Recommended Ciprofloxacin x 5 days for
chondritis prophylaxis. Right forearm: BID xeroform with 4x4
gauze ___. please minimize adhesive tape given thin skin.
Medications on Admission:
Prednisone 5mg daily
Metoprolol 12.5mg daily
Omeprazole 20mg daily
align probiotic 4mg daily
aspirin 81mg daily
atorvastatin 20mg daily
Colace 100mg daily
floxmax 0.8mg daily
fluoxetine 20mg daily
proscar 5mg daily
vit b12 100mcg daily
vit d3 1,000 units daily
metoprolol 12.5mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bacitracin Ointment 1 Appl TP BID ear laceration
3. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 5 Days
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. LevETIRAcetam 500 mg PO BID Duration: 7 Days
7. Atorvastatin 20 mg PO QPM
8. Cyanocobalamin 100 mcg PO DAILY
9. Finasteride 5 mg PO DAILY
10. FLUoxetine 20 mg PO DAILY
11. Metoprolol Tartrate 12.5 mg PO BID
12. Omeprazole 20 mg PO QHS
13. PredniSONE 5 mg PO DAILY
14. Tamsulosin 0.8 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic Brain Injury
Subarachnoid Hemorrhage
Subdural Hematoma
Intraparenchymal contusion
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 for monitoring after a traumatic brain injury.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may resume Aspirin 81mg in 1 week from your fall (___)
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time. Continue this medication for a total of 7 days (___)
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 symptoms after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
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:
___
|
19657904-DS-14
| 19,657,904 | 20,004,357 |
DS
| 14 |
2157-08-12 00:00:00
|
2157-08-13 18:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) /
Azithromycin / Iodine-Iodine Containing / Atenolol / Metoprolol
Tartrate / Lipitor / Clindamycin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ endotracheal intubation
History of Present Illness:
Ms. ___ is a ___ year old female with asthma requiring 2LNC at
home though no PFTs in the system and coronary artery disease
complicated by ischemic cardiomyopathy with LVEF of 35-40% on
TTE in ___ who has had frequent ___ visits and hospitilization
for shortness of breath this year. She recently presented to
___ ___ on ___ with asthma exacerbation and tranferred
to ___ per her wish. At ___, she was
treated for asthma exacerbation and discharged home. She saw
her PCP ___ ___. SBP was 172. Oxygen saturation was normal.
There was concern for running out of oxygen. Home ___:
___ ___ who saw her last was concerned
about her medical noncompliance with her medications. She
presented to ___ on ___ with SOB and discharged that
day without any prednsione per patient.
.
She presents to ___ last night with 7 days of shortness of
breath.
.
In the ___, initial VS were: 96.9 86 173/113 36 100% 15L
nonrebreather. ABG showed 7.49/35/45. Labs were notable for
normal electrolytes, creatinine, troponin less than 0.01, BNP of
1080, HCT of 34, normal WBC and coags. CXR showed no acute
process with mild hilar congestion. EKG showed sinus rhythm
with IVCD and LVH without any acute ST-T changes compared to
prior EKG. She was given combivent nebs X 2 and solumedrol
along with magnesium for asthama exacerbatoin. She was given
levaquin for empiric coverage of community acquird pneumonia and
lasix IV 40 mg x 1 for acute on chronic systolic heart failure.
She was placed on BiPAP for hypoxemic respiratory failure with
imporvement to ABG of 7.___ and clinical improvement of
respiratory status. Four hours later, she failed weaning off
BiPAP due to increase in respiratory effort. She was
subsequently transferred to MICU for further evaluation and
management of hypoxemic respiratory failure.
.
.
On arrival to the MICU, she reports feeling slightly better
though is a poor historian and her only complain is epigastric
pain. She reports feeling short of breath for past seven days
but does not report fever, cough, chest pain, palpatations,
abdominal pain, nausea/diarrhea/joint pain/rash. She does not
report sick contacts, eating out or high sodium intake.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
1. Coronary artery disease.
2. Ischemic cardiomyopathy. EF 35-40% on ECHO in ___.
3. Asthma, though no PFTs in system and no documented outside
PFTs. uses 2LNC at home
4. Lower extremity DVT that was diagnosed at ___ at an unknown
time and was treated for an unknown length of time, but this was
many years ago.
5. Dyslipidemia.
6. Hypertension.
7. Normocytic anemia.
8. Chronic rhinosinusitis.
9. Depression.
10. Adenoid hyperplasia
Social History:
___
Family History:
She has several members of family with coronary artery disease
and heart attacks, no diabetes, no cancer reported.
Physical Exam:
PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2. , rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
___ 03:45AM BLOOD WBC-5.3 RBC-3.99* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.9 Plt ___
___ 03:45AM BLOOD Neuts-57.0 ___ Monos-4.3 Eos-1.8
Baso-0.4
___ 03:45AM BLOOD ___ PTT-25.4 ___
___ 03:45AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-140
K-3.8 Cl-102 HCO3-28 AnGap-14
___ 01:19PM BLOOD ALT-15 AST-13 LD(LDH)-205 CK(CPK)-62
AlkPhos-81 TotBili-0.2
___ 04:37PM BLOOD Lipase-27
___ 03:45AM BLOOD proBNP-1080*
___ 03:53AM BLOOD cTropnT-<0.01
___ 01:19PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:37PM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:37PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.0 Mg-2.4
___ 03:51AM BLOOD ___ pO2-45* pCO2-35 pH-7.49*
calTCO2-27 Base XS-3 Intubat-NOT INTUBA Comment-NEBULIZER
___ 06:05PM BLOOD Lactate-8.0*
___ 11:41PM BLOOD Lactate-2.0
___ 01:55PM BLOOD Lactate-2.4*
___ 02:42AM BLOOD Lactate-1.4
___ 08:10AM BLOOD Lactate-1.3
.
Discharge Labs:
___ 05:55AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.4* Hct-28.4*
MCV-88 MCH-29.1 MCHC-33.2 RDW-14.2 Plt ___
___ 05:55AM BLOOD Glucose-93 UreaN-19 Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-30 AnGap-9
___ 05:55AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4
.
MICRO:
___ BLOOD CULTURE NO GROWTH TO DATE
___ MRSA SCREEN POSITIVE
.
IMAGING:
___ TTE: There is regional left ventricular systolic
dysfunction with inferior hypokinesis similar to prior echo in
___. There is an inferoposterobasal left ventricular aneurysm.
Left ventricular dyssynchrony consistent with left bundle branch
block. Right ventricular chamber size and free wall motion are
normal. There is an anterior space which most likely represents
a prominent fat pad. LVEF 45%.
.
___ TEE: This study was compared to the prior study of
___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Complex (>4mm) atheroma in the ascending aorta. Complex (>4mm)
atheroma in the aortic arch. Complex (>4mm) atheroma in the
descending thoracic aorta. No thoracic aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). Moderately
thickened aortic valve leaflets. Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
___ VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR. Dilated main PA.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with ___
regulations. The patient was monitored by a nurse in ___
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). No glycopyrrolate was administered. No TEE related
complications. The patient appears to be in sinus rhythm.
Echocardiographic results were reviewed with the houseofficer
caring for the patient.
Conclusions
No atrial septal defect is seen by 2D or color Doppler.Right
ventricular systolic function is ___, with normal free wall
contractility. The ascending aorta is mildly dilated. There are
complex (>4mm) atheroma in the ascending aorta, aortic arch, and
descending thoracic aorta. No thoracic aortic dissection is seen
from the aortic root to the descending aorta at 40 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. The aortic valve leaflets
are moderately thickened and there is moderate aortic
regurgitation.The mitral valve leaflets are mildly thickened and
there is mild mitral regurgitation. The tricuspid valve leaflets
are mildly thickened. The main pulmonary artery is dilated.
There is no pericardial effusion.
IMPRESSION: No aortic dissection seen. No saddle pulmonary
embolus seen. Dilated main PA. Normal right ventricular systolic
function. Moderate aortic regurgitation. If clinically
indicated, evaluation for smaller pulmonary emboli may be
prudent.
Compared with the prior study (images reviewed) of ___, the
degree of aortic regurgitation is similar.
.
___ LUNG SCAN: INTERPRETATION: Ventilation images could not
be obtained because the patient was intubated and ventilated via
respirator.
Perfusion images in 6 views show no evidence of perfusion
defects.
Chest CT shows right lung base atelectasis.
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
.
___ CT CHEST/ABD/PELVIS: COMPARISONS: CT chest without
contrast from ___.
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet to the
pubic symphysis without the administration of intravenous
contrast material. Coronal and sagittal reformats were
completed. DLP: 1088.78 mGy-cm.
CT CHEST WITHOUT CONTRAST: The thyroid gland is incompletely
visualized but unremarkable. There is no supraclavicular,
axillary, or mediastinal
lymphadenopathy. There is a central venous catheter terminating
in the distal SVC. ET tube terminates at the right mainstem
bronchus. There is an NG tube terminating within the stomach.
The heart and pericardium are notable for a small pericardial
effusion which was seen on the prior exam. There are bibasilar
opacities, which may represent aspiration vs. atelectasis or
infectious process. The airways are patent to the subsegmental
levels. There are no lung masses or nodules seen.
CT ABDOMEN WITHOUT CONTRAST: Evaluation of the intra-abdominal
solid organs and vasculature is limited without the
administration of intravenous contrast material. Given these
limitations, there are no focal liver lesions. The gallbladder,
pancreas, spleen, adrenal glands, and kidneys are unremarkable.
There is no hydronephrosis or focal lesions. Evaluation of the
bowel is limited without the administration of intravenous or
oral contrast; however, the stomach, small and intra-abdominal
large bowel are unremarkable. There is no evidence of bowel wall
thickening or pneumatosis to suggest ischemia. There is no free
fluid or free air within the abdomen. There are atherosclerotic
calcifications of the abdominal aorta extending to the iliac
arteries.
CT PELVIS: There is a Foley catheter within the bladder, which
is otherwise unremarkable. The rectum, uterus, sigmoid colon are
unremarkable. There is no free fluid or free air,
lymphadenopathy within the pelvis.
OSSEOUS STRUCTURES: Degenerative changes of the spine at
multiple levels with disc space narrowing and anterior
osteophytes of the lumbar spine. There are no suspicious lytic
or sclerotic lesions.
IMPRESSION:
1. No evidence of pneumatosis or bowel wall edema to suggest
ischemia;
however, the study is limited due to lack of contrast
administration. No
evidence of obstruction.
2. ET tube at the level of the right main stem bronchus which
needs to be
retracted.
3. Small bilateral consolidations at the lung bases which may
represent
atelectasis, aspiration, or infection.
.
___ BILATERAL LOWER EXTREMITY DOPPLERS: COMPARISON: Right
leg ultrasound ___.
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
Nonocclusive thrombus is seen at the junction of the left deep
femoral vein and common femoral vein. At this level and the
vessel does not compress appropriately. Vascular flow continues
to course past this thrombus.
Normal flow and compression is seen in the remainder of the
veins of the left leg and in all of the veins of the right leg.
IMPRESSION: Acute left DVT with nonocclusive thrombus seen at
the junction of the left deep femoral vein and the left common
femoral vein. No DVT seen in the right leg.
Brief Hospital Course:
Ms. ___ is a ___ year old female with asthma (2LNC at home) and
CAD complicated by ischemic cardiomyopathy (LVEF of 35-40%) who
presents with hypoxemic respiratory failure.
.
# Hypoxemic respiratory failure: Likely due to asthma
exacerbation precipitated by medical noncompliance and seasonal
allergies. She was treated with albuterol and ipratroprium
nebulizers as well as methylprednisolone tapered to prednisone.
She had to be briefly intubated to resolve her hypoxia. There
was also initial concern for pulmonary embolism though unlikely
with appropriate augmentation of oxygenation on biPAP. Because
she did not improve over the course of a few hours, she
underwent a V/Q scan which was negative for PE with limitations
due to being intubated. She also underwent a TEE to assess for
aortic dissection as the cause of her shortness of breath, new
left bundle branch block, and chest pain, however this was
negative for dissection. Her LVEF was 45%, not significantly
worse from baseline in ___. Finally, she underwent a CT torso
to assess for mesenteric ischemia as a cause for her elevated
lactate, hypertension, chest pain, and shortness of breath,
however this was also negative and all lab values rapidly
corrected. The most likely cause was determined to be a
combination of asthma and heart failure.
.
# Chronic ischemic Systolic heart failure with EF of 35-40%: Her
troponins did not rise and her ECHOs did not show acute change
in LVEF. Continued home aspirin, simvastatin, and imdur. Due
to hypertensive urgency, she was initially treated aggressively
with Lasix, Imdur, and hydralazine. Her home diltiazem was
changed to amlodipine as this is the only calcium channel
blocker known to be safe in ischemic heart failure. The patient
endorses 6-pillow orthopnea and PND at home, consistent with
moderate heart failure.
.
# Medication Adherence: The patient has a very difficult time
with medication adherence, and we noted that her medication list
from her PCP is very different from that in our online system,
possibly due to the involvement of multiple specialists. We
attempted to streamline this list to the necessary respiratory
and cardiac medications. It may be necessary to adjust this
further to control her blood pressure and breathing.
.
# DVT: ___ ultrasound found non-occlusive unilateral lower
extremity deep vein thrombosis. For the DVT, she was started on
heparin, transitioned to Lovenox for outpatient management. As
her daughter notes that she also has frequent clotting, it would
be helpful to do an outpatient hypercoagulable workup and
determine if the patient should be on Lovenox for 6 months or
for life.
.
# Hypertensive urgency: While in the ICU, she was treated with
nitro gtt to keep SBP < 120 to prevent flash pulmonary edema due
to LVH and systolic dysfunction. As she recovered, her PO
regimen was optimized.
.
# Hyperlipidemia: Continued simvastatin
.
# Depression: Tapered amytriptiline to 50 mg po qhs as patient
has QRS prolongation.
.
TRANSITIONAL ISSUES:
- Patient is not on ACE-I and BB due to allergies of unknown
etiology. There needs to be a discussion with her regarding
benefit of these medications. It may be possible to find drugs
in these classes that she can take despite her allergies.
- In lieu of recent data of benefit of spironolactone in
patients with systolic heart failure with any NHYA class and her
inability to take ACE-I or BB as described above, suggest
instead starting spironolactone.
- The patient will need an outpatient EGD to follow-up her GERD.
- The patient will need outpatient ENT follow-up for her
secretion management.
- We streamlined the patient's medication list and provided
blister packed medication to improve compliance. It may be
necessary to add back inhalers or blood pressure mediations (as
noted above).
- The patient's daughter states she has frequent clotting and
has used Lovenox in the past. The patient may benefit from a
hypercoagulable workup to determine if she needs Lovenox for
life.
Medications on Admission:
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
amitriptyline 100 mg po qhs
aspirin 325 mg po qdaily
azelastine 137 mcg 2 sprays inh BID
cetirizine 10 mg po qdaily
cholecalciferol (vitamin D3) 2,000 unit Tablet po qdaily
diltiazem HCl 180 mg Capsule, Extended Release po qdaily
Nexium 40 mg po BID
fluticasone 50 mcg/Actuation Spray 2 sprays daily
fluticasone 110 mcg/Actuation Aerosol 2 puff BID
ipratropium bromide 0.02 % inh BID SOB
isosorbide mononitrate 30 mg Tablet ER po qdaily
nitroglycerin 0.3 mg Tablet SL prn
simvastatin 10 mg po qdialy
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every ___ hours as needed for shortness of
breath or wheezing.
Disp:*1 * Refills:*11*
2. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
3. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*11*
4. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*11*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day: 2 sprays each nostril daily.
Disp:*1 unit* Refills:*11*
6. enoxaparin 150 mg/mL Syringe Sig: One (1) injection
Subcutaneous once a day.
Disp:*30 * Refills:*3*
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*11*
8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: Take 30 minutes
before a meal.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute asthma exacerbation
SECONDARY DIAGNOSIS
Chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
shortness of breath. We think that you had an exacerbation of
your asthma which caused this. Sometimes asthma is exacerbated
by cold weather, a viral illness, or allergies. It is also
possible that your blood pressure got too high which caused
fluid to build up in your lungs and cause shortness of breath.
For a short time, you were put on a ventilator to support your
breathing and you were treated with antibiotics, steroids, and
blood pressure lowering medications.
As you improved you were transferred to a regular medicine
floor. There we continued your inhaler and antibiotics for your
breathing. We used your home medications to lower your blood
pressure.
We want to give you fewer mediations to manage, so that it is
easier to get and take your medicine. Your primary care
physician ___ continue to adjust this list, so please work with
Dr ___ to make sure your blood pressure and asthma are well
treated.
We made the following changes to your medications:
- STOP amitriptyline, aspirin, azelastine, doxepin, Nexium,
Fluticasone inhaler, iprtropium inhaler, Imdur, and
nitroglycerin
- START cetirizine for allergies
- START vitamin D
- START Flonase nasal spray for allergies
- START Lovenox injections for your blood clot
It is very important that you keep all of the follow-up
appointments listed below.
Weigh yourself every morning, call Dr ___ your weight
goes up more than 3 lbs.
Followup Instructions:
___
|
19657904-DS-17
| 19,657,904 | 26,507,601 |
DS
| 17 |
2158-08-12 00:00:00
|
2158-08-16 20:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) /
Azithromycin / Iodine-Iodine Containing / Atenolol / Metoprolol
Tartrate / Lipitor / Clindamycin
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
___ Electrical cardioversion
History of Present Illness:
___ with distant DVT on enoxaparin, GERD, CAD, chronic sCHF (EF
45% in ___, HTN, asthma on 2L NC home O2 who presents after
syncopal event. She was standing in the bank when she suddenly
lost consciousness and fell to the ground, which was witnessed
by her daughter. She ___ feeling hot prior to the syncopal
event and remembers starting to fall, she subnsequenyly
remembers waking up on the floor of the bank. She reported a
chest "tightness" during this time. She reports no prior
syncopal events but is a poor historian.
She arrived to the ED and was found to be in sinus tach with
LBBB, prior EKGs notable for IVCD when her rate is slower. She
subsequently developed a wide complex tachycardia and was given
amiodarone 150mg with no improvement. Rhythm appeared to be SVT
with aberrancy vs Vtach. Cardiology consulted and she was given
250mg procainamide with conversion to sinus tach per report. She
had mild chest "tightness" during this time but was not
hemodynamically unstable and was mentating.
She was recently admitted to ___ for abd pain and reflux and
was discharged yesterday. Of note, she was in sinus tach with
IVCD that admission which improved with reinitiation of her home
diltiazem (unclear if she was taking as prescribed at home). She
has a h/o DVT and is reportedly supposed to be on Lovenox,
although details of this are unclear. She has allergy to
contrast and had a V/Q scan last admission which was low
probability for PE.
In the ED, initial vitals were 98.6 ___ 18 100%
Labs and imaging significant for stable anemia (32), trop of
0.02, lactate of 2.2. She had CT head and abd/pelvis which were
notable for a trace pericardial effusion and non-specific
calvarial lesion. Patient given amiodarone and procainamide as
noted above.
Vitals on transfer were 120 129/84 16 100%
On arrival to the floor, patient reports only mild epigastric
pain. She has no other complaints.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, 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. Coronary artery disease.
2. Ischemic cardiomyopathy. EF 35-40% on ECHO in ___.
3. Asthma, though no PFTs in system and no documented outside
PFTs. uses 2LNC at home
4. Lower extremity DVT that was diagnosed at ___ at an unknown
time and was treated for an unknown length of time, but this was
many years ago.
5. Dyslipidemia.
6. Hypertension.
7. Normocytic anemia.
8. Chronic rhinosinusitis.
9. Depression.
10. Adenoid hyperplasia
11. ventricular tachycardia and atrial flutter s/p electrical
cardioversion ___
Social History:
___
Family History:
She has several members of family with coronary artery disease
and heart attacks, no diabetes, no cancer reported.
Physical Exam:
Admission:
VS- 151/97 92 20 98%/RA
GENERAL- WDWN female in NAD. Oriented x3. Strange affect.
Repetitive lip smacking movements.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI.
NECK- JVP difficult to assess given habitus, does not appear
markedly elevated
CARDIAC- irregularly irregular, normal S1, S2. No m/r/g.
LUNGS- CTAB
ABDOMEN- Soft, NT, obese. No HSM or tenderness.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Discharge:
VS- 98, 135-179/84-92, 106-161, 20, 100% RA
GENERAL- WDWN female in NAD.
HEENT- MMM
NECK- JVP ___
CARDIAC- RR tachycardic, normal S1, S2. No m/r/g.
LUNGS- CTAB on anterior and lateral lung fields, pt refuses to
move for post lung fields
ABDOMEN- Soft, NT, obese. No HSM or tenderness.
EXTREMITIES- No c/c/e.
Pertinent Results:
Admission:
___ 07:30AM PLT COUNT-268
___ 07:30AM WBC-4.7 RBC-3.52* HGB-10.3* HCT-31.5* MCV-90
MCH-29.4 MCHC-32.8 RDW-13.8
___ 07:30AM ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-5.0*
MAGNESIUM-2.9*
___ 07:30AM cTropnT-<0.01
___ 07:30AM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-59 TOT
BILI-0.2
___ 07:30AM GLUCOSE-102* UREA N-18 CREAT-1.2* SODIUM-142
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-18
___ 03:45PM cTropnT-0.02*
___ 03:45PM LIPASE-35
___ 03:45PM ALT(SGPT)-15 AST(SGOT)-23 ALK PHOS-66 TOT
BILI-0.2
___ 03:48PM LACTATE-2.2*
___ 11:56PM CK-MB-4 cTropnT-0.02*
___ 11:56PM CK(CPK)-82
Discharge:
___ 09:30AM BLOOD WBC-6.3 RBC-3.54* Hgb-10.5* Hct-31.5*
MCV-89 MCH-29.8 MCHC-33.5 RDW-13.6 Plt ___
___ 09:30AM BLOOD UreaN-16 Creat-0.9 Na-140 K-4.2 Cl-106
HCO3-22 AnGap-16
___ 04:26AM BLOOD CK(CPK)-51
___ 09:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.3
___ 07:06AM BLOOD TSH-0.65
Imaging:
CHEST (PA & LAT) Study Date of ___
FINDINGS: Lung volumes are low. There is no focal
consolidation. Moderate cardiomegaly is not significantly
changed. The descending thoracic aorta is mildly tortuous, as
before. There are no definite pleural effusions. No
pneumothorax is seen.
IMPRESSION:
1. Low lung volumes. No focal consolidation.
2. Unchanged moderate cardiomegaly.
CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
1. No acute intracranial process.
2. Nonspecific hypodense bony lesions within the calvarial
vertex; if this patient has a history of malignancy, metastases
are not excluded. Otherwise, these lesions are nonspecific in
nature.
CT ABD & PELVIS W/O CONTRAST Study Date of ___
IMPRESSION:
1. Heavily calcified abdominal aorta, without associated
aneurysmal dilation.
2. Mild cardiomegaly and trace pericardial effusion.
Portable TTE (Complete) Done ___
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe regional left ventricular
systolic dysfunction with hypokinesis of the inferior and
inferoseptal walls and akinesis of the inferolateral segments.
There is visual dyssynchrony of the septum. There is an
inferobasal left ventricular aneurysm. Right ventricular chamber
size is normal. with mild global free wall hypokinesis. There is
abnormal septal motion/position. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with moderate
symmetric left ventricular hypertrophy and moderate to severe
left ventricular systolic dysfunction as described above.
Inferobasal left ventricular aneurysm. Mild aortic, mitral, and
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
ECG Study Date of ___ 2:15:06 AM
Ventricular tachycardia with right bundle-branch block
configuration, new as compared with previous tracing of ___.
ECG Study Date of ___ 8:11:50 AM
Baseline artifact. Sinus tachycardia. Intraventricular
conduction defect.
Diffuse non-specific ST-T abnormalities. Compared to the
previous tracing of ___ left bundle-branch block has
resolved. Clinical correlation is suggested.
Brief Hospital Course:
___ with h/o DVT not on anticoagulation, GERD, CAD, chronic sCHF
(EF 45% in ___, HTN, asthma on 2L NC home O2 who presents
after syncopal event
# Syncope: Patient presented after syncopal event. PMH is
notable for presumed CAD and ischemic cardiomyopathy. While in
the ED, patient had an episode of ventricular tachycardia and
dropped her pressure somewhat. It is likely that this episode of
syncope was secondary to arrhythmia.
# Monomorphic ventricular tachycardia: Patient had episode of
wide complex tachycardia in the ED and a recurrent event during
the hospitalization that lasted for 45 minutes. She was treated
both times with 300 mg procainamide and responded to this. She
was asymptomatic during these events. Etiology unclear as
monomorphic VT is typically not secondary to ischemic
cardiomyopathy. Patient declined any invasive procedures that
may have helped elucidate the etiology. There were no
electrolyte abnormalities to account for rhythm.
# Supraventricular tachycardia: Rhythm was narrow complex
tachycardia at rate of 125, consistent with atrial tachycardia
or atrial flutter, but most likely atrial flutter. Patient was
started on amiodarone and diltiazem was discontinued. She
converted to NSR after several days of amiodarone loading. She
was discharged on 400 mg BID for one week to be decreased to 400
mg daily after that. She was also started on warfarin with a
lovenox bridge.
#Chronic systolic CHF: History of chronic systolic heart failure
with EF 45%. Patient appeared euvolemic on exam. She is not on
an ace inhibitor, angiotensin receptor blocker or beta blocker
due to allergies. ECHO done on ___ showed EF 35%hypokinesis of
the inferior and inferoseptal walls and akinesis of the
inferolateral segments and an inferobasal left ventricular
aneurysm.
#CAD: #CAD: Has evidence of inferior hypokinesis/akinesis on
ECHO, likely from prior cardiac events. Also has LV aneurysm
which suggests possibility of prior ischemia/infarction. Unclear
if this is contributing to her arrhythmia. Trop 0.02, 0.03.
Can't tolerate beta blocker, allergy to lisinopril and possibly
losartan. Patient refused cardiac catheterization. Aspirin
continued.
# Hypertension: Patient had blood pressures that were
persisently high. Medications were titrated and she was started
on amlodipine, hydralazine and isosorbide mononitrate with
acceptable blood pressure control. She cannot tolerate beta
blockers due to her asthma and has an allergy to lisinopril and
losartan.
Transitional Issues:
- Coumadin titration needed
- Ongoing discussion of goals of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN cough, wheeze,
dyspnea
2. Amitriptyline 100 mg PO HS
3. Aspirin 325 mg PO DAILY
4. Diltiazem Extended-Release 360 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN cough, wheeze,
dyspnea
8. Prochlorperazine 10 mg PO BID
9. Albuterol Inhaler 1 PUFF IH Q4H:PRN cough, wheeze, dyspnea
10. Ranitidine 150 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
Discharge Medications:
1. Hospital Bed
Mass ___ ___
Diagnosis: congestive heart failure, ventricular tachycardia
Length: one year
For Home Use
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN cough, wheeze,
dyspnea
3. Amitriptyline 100 mg PO HS
4. Aspirin 81 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN cough, wheeze,
dyspnea
7. Ranitidine 150 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Amiodarone 400 mg PO BID Duration: 7 Days
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*7
Tablet Refills:*0
10. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. HydrALAzine 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
12. 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
13. Enoxaparin Sodium 100 mg SC EVERY 12 HOURS
RX *enoxaparin 100 mg/mL 100 mg twice a day Disp #*10 Syringe
Refills:*0
14. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
15. Albuterol Inhaler 1 PUFF IH Q4H:PRN cough, wheeze, dyspnea
16. Prochlorperazine 10 mg PO BID
17. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
18. Amiodarone 400 mg PO DAILY
start on ___
RX *amiodarone 400 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
19. Outpatient Lab Work
Please check INR on ___ and fax the results to Dr. ___
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: atrial flutter, ventricular tachycardia
Secondary: chronic systolic congestive heart failure, coronary
artery disease, hypertension, asthma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
with an irregular heart rhythm that was treated with medications
and a cardioversion.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Medication changes:
STOP diltiazem
STOP hydrochlorothiazide
START coumadin
START amlodipine
START hydralazine
START lovenox until INR therapeutic
START amiodarone 400 mg BID for one week then decrease to 400 mg
daily
Followup Instructions:
___
|
19657931-DS-12
| 19,657,931 | 20,702,483 |
DS
| 12 |
2182-05-06 00:00:00
|
2182-05-06 21:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pt with PMH of HTN, cataracts, and recent episode of
diverticulitis requiring hospitalization, brought in by her
sister and her sons for increasing confusion over 1 month. She
saw her PCP last week, who recommended that she followup with
___. She does have an appointment ___
___ here, however her family feel that she is
continuing to deteriorate and was concerned that the appointment
is too far away. They brought her to ED because they don't feel
like she is adequately caring for herself at home. Pt's sister
feels that the pt is suicidal but believes that the pt has no
specific plan. Family report that prior to her admission for
diverticulitis, she was "out and had to be revived," and reports
that her brother who found her did mouth to mouth because she
was not breathing. Patient has been recalling his episode often
and saying "I should have died then."
In the ED, initial vs were: 95.1 50 151/66 16 100%. Labs were
remarkable for hyponatremia to 123, unclear baseline. Her UA was
positive for leuk esterase, nitrites, WBC/bacteria. Psychiatry
was consulted for depression. CT of the head showed enlarged
ventricles/sulci consistent with age-related volume loss, no
acute abnormalities. Vitals on Transfer: 98.3 73 135/78 18 96 %
On the floor, vs were: T P 54 BP 185/84 R 18 O2 sat 95% RA
Past Medical History:
Cataracts
HTN
OA
Diverticulosis
GI bleed and syncope (___)
new diagnoses during this admission:
Hypothyroidism
Relative adrenal insufficiency
___
Social History:
___
Family History:
Mother with DM, sister with a "heart condition." Sister alive
and well at age ___, brother also alive and well, in his ___.
Physical Exam:
ADMISSION EXAM:
T P 54 BP 185/84 R 18 O2 sat 95% RA
General: Elderly female, alert, oriented x3, no acute distress.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: slow rate but regular, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing or cyanosis. 2+ pitting
edema bilaterally to mid shin, worse than usual per
patient/family.
Skin: ecchymoses on L arm and bilateral ankles, reportedly from
her recent fall.
Neuro:
CN III-XII intact, acuity not tested (pt with known bilateral
cataracts). Strength in upper and lower extremity ___. Unable to
elicit biceps and patellar reflexes bilaterally. Sensation
intact to light touch in both lower extremities. Gait not
tested.
MMSE:
Orientation to date: 5
Orientation to location: 5
Registration: 3 (apple, table, ___
Serial 7s: 1, and then gives up.
Recall: 1 for apple, able to get table and ___ with prompt
Naming: 2 (pen/stethoscope)
Repeating: 0
3 stage command: 3
"Close your eyes": 1
Drawing: 0
==========
total: 21
DISCHARGE EXAM:
VS 97.3 138/80 82 18 98%RA
GEN: tired appearing, arousable to voice, conversant once awake.
HEENT: MM dry.
CV: RRR, nl S1/S2, no m/r/g
LUNG: poor respiratory effort, but no crackles/wheezes
anteriorly
EXT: knees/ankles mildly tender to palpation, +lower extremity
swelling. no joint effusion noted.
NEURO: moving all extremities on command
Pertinent Results:
ADMISSION LABS:
___ 12:05PM BLOOD WBC-4.9 RBC-3.75* Hgb-11.3* Hct-34.1*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.1 Plt ___
___ 12:05PM BLOOD Neuts-74.0* ___ Monos-5.2 Eos-0.5
Baso-0.2
___ 12:05PM BLOOD Glucose-82 UreaN-36* Creat-1.1 Na-123*
K-4.3 Cl-89* HCO3-21* AnGap-17
___ 12:05PM BLOOD ALT-31 AST-36 LD(LDH)-284* AlkPhos-88
TotBili-0.2
___ 12:05PM BLOOD Albumin-4.4 Calcium-10.0 Phos-3.3 Mg-2.4
___ 12:05PM BLOOD VitB12-GREATER TH Folate-GREATER TH
ENDOCRINE:
___ 12:05PM BLOOD TSH-13*
___ 10:59AM BLOOD FSH-14* LH-5.8 Prolact-5.6 TSH-16*
___ 07:30AM BLOOD T3-62* Free T4-0.99
___ 10:59AM BLOOD T4-5.3
___ 07:55AM BLOOD Cortsol-9.5
___ 07:45AM BLOOD Cortsol-5.1
___ 10:59AM BLOOD Cortsol-4.5
___ 12:10PM BLOOD Cortsol-30.6*
SERUM TOX:
___ 12:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-10
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
HEAD CT ___: No acute intracranial process. If concern for
acute infarction persists, then MRI would be the study of
choice.
CXR ___: No acute cardiopulmonary abnormality. Moderate size
hiatal hernia.
CXR ___: There is mild enlargement of the cardiac
silhouette. There is no focal consolidation or definite pleural
effusions. There is no overt pulmonary edema. There is
atelectasis and likely a small effusion at the left lung base.
HEAD CT ___: IMPRESSION:
1. No acute intracranial process.
2. Pituitary enlargement, most likely an adenoma, but may be
further evaluated with MR. ___ since study from ___.
MICROBIOLOGY:
UCx ___: pan-sensitive e coli
UCx subsequently, all negative
BCx ___: negative
BCx ___ and ___ -> NGTD
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] Monitor Na, consider changing fluid restriction to 1L or
stopping celexa if worsening hyponatremia
[ ] Patient will need to follow up with endocrine for
hypothyroidism/adrenal insufficiency, urology for urinary
retention and gerontology for her confusion
=============================
___ yo F brought in by family for worsening confusion and
increasing SI/depression, found to have hyponatremia,
hypothyroidism and urinary tract infection. Her reversible
metabolic derangements were medically managed, however,
patient's mental status remained depressed. She was seen by
geriatric psychiatry who recommended Celexa.
# Confusion/Depression: on history, it appears that family's
concern mostly is with safety. Though they report that patient
is "confused," they agree that she has been able to do basic ADL
including cooking/feeding herself. Initial work for reversible
causes of dementia initiated by ED, CT of head showed
age-related volume loss. TSH was found to be elevated, with
low/normal free T4 and low T3. B12 and folate were above normal.
She was also found to be hyponatremic, which was treated as
below. Her UTI was also treated as below. She had waxing and
waning mental status throughout the hospitalization, alternating
between more somnolent and having a poor PO intake and having
more awake and interactive days.
# Endocrine: pt with an intrasellar mass on CT per OSH discharge
summary, repeat head CTs here without interval change. Endocrine
c/s obtained given pt's hypothyroidism and ?adrenal
insufficiency given episodes of hypotension in house. Pt had
low/normal AM cortisol levels (in the setting of stress) and an
appropriate cosyntropin stim test, which means that her adrenals
are responsive, however, there was a question of hypopituitarism
and relative adrenal insufficiency given low FSH/LH (should be
high in post-menopausal woman) in the patient. Given episodes of
hypotension, she was started on 5 mg prednisone daily per
endocrine recs. She was also started on levothyroxine 25 mcg
daily for her hypothyroidism. MRI of head was considered, but as
it was thought not to provide much additional
information/benefit and given that patient and her family were
against surgical intervention, it was not obtained. Patient will
need to follow.
# Hyponatremia: Na found to be 123 on admission, normal Na
during hospitalization in ___. Thought to be due to SIADH, so
started on fluid restriction and salt tabs per renal and Na
improved to 134. It was stable around 134, however, decreased to
127 with initiation of celexa. So salt tab was increased.
# Hypotension: episode of hypotension after patient had been
sitting up. thought to be due to orthostatic hypotension and
hypovolemia. Patient's blood pressure improved very quickly with
IVF. Infectious w/u underway to rule out sepsis.
# UTI: patient with UA positive for bacteria, leuks/WBC and
nitrites, grew pan-sensitive E coli. She was initially treated
with ceftriaxone and antibiotic was broadened when she became
hypothermic and hypotensive, and she completed her course of
antibiotics. Her repeat UA and UCx were negative.
# HTN: As she became normotensive, her atenolol and hydralazine
were held.
# CODE: DNR/DNI
# CONTACT: Son ___: CELL ___ home ___
Medications on Admission:
atenolol 50 mg daily
hydralazine 20 mg TID
multivitamin
metamucil
mineral oil
fish oil
vitamin B12
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
please notify ___ if giving for fever. thank you.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
hold for loose stool
3. Calcium Carbonate 1500 mg PO BID
4. Cyanocobalamin 50 mcg PO DAILY Start: In am
5. Docusate Sodium 100 mg PO BID
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Multivitamins 1 TAB PO DAILY Start: In am
9. Polyethylene Glycol 17 g PO DAILY
hold for loose stool
10. PredniSONE 5 mg PO DAILY
11. Senna 1 TAB PO BID
12. Sodium Chloride 2 gm PO TID
hold for Na >140
13. Vitamin D 800 UNIT PO DAILY Start: In am
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hypoactive delirium, hyponatremia,
hypothyroidism, adrenal insufficiency, urinary retention
Secondary Diagnosis: hypertension, constipation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
confusion. You were found to have low sodium, low adrenal
function and low thyroid function, so you were started on
medications for those medical problems. You also had a foley
catheter placed because you were unable to urinate on your own.
Please follow up with endocrine and urology doctors as below.
Your hypertension medications were stopped because you had some
low blood pressures.
STOP atenolol and hydralazine for now. This can be restarted if
your blood pressure improves.
Followup Instructions:
___
|
19657946-DS-17
| 19,657,946 | 20,573,653 |
DS
| 17 |
2116-04-16 00:00:00
|
2116-04-18 10:51:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
two episodes of loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old female with a history of
vasovagal syncope, hypertension, hyperlipidemia, and ocular
migraines who presents with two episodes of loss of
consciousness
with neurology consulted for seizure vs syncope.
Ms. ___ was in her usual state of health when she returned
from vacation in ___ on ___ at 2 AM. Patient says she
woke at 6 AM and was feeling very fatigued and overall unwell.
She says she had an episode of her atypical ocular migraines in
the morning but it resolved on its own without intervention.
She
has not had a headache associated with it. After this she
started to feel nauseous with abdominal cramping and had an
episode of diarrhea. She remembers getting up and walking out
of
the bathroom and feeling "drained" with some abdominal cramping.
The last thing she remembers and then she says that she vaguely
remembers EMS being at her house but cannot say how they got
there remembers them coming into the house. She was told that
she had passed out and her husband found her face on the floor.
She was told that she was in and out of consciousness would
start
to wake back up and then passed back out per her husband and
this
is what made him called the ambulance. Per notes, EMS and
patient's husband, who is not at bedside, said that the second
episode of syncope happened when she stood up to get on the
stretcher. This episode also had full body shaking that lasted
for about 30 seconds. After this she regained consciousness and
was back at baseline without any reported confusion. She denied
any tongue biting, urinary incontinence. Currently she feels
that she is mentally at baseline and feels well other than her
nose hurting and being very tired.
He was initially brought to ___ where she had a CT head that
was read as no acute intracranial process. On review she has
likely chronic white matter disease, and a very small right
occipital calcified cyst.
Labs at ___ were significant for WBC 5.6, Hgb 14.1, Plts 201.
Potassium was mildly low at 3.4, Na 137.
She was transferred to ___ ED for evaluation by neurology as the
hospitalist on-call felt that patient may need an EEG and that
was not able to be done at ___.
Other than feeling tired and having abdominal cramping she
denies
any dizziness, lightheadedness, chest pain, palpitations,
shortness of breath prior to her syncopal episode.
Per patient this episode is similar to her prior vasovagal
episodes. The last episode being about ___ years ago where she
syncopized getting off the T and had a concussion afterwards.
Prior episodes have been associated with abdominal discomfort,
cramping and diarrhea. Per patient the syncope has been worked
up at ___ where she had a tilt table test that confirmed
vasovagal syncope.
Per patient she recently had an echo and a carotid ultrasound at
___. She was told these were normal other than some mild aortic
valve disease. When asked why she got the study she said she
wanted it because her sister has had some issues with her heart
wanted to have her's evaluated.
She denies any other head trauma other than concussion
associated
with her last syncope ___ years ago. She endorses a history of
viral meningitis about ___ years ago. No other history of
seizures.
On neuro ROS, positives noted in HPI, the pt denies headache,
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, positives noted in HPI, 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 vomiting, constipation.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hypertension
Vasovagal syncope
Hyperlipidemia
Ocular migraines
Mild aortic stenosis
Osteoporosis
Social History:
___
Family History:
Her mother passed away in her ___ from a car accident
Her sister has had strokes and MIs in the past
Brother with hypertension hyperlipidemia
Her father was healthy and lived to the age of ___
There is no family history of seizures or other neurologic
disorders
Physical Exam:
ADMISSION
=========
Vitals: T98.3, HR78, BP113/64, RR21, 94% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, MMM, no lesions noted in
oropharynx, dried blood in bilateral nostrils, nose is mildly
erythematous and swollen
Neck: Supple, no nuchal rigidity, no carotid bruits appreciated
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused, III/IV systolic murmur best
heard at RUSB
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam
performed, revealed crisp disc margins with no papilledema,
exudates, or hemorrhages. EOMI without nystagmus. Normal
saccades. Facial sensation intact to light touch. No facial
droop, facial musculature symmetric.Hearing intact to finger-rub
bilaterally. Palate elevates symmetrically. ___ strength in
trapezii bilaterally. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 3+ 2 3+ 3+ 2
R 3+ 2 3+ 3+ 2
Biceps and brachioradialis reflexes brisk with spread
bilaterally
Patella with bilateral cross adductors and suprapatella reflexes
no clonus bilaterally
Plantar response was withdraw bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally. Finger taps are small and
mildly
uncoordinated bilaterally
-Gait: Good initiation. mildly wide based normal stride and arm
swing. Able to walk in tandem but seems to swing her right foot
over further past left foot when doing so. Romberg absent but
does sway
DISCHARGE
========
max: 37.3 °C (99.1 °F)
Tcurrent: 98.2 °F
HR: 68
BP: 117/69 mmHg
RR: 16 insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
PHYSICAL EXAM:
General: Awake, cooperative, comfortable sitting up in bed.
HEENT: NC/AT, no scleral icterus noted, moist mucous membranes.
Neck: Supple, No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions.
NEUROLOGIC:
-Mental Status: Awake, alert, oriented to person, place, time
and
event. Relays history without difficulty. Language is fluent
with
intact comprehension and normal prosody. There were no
paraphasic
errors, and speech was not dysarthric. No evidence of apraxia or
neglect.
-Cranial Nerves: PERRL 3 to 2mm and brisk. VFF to confrontation.
EOMI without nystagmus. Facial sensation intact to light touch.
No facial droop, facial musculature symmetric.
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No
adventitious movements, such as tremor, noted. No asterixis
noted.
-DTRs: deferred
-___: No intention tremor or dysmetria.
-Gait: Deferred
Pertinent Results:
LABS
====
___ 09:51AM BLOOD WBC-5.4 RBC-4.20 Hgb-13.6 Hct-42.0
MCV-100* MCH-32.4* MCHC-32.4 RDW-12.9 RDWSD-47.6* Plt ___
___ 12:50AM BLOOD Neuts-80.4* Lymphs-11.4* Monos-7.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.47 AbsLymp-0.63*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.01
___ 09:51AM BLOOD Plt ___
___ 09:51AM BLOOD ___ PTT-23.4* ___
___ 12:50AM BLOOD Plt ___
___ 12:50AM BLOOD ___ PTT-22.1* ___
___ 09:51AM BLOOD Glucose-178* UreaN-12 Creat-0.8 Na-140
K-4.1 Cl-108 HCO3-19* AnGap-13
___ 09:51AM BLOOD Calcium-8.5 Phos-2.0* Mg-3.3* Cholest-152
___ 07:48PM BLOOD %HbA1c-5.5 eAG-111
___ 09:51AM BLOOD Triglyc-94 HDL-86 CHOL/HD-1.8 LDLcalc-47
IMAGING
=======
MR ___ and WO CONTRAST
IMPRESSION:
1. A punctate focus of slow diffusion in the left occipital
lobe, without
definite correlate on T2 weighted imaging, likely representing
acute/the early
subacute infarct.
2. Right occipital cyst measuring up to 1.2 cm without
associated edema or
restricted diffusion. Given its location, this likely
represents an
porencephalic cyst as opposed to an ependymal cyst as a clear
connection with
the ventricle is not discerned, a benign entity.
3. 5 mm aneurysm incidentally noted at the right M1/M2
bifurcation.
CTA W and WO CONTRAST
IMPRESSION:
1. No acute intracranial abnormalities.
2. No evidence of large vessel occlusion or high-grade stenosis.
3. 5 mm saccular aneurysm arising from the right MCA
bifurcation.
4. 20% narrowing of the proximal right internal carotid artery
by NASCET
criteria due to calcified plaque. No left internal carotid
artery stenosis by
NASCET criteria.
5. 3 mm hypodense nodule within the right lobe of the thyroid.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mrs. ___ is a ___ female with a history of
vasovagal syncope, hypertension, hyperlipidemia, ocular
migraines, and mild aortic stenosis who presented after 2
syncopal events 1 of which was associated with 30 seconds of
full body shaking.
On imaging, head CT ruled out hemorrhage. Given her recent
travel to ___, an MRI of the brain was obtained to rule
out acute infectious process which could precipitate seizures.
This revealed a 1.2 x 0.8 cm left occipital lobe acute/early
subacute infarct.
This very small infarct was felt to be entirely unrelated to her
presenting symptoms given the location (left occipital lobe) and
small size.
Etiology of her syncopal episodes felt to be vasovagal syncope
in the setting of dehydration from recent GI illness. She has
had similar syncopal episodes in the past which have also been
triggered by diarrhea and abdominal cramping in the past.
Shaking movements observed after the syncopal event most likely
represent convulsive syncope. Routine extended EEG was obtained
to rule out epileptiform discharges. This was unremarkable.
With respect to etiology of stroke, the patient underwent TTE
with bubble study to assess for PFO. This was negative and
showed no ASD or PFO. She also underwent lower extremity
ultrasound duplex studies (given recent plane ride) which
revealed no DVT in either leg.
The patient was discharged with a Ziopatch for extended cardiac
monitoring given concern for cardio-embolic etiology. She was
also started on 81 mg aspirin daily as secondary prevention. LDL
47 so statin dose was not changed.
TRANSITIONAL ISSUES:
====================
# Patient had Ziopatch placed prior to discharge to assess for
occult atrial fibrillation. Please follow up read in outpatient
setting.
# Started aspirin 81 mg daily.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 50 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO QPM
4. coenzyme Q10 100 mg oral DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection qMonth
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
2. amLODIPine 5 mg PO DAILY
3. coenzyme Q10 100 mg oral DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection qMonth
6. Rosuvastatin Calcium 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left occipital ischemic stroke
Aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of syncope and abnormal
movements. While in the emergency room, ___ had an MRI of your
brain which revealed an ACUTE ISCHEMIC STROKE, a condition where
a blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. We believe that this is unrelated to the
symptoms that ___ presented with. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High blood pressure
We are changing your medications as follows:
- Started a baby aspirin (81 mg per day)
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19658009-DS-19
| 19,658,009 | 28,028,772 |
DS
| 19 |
2119-01-18 00:00:00
|
2119-01-19 10:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hypertension, hypothyroidism, and no prior CHF history
intially presented to ___ with dyspnea at rest for 1 day. She
was found to have CHF exacerbation with proBNP 4000 and SBP 200.
UA at ___ with many bacteria, nitrite positive and she had
lactate 4.2. She was given ceftriaxone, aspirin 81mg, Lasix 80mg
IV, and started on NTG drip. She was transferred from ___ on
BiPAP and transitioned to CPAP by EMS. Both BiPAP/CPAP and NTG
drip were discontinued on arrival to ___.
In the ED, initial vitals were 97.6 60 ___ 99%. She was on
3L NC satting well, no respiratory distress and unlabored
breathing. Foley from OSH draining clear yellow urine. Labs here
notable for BNP 4357, lactate 2.1, troponin 0.08->0.06, and Cr
1.0. EKG without acute findings. In the ED, she was given
ceftriaxone 1g IV, HCTZ 12.5mg, and lisinopril 10mg.
On the floor, patient is feeling much better without acute
complaints. She reports she had a blood clot diagnosed in her
LLE several weeks prior. She was not started on treatment but
asked to elevate her legs.
Past Medical History:
PMH:
-Hypertension
-Hypothyroidism
-Osteoporosis
-Hearing loss
Social History:
___
Family History:
Father with heart problems. Brother with prostate cancer.
Physical Exam:
ADMISSION PHYSICAL:
VS: T97.5 148/63 68 16 100% on 4L NC, 46.9kg
GENERAL: Elderly woman, hard of hearing, no acute distress
HEENT: anicteric sclera, MMM
NECK: JVP elevated to 12 cm
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNG: Bibasilar rales R>L halfway up lung, no wheezing,
unlabored and easy breathing
ABD: nondistended, +BS, nontender, no rebound/guarding
EXT: 2+ pitting edema in ___ up calves, LLE slightly pink and
tender to touch, calves are symmetric size, L foot slightly
cool, R warm
PULSES: nonpalpable, but DP and ___ have strong Dopplers
bilaterally
NEURO: alert and oriented
DISCHARGE PHYSICAL:
98.8 128/50-163/49 ___ RA
W: 44.4 I/O: 1041/2360
GEN: NAD, breathing comfortably on 3L NC
HEENT: conjunctiva pink, sclera anicteric
NECK: supple, from, no LAD, JVP <8cm
CV: rrr, no m/r/g, nml s1/s2
LUNG: faint crackles b/l in both
ABD: benign
EXT: wwp, 1+ pitting edema to shins b/l
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS
___ 09:00AM BLOOD Glucose-113* UreaN-26* Creat-1.0 Na-143
K-3.7 Cl-105 HCO3-24 AnGap-18
___ 09:00AM BLOOD proBNP-4357*
___ 09:00AM BLOOD cTropnT-0.08*
___ 04:25PM BLOOD cTropnT-0.06*
___ 07:20AM BLOOD CK-MB-2 cTropnT-0.04*
___ 09:07AM BLOOD Lactate-2.1*
___ 08:17AM BLOOD Lactate-1.8
DISCHARGE LABS
___ 07:25AM BLOOD WBC-4.7 RBC-3.25* Hgb-9.0* Hct-28.5*
MCV-88 MCH-27.8 MCHC-31.7 RDW-15.6* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-29.6 ___
___ 07:25AM BLOOD Glucose-86 UreaN-45* Creat-1.1 Na-140
K-3.7 Cl-102 HCO3-29 AnGap-13
___ 07:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
TTE:
Conclusions
The left atrium is elongated. The left atrial volume index is
severely increased. The estimated right atrial pressure is ___
mmHg. Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 65 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). 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.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a small pericardial effusion.
The effusion is echo dense, consistent with blood, inflammation
or other cellular elements. There is no echocardiographic
evidence of tamponade.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. Moderate aortic regurgitation. Moderate
mitral regurgitation. Moderate pulmonary artery hypertension.
Small, echodense circumferential pericardial effusion.
___:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
CXR
IMPRESSION:
Low lung volumes. Moderate cardiomegaly. Signs of mild to
moderate chronic interstitial edema, combined 9 by small
bilateral pleural effusions and subsequent areas of atelectasis.
No evidence of pneumonia. Old healed rib fractures. No
pneumothorax.
Brief Hospital Course:
___ with h/o HTN and hypothyroidism p/w DOE x1 day found to have
elevated pro-BNP to 4000 and elevated lactate in the context of
htn urgency with SBPs in 200s and UA grossly positive for
infection leading to flash pulmonary edema.
ACTIVE ISSUES:
#acute dCHF: The pt presented with dyspnea, evidence of volume
overload on exam most noteably for pulmonary edema and a CXR c/w
acute CHF. An ECHO showed preserved ventricular function
(LVEF>65%) thereby qualifying this as dCHF. It was likely
precipitated by htn urgency with a component of demand from her
UTI. She was given lasix 40 mg IV x1 and diuresed very well
(~2L). She had subsequent decreases in her O2 requirement and
she was weaned to room air. Her lisinopril was increased to 20
mg PO BID. Discharged on 20 mg PO lasix and supplemental Mg,
with d/c weight of 44.4 kg.
#HTN Urgency: upon presentation at the OSH, the pt had SBP in
200s and was placed on a nitro gtt. Upon arrival to ___, her
blood pressures were more stable and did not require a nitro
gtt. Her lisinopril was increased to 20 mg PO BID. Home HCTZ was
stopped.
#UTI: grossly positive UA at OSH and she was given 1 dose of
ceftriaxone. Urine cultures speciated to E coli sensitive to
ceftriaxone and bactrim. She was continued on ceftriaxone while
she was an in patient and finished a 5d course.
#Anemia: Hb/Hct 8.7/27.3. Stable here, but at OSH was 10.3. No
s/s of GIB, stool per nursing was not melanotic. This was
trended here.
___: Cr up to 1.3 from baseline 1.0. In context of diuresis,
likely pre-renal. Resolved prior to d/c.
CHRONIC ISSUES:
#Hypothyroidism: continued on home levothyroxine
TRANSITIONAL ISSUES:
-Blood Pressure: ensure pt is adequately treated as her
hypertensive urgency likely precipitated her flash pulmonary
edema.
TRANSITIONAL ISSUES:
-Blood Pressure: ensure pt is adequately treated as her
hypertensive urgency likely precipitated her flash pulmonary
edema
-Needs electrolyte monitoring, next check should be on ___
-D/c'd on supplemental Mg
-Continue to assess volume status with daily weights, need for
lasix titration; discharged on 20 mg PO lasix
-Can start 5 mg of amlodipine if blood pressures are sustained
greater than 150 mm Hg
-Lisinopril dose increased, HCTZ stopped
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. alendronate 35 mg oral QWEEKLY
3. Lisinopril 10 mg PO BID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Gabapentin 100 mg PO QHS
7. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
8. Vitamin B Complex 1 CAP PO DAILY
9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO QHS
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
5. alendronate 35 mg oral QWEEKLY
6. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Lisinopril 20 mg PO BID
9. Furosemide 20 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
do not take within two hours of levothyroxine or alendronate
11. Docusate Sodium 100 mg PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACTIVE ISSUES:
#Hypertensive Urgency
#Acute dCHF exacerbation
#UTI
___
CHRONIC:
#hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were transferred from an outside hospital to ___ because
you were found to have extremely high blood pressures and fluid
in your lungs causing your shortness of breath. You were also
found to have a urinary tract infection. You were treated with a
medication to lower your blood pressure, and another medication
to remove fluid from your lungs. You were given a course of
antibiotics to treat your UTI.
An ultrasound of your heart called a echocardiogram revealed
your heart is function is normal.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team
Followup Instructions:
___
|
19658135-DS-8
| 19,658,135 | 20,850,089 |
DS
| 8 |
2136-04-12 00:00:00
|
2136-04-12 15:57:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / hayfever / ragweed / mold / perfume /
Sulfa(Sulfonamide Antibiotics) / Bactrim
Attending: ___.
Chief Complaint:
Fevers, Dyspnea
Major Surgical or Invasive Procedure:
No
History of Present Illness:
Mr. ___ is a ___ w/ hx of HIV on ART w/ last CD4 of 522 in
___, remote hx of PCP, and HBV cirrhosis c/b ___ s/p RFA,
AV replacement secondary to endocarditis in ___, who presents
w/ shortness of breath, subjective fevers, and tachypnea
concerning for pneumonia prompting admission to ICU.
He states he was in his normal state of health before he
developed "cold symptoms" with a cough and sputum production on
___ that has been primarily clear to yellow with some streaks
of red. It then progressed to shortness of breath two days ago.
Overnight and this morning, his dyspnea worsened and so he
presented to the emergency department. States he had been normal
functional status beforehand. He has no chest pain. He denies
subjective fevers, though per another OMR note he endorsed
subjective fevers. No sick contacts.
On ___, had CT abd for liver staging showed lungs w/ new
areas of mixed ground glass and consolidative opacities in the
more superior portion of the right lower lobe and in the right
middle lobe with concern for ongoing multifocal pneumonia.
Of note, underwent second radio-frequency ablation of HCC
___. No leg pain, no swelling
ED course:
- initial vitals 98.6 100 120/43 RR 40 93% RA
- respiratory rate in 40's, satting 90's on RA
- able to speak in full sentences
- CXR: concern for worsening multifocal pneumonia
- ID c/s in ED thought to defer PCP coverage based on last CD4
- given Vanc, Cefepime, Primaquine
- transfer vitals 96.0 120/46 32 94% RA
On arrival to the MICU, patient states he was not feeling
better. Still tachypneic but thinks he may be slightly improved.
Past Medical History:
AI/asc. aortic aneursym
HIV+
chronic Hep. B
cirrhosis
pancreatitis
cholelithiasis
nephrolithiasis
HTN
BPH
depression/anxiety
chronic fatigue
prior pneumocystis PNA
Social History:
___
Family History:
father CVA at ___
sister with HTN
Physical Exam:
Admission Physical
===================
Tmax: 37.1 °C HR: 96 BP: 120/47 RR: 40 SpO2: 96%
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, minimal white exudates on
oropharynx
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, ___ holosytolic murmur, ___
diastolic murmur
Abdomen- soft, TTP in RUQ, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no ___ lesions, no ___ nodes, no tenderness over
spine, chronic rash on left arm with that is linear/serpentine,
raised, nontender, nonerythematous
Neuro- CNs ___ intact, motor function grossly normal
Discharge Physical
====================
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM
Neck- supple, JVP not elevated, no LAD
Lungs- decreased breath sounds on right, bilateral crackles
CV- Regular rate and rhythm, ___ holosytolic murmur, ___
diastolic murmur
Abdomen- soft, nontender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no ___ lesions, no ___ nodes, no tenderness over
spine, chronic rash on left arm with that is linear/serpentine,
raised, nontender, nonerythematous
Neuro- CNs ___ intact, motor function grossly normal
Pertinent Results:
Admission Labs
===============
___ 09:55AM BLOOD WBC-6.0# RBC-4.40* Hgb-12.9* Hct-39.4*
MCV-90 MCH-29.4 MCHC-32.9 RDW-14.9 Plt ___
___ 09:55AM BLOOD Neuts-75.0* Lymphs-14.4* Monos-9.3
Eos-0.3 Baso-0.9
___ 09:55AM BLOOD ___ PTT-36.6* ___
___ 09:55AM BLOOD Glucose-101* UreaN-14 Creat-0.8 Na-137
K-3.9 Cl-102 HCO3-23 AnGap-16
___ 09:55AM BLOOD ALT-37 AST-29 LD(LDH)-226 AlkPhos-77
TotBili-4.0*
___ 09:55AM BLOOD cTropnT-0.03*
___ 09:55AM BLOOD Albumin-3.1*
___ 04:48AM BLOOD Calcium-7.7* Phos-2.2* Mg-1.9
___ 10:15AM BLOOD Type-ART pO2-71* pCO2-27* pH-7.56*
calTCO2-25 Base XS-2 Intubat-NOT INTUBA
___ 10:02AM BLOOD Lactate-3.1*
B-Glucan
========
___ 12:27
B-GLUCAN
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to 80
pg/mL
Discharge Labs
===============
___ 04:47AM BLOOD WBC-13.4* RBC-4.38* Hgb-12.6* Hct-39.4*
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.0 Plt ___
___ 04:47AM BLOOD Glucose-115* UreaN-16 Creat-0.7 Na-133
K-3.9 Cl-99 HCO3-24 AnGap-14
___ 04:47AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
Microbiology
=============
___ 9:55 am BLOOD CULTURE
Blood Culture, Routine (Pending):
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Imaging
=========
Chest Xray ___
FINDINGS: As compared to prior exam dated ___,
there has been slight improvement in the right lung
opacification, and slight worsening of the left lung
opacification. Bilateral, small pleural effusions are noted.
Severe cardiomegaly and pulmonary vascular congestion are
essentially stable.
The study and the report were reviewed by the staff radiologist.
ECHO ___
IMPRESSION: Suboptimal image quality. Thickened and deformed
aortic valve homograft leaflets with no overt vegetation
identified, though study technically limited. Increased
transvalvular gradient, likely due to structural deterioration
of valve and aortic regurgitation. Moderate to severe aortic
regurgitation. Mild aortic regurgitation. Moderate pulmonary
artery systolic hypertension. Mild symmetric left ventricular
hypertrophy with low-normal ejection fraction. Depressed right
ventricular function.
Compared with the prior study (images reviewed) of ___,
left ventricular cavity size has increased and systolic function
is less vigorous. Left ventricular wall thickness has decreased.
Pulmonary artery pressure is able to be estimated and is
moderately elevated. Right ventricular systolic function appears
more depressed.
Brief Hospital Course:
Mr. ___ is a ___ w/ hx of HIV on ART w/ last CD4 of 522 in
___ and HBV cirrhosis c/b HCC who presents w/ shortness of
breath, subjective fevers, and tachypnea concerning for
pneumonia prompting admission to ICU.
# Severe Sepsis with Pneumonia: Incidentally seen on ___ CT
abd/pelv during monitoring status post ablation of HCC. In the
ED, he required large amount of fluid resuscitation. In the ICU
he had no fevers, and maintained his blood presssure. He
remained tachypneic throughout his stay. He did require oxygen
for which he was weaned off prior to discharge. He
symptomatically improved with antibiotics. He was started on
broad spectrum antibiotics with vancomycin, cefepime, and
azithromycin. His urine legionella was negative. His sputum gram
stain and culture did not yield a definitive organism. As his
his CD4 count was above 500 in ___ it was thought he was
unlikely to be immunosuppressed. He was discharged with a 7 day
course of levofloxacin. He was to have close follow up with PCP
and with ___ ___ to come visit.
# Dyspnea with Tachypnea Initially, this was most likely due
to a severe pneumonia infection with stimulation of irritant
receptors in the lung leading to tachypnea. He improved
throughout his stay. As a consequence of the volume
resuscitation he received in the ED, he developed pulmonary
edema, which can cause tachypnea due to stimulation of
J-receptors in the lung. He was then diuresed with symptomatic
improvement. Additionally, he was noted to have a prominent
murmur consistent with aortic insufficiency. This was an old
finding attributed to a failing aortic valve replacement. He had
an ECHO which did not show acute mitral regurgitation as a
contributor to the pulmonary edema. The patient was able to
ambulate on the unit without significant discomfort prior to
discharge.
# Hyperbilirubinemia - He has had elevated bilirubin in the past
which may have been related to worsening obstruction from
malignant process vs. HIV medications vs. changes from recent
radiofrequency ablation of his HCC. He remained asymptomatic and
his bilirubin downtrended through his stay.
# HIV on ART, and Cirrhosis with Hep B: Last CD4 was 522 in ___. Hx PCP ___. He was continued on his home medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg oral qam
2. Atazanavir 300 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO DAILY
4. Entecavir 1 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Epzicom (abacavir-lamivudine) 600-300 mg oral qd
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
10. Senna 1 TAB PO DAILY:PRN constipation
11. QUEtiapine Fumarate 50 mg PO HS:PRN insomnia
12. Lidocaine 5% Patch 1 PTCH TD DAILY back or right elbow as
directed
13. Ketoconazole 2% 1 Appl TP DAILY:PRN as indicated
14. Fish Oil (Omega 3) 1000 mg PO BID
15. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES Q6H:PRN eye
irritation
16. Docusate Sodium 100 mg PO BID
17. Creon 12 3 CAP PO TID W/MEALS
18. Clotrimazole 1 TROC PO 5X/DAY
19. ClonazePAM 1 mg PO DAILY:PRN seizures
20. ClonazePAM ___ mg PO DAILY anxiety
21. Cialis (tadalafil) 20 mg oral prn ED
22. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atazanavir 300 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO DAILY
4. ClonazePAM 1 mg PO DAILY:PRN seizures
5. Clotrimazole 1 TROC PO 5X/DAY
6. Docusate Sodium 100 mg PO BID
7. Entecavir 1 mg PO DAILY
8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES Q6H:PRN eye
irritation
9. Ketoconazole 2% 1 Appl TP DAILY:PRN as indicated
10. Lidocaine 5% Patch 1 PTCH TD DAILY back or right elbow as
directed
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. QUEtiapine Fumarate 50 mg PO HS:PRN insomnia
13. RiTONAvir 100 mg PO DAILY
14. Senna 1 TAB PO DAILY:PRN constipation
15. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
16. Epzicom (abacavir-lamivudine) 600-300 mg oral qd
17. Omeprazole 20 mg PO DAILY
18. Fish Oil (Omega 3) 1000 mg PO BID
19. Creon 12 3 CAP PO TID W/MEALS
20. ClonazePAM ___ mg PO DAILY anxiety
21. Cialis (tadalafil) 20 mg oral prn ED
22. ALPRAZolam 1 mg ORAL QAM
23. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
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 during your admission to ___
___. You were admitted for
evaluation and treatment of shortness of breath and fevers. You
were treated for a pneumonia with antibiotics. In addition you
received medicine to help remove excess fluid from you lungs.
Your breathing improved and you had no further fevers. It was
determined you could be discharged to home with close follow-up
with your primary care physician. You will prescribed seven
days of antibiotics which you should take as directed. In
addition, you have an appointment with your PCP, ___
coming ___, for post-discharge follow-up of your pneumonia.
If you should develop fevers, worsening shortness of breath,
please seek care at your nearest emergency department.
Followup Instructions:
___
|
19658144-DS-15
| 19,658,144 | 24,381,085 |
DS
| 15 |
2169-08-23 00:00:00
|
2169-08-23 09:35:00
|
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 leg pain
Major Surgical or Invasive Procedure:
Left retrograde IMN ___
History of Present Illness:
___ s/p mech fall, transferred with L periprosthetic femur
fracture. Patient was walking in her house in the hallway when
she tripped over her walker last night. She denies HS/LOC. She
was brought to ___ where plain films showed a left
femur fracture below a L hip DHS from ___. She was transferred
to ___ for further management.
Past Medical History:
Aspirin 81 mg PO DAILY
Calcium Carbonate 1250 mg PO BID
Docusate Sodium 100 mg PO BID
Furosemide 20 mg PO DAILY
Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Lisinopril 20 mg PO DAILY
Metoprolol Tartrate 6.25 mg PO BID
Potassium Chloride 20 mEq PO DAILY
Simvastatin 40 mg PO QPM
Vitamin D ___ UNIT PO DAILY
Social History:
___
Family History:
NC
Physical Exam:
NAD, Pain controlled
AFVSS
LLE: incision d/c/i without erythemia, silt s/s/sp/dp/pt,
___, WWP
Pertinent Results:
Xray of left femur fx and after surgical fixation.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femur fx and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for L retrograde IMN 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 wbat in the left 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 may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Tartrate 6.25 mg PO BID
5. Simvastatin 40 mg PO QPM
6. Vitamin D ___ UNIT PO DAILY
7. Calcium Carbonate 1250 mg PO BID
Discharge Medications:
1. Calcium Carbonate 1250 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Tartrate 6.25 mg PO BID
5. Simvastatin 40 mg PO QPM
6. Vitamin D ___ UNIT PO DAILY
7. Acetaminophen 650 mg PO Q6H
8. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sq qpm Disp #*14 Syringe
Refills:*0
9. Multivitamins 1 CAP PO DAILY
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
11. Aspirin 81 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left femur shaft fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Discharge Instructions:
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- weight bear as tolerated in left lower extremity
Physical Therapy:
Weight bear as tolerated left lower extremity
Treatments Frequency:
Does not need dressing if incision remains non draining.
Followup Instructions:
___
|
19658144-DS-16
| 19,658,144 | 26,269,154 |
DS
| 16 |
2171-05-08 00:00:00
|
2171-05-08 15:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is an ___ yo woman with HTN, HLD, dementia who
presented with aphasia and right weakness.
Today, per unit manager, CNA went to give her breakfast at 8:30
am and noticed that the patient was unable to carry on a
conversation and that she had right facial droop. On nursing
assessment, she also had right hand weakness.
No recent illness.
ROS unable to obtain
Past Medical History:
Arthritis
Anxiety
Depression
HTN
HLD
Osteoporosis
Dementia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
General: Awake, NAD.
HEENT: NC/AT, dry MM
Neck: patient complains of pain if neck is manipulated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: ecchymoses on right arm, left arm in bandage.
Neurologic:
-Mental Status: awake, speaking softly, normal prosody. Fixes
and followed. Cannot state name. language content largely does
not make sense. does not answer questions or follow commands.
-Cranial Nerves:
PERRL, EOMI, right facial droop, hearing grossly intact.
-SensoriMotor: decreased bulk throughout, paratonia throughout.
Moves left arm spontaneously, good antigravity. Left leg minimal
spontaneous movement, says ___ to noxious. Right arm flaccid,
no
response to noxious. Right leg stiff, no spontaneous movement,
triple flexion to noxious.
-DTRs:
Unable to elicit reflexes due to paratonia and patient yelling
"get out of my room"
- right toe mute, left toe down
-Coordination/Gait: unable to test due to language barrier and
patient non-ambulatory at baseline.
DISCHARGE PHYSICAL EXAMINATION:
MS: Speaking formed language, very fluently but is not in
context to hospital. She appears anxious. When using a loud
voice, as she is hard of hearing, she is able to follow simple
commands on the left.
CN: Pupils equal and reactive, right facial droop.
Motor: Left upper extremity is brisk, Bilateral lower
extremities are contracted. Right upper extremity seen to be
moving horizontally in the plane of the bed.
Sensory: noxious stimulation not tested.
Coordination and Gait: Deferred
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 06:15AM 7.6 3.40* 10.6* 33.5* 99* 31.2 31.6* 12.9
46.0 176 Import Result
___ 06:25AM 7.4 3.46* 10.8* 34.4 99* 31.2 31.4* 12.7
46.2 175 Import Result
___ 07:05AM 8.5 3.59* 11.3 35.5 99* 31.5 31.8* 12.8
46.5* 202 Import Result
___ 06:20AM 8.3 4.04 12.4 40.2 100* 30.7 30.8* 12.4
45.2 212 Import Result
___ 11:40AM 9.1 4.57# 14.1# 44.4# 97 30.9 31.8* 12.2
43.8 227 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 11:40AM 70.7 21.5 6.1 1.0 0.3 0.4 6.43*
1.96 0.56 0.09 0.03 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 06:15AM 176 Import Result
___ 06:15AM 11.0 1.0 Import Result
___ 06:25AM 175 Import Result
___ 06:25AM 10.6 27.5 1.0 Import Result
___ 07:05AM 202 Import Result
___ 07:05AM 11.1 27.8 1.0 Import Result
___ 06:20AM 212 Import Result
___ 06:20AM 11.3 29.8 1.0 Import Result
___ 11:40AM 227 Import Result
___ 11:40AM 11.4 33.4 1.1 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:15AM ___ 146* 3.3 110* 23 16 Import
Result
___ 06:25AM 73 17 0.3* 144 3.1* 112* 22 13 Import
Result
___ 07:05AM 71 25* 0.4 144 3.3 108 21* 18 Import
Result
___ 06:20AM 90 23* 0.4 145 3.9 ___ Import
Result
___ 11:40AM 94 20 0.4 142 3.8 ___ Import Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 11:40AM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 11:40AM 9 18 85 0.9 Import Result
CPK ISOENZYMES cTropnT
___ 06:20AM <0.01 Import Result
___ 11:40AM <0.01 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 06:15AM 9.3 2.0* 1.5* Import Result
___ 06:25AM 9.1 1.9* 1.7 Import Result
___ 07:05AM 9.5 2.7 2.2 Import Result
___ 06:20AM 10.0 3.2 1.5* 174 Import Result
___ 11:40AM 4.2 Import Result
HEMATOLOGIC VitB12 Folate
___ 06:20AM 267 >20 Import Result
DIABETES MONITORING %HbA1c eAG
___ 06:20AM 5.3 105 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 06:20AM 94 42 4.1 113 Import Result
PITUITARY TSH
___ 06:20AM 0.98 Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
___ 11:40AM NEG NEG NEG NEG NEG NEG Import Result
IMAGING:
Non Contrast CT Head (___): 1. Grossly stable left basal
ganglia and external capsule intraparenchymal hemorrhage, with
no definite midline shift. While finding may be hypertensive in
etiology, underlying mass is not excluded. Recommend follow-up
imaging to
resolution. If clinically warranted, a contrast-enhanced brain
MRI can be
performed for further characterization.
2. Atrophic changes and chronic microvascular ischemic disease.
Brief Hospital Course:
Ms. ___ is an ___ woman with a past medical
history of hypertension, hyperlipidemia, and dementia who
presents from her nursing home with inability to carry her
breakfast tray, not able to speak properly in coherent
sentences, and a right facial droop. On evaluation in the OSH,
patient was noted to have a left basal ganglia hemorrhage, she
was transferred to ___ for further monitoring.
The following issues were managed:
#Neurology: L Basal Ganglia and Insular Hemorrhage:
-The patient was admitted to the step down unit for close
neurologic monitoring. The patient was noted to have a right
sided hemiplegia.
-Due to the location and extent of bleed, likely the etiology is
hypertensive. The patient's blood pressure was carefully
monitored and adjusted first with IV medications in the acute
phase. Once the patient was able to safely take PO (after a
formal swallowing evaluation), she was transitioned to PO
medication with lisinopril and resumed on her home metoprolol
dose.
-BP was stabilized in an appropriate range.
-The patient also became more verbal and lucid during the
hospitalization and on the last day of admission, she was able
to follow simple commands using the left upper extremity and in
the midline.
-The patient's aspirin was held as well as other NSAIDs. She was
started on subQ heparin 48 hours after bleed.
-The patient was placed on a modified diet of pureed softs with
thin liquids (1:1 supervision and crushed medications) as per a
formal swallowing evaluation.
-Lastly, the patient was evaluated by ___ and was referred for
further rehab.
#HTN:
-See above. It was monitored closely, lisinopril 10mg started.
#Urinary Tract Infection:
-UA showed infected urine. Patient was started on IV ceftriaxone
x3 days, urine grew Proteus mirabalis sensitive to the
antibiotic that was initiated. Patient remained aefebrile during
the hospitalization.
#Dehydration:
-Patient was maintained on IV fluids when she was not having
adequate PO intake in the initial stages of hospitalization.
The patient was safely discharged with stroke follow-up
scheduled.
Transitions of Care:
1. Please follow-up with the Stroke Attending on ___,
___.
2. Please follow-up with your primary care physician for further
blood pressure control, goal systolic <140 mmHg. The patient was
started on lisinopril with appropriate bp control.
3. MRI with and without contrast in ___ months for evaluation of
bleed and evaluation for any underlying mass lesions.
4. Encourage PO intake, she was not having adequate intake
during hospitalization, however we did not want to start tube
feeding as she was able to swallow. Re-assess as patient
improves.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
3. Citalopram 50 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H Duration: 3 Doses
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Tartrate 6.25 mg PO BID
4. Acetaminophen 650 mg PO TID:PRN Pain - Mild
5. Citalopram 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L Basal ganglia hemorrhage due to hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficult speaking
resulting from an acute brain bleed in the deep structures of
your brain. You will be transferred to a rehab facility for
further care.
We are changing your medications as follows:
1. Stop aspirin
2. Start lisinopril 10mg daily PO for blood pressure control.
Goal pressure should be less than 140 systolic BP.
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
Followup Instructions:
___
|
19658243-DS-10
| 19,658,243 | 20,018,154 |
DS
| 10 |
2127-05-29 00:00:00
|
2127-05-29 16:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / Klonopin / Ativan / Risperdal / Zyprexa / Seroquel /
Penicillins / Sulfa (Sulfonamide Antibiotics) / Chlorpromazine /
Trifluoperazine
Attending: ___.
Chief Complaint:
Altered Mental Status, Weakness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with ESRD on HD T/ThSa and schizophrenia presents with AMS
after she had dyruria x 2 days. She was started on Bactrim 1 day
ago for UTI with some resolution of her symptoms. She still
makes urine. She received HD yesterday ___ (she was on a
___ schedule this week due to
___) and tolerated it well. Today, around ___ she was
found sitting in the living room in the dark telling her family
she needed to go to dialysis despite having already received it.
In the middle of the night, she woke her husband to use to the
restroom. While she was in the restroom, she started to take a
shower and told her husband she was going to work. Husband
states she also had a few bouts of instability and needed
assistance to the car. Most of the history came from husband and
daughter, but patient is alert and oriented and added that she
was having bouts of confusion. She currently denies any
headache, vision changes, rhinorrhea, odynophagia, chest pain,
heart palpitations, SOB, cough, wheezing, abdominal pain, N/V/D,
leg pain, difficulty ambulating.
In the ED, initial vitals:
100.8 102 104/52 18 97% RA
Labs were significant for:
UA WBC >182, lactate 4.1 --> 2.9 after IVF, WBC 11.2, H/H
9.9/30.7
Imaging showed:
No acute cardiopulmonary abnormality.
In the ED, pt received:
PO Acetaminophen 1000 mg
IVF 500 mL NS
IV Piperacillin-Tazobactam
IV Vancomycin
IVF 500 mL
PO/NG Levothyroxine Sodium 25 mcg
PO Cinacalcet 120 mg
PO OXcarbazepine 150 mg
SC Insulin 4 Units
PO RisperiDONE 2 mg
Vitals prior to transfer:
99.0 78 103/50 17 100% RA
Currently, patient reports feeling better. Exam was limited ___
to patient confusion. She reports dysuria this AM but unable to
recall the last few days.
ROS:
(+) ROS as above. Otherwise negative
Past Medical History:
PSYCHIATRIC HISTORY:
- Long history of bipolar disorder. Multiple psychiatric
hospitalizations in the past at ___ and ___ and has been in the ___ hospital system; Was briefly
hospitalized on Deac4 in ___. Prior to then, last
hospitalized was almost ___ years ago.
- Well-controlled on Lithium for nearly ___ years. Has grown
toxic on Lithium x2, one of which involved ___ medical
stay at ___ (___).
- According to her former outpt psychiatrist, past failed med
trials include: Depakote (despite therapeutic levels, d/c'd
because of c/o SE), Tegretol, Neurontin, Zyprexa, Risperdal,
Seroquel, Abilify, possibly others.
- No hx of suicide attempts, SIB, HI
PAST MEDICAL HISTORY:
PCP ___ (___)
- ESRD likely from diabetic nephropathy vs. lithium toxicity
- NIDDM w/ poor compliance
- Hypothyroidism
- Chronic bronchitis
- Hyperlipidemia
- Hyperparathyroidism (likely parathyroid adenoma) with chronic
hypercalcemia
- Low back pain and leg cramps
- Hypertension
- Encephalomalacia and evidence of prior CVA seen on CT Head in
___. Negative w/u by neurology in past
Social History:
___
Family History:
Mother with post-partum depression.
Mat grandfather with bipolar ___ and hospitalzations.
Mat uncle ___.
Mat aunt with ___.
Physical Exam:
ADMISSION
VS: 98.1 PO 100 / 63 R Lying 76 18 95 Ra
GEN: alert, AOx3. NAD. Patient slow to respond to questions and
appears confused.
HEENT: No OP lesions, MMM.
Neck: neck veins flat
Resp: Breathing comfortably on RA. No incr WOB, CTAB.
CV: RRR. S1/S2 with systolic murmur. 2+ radial and DP pulses
bilaterally.
Abd: Soft, NT, ND
MSK: ___ without edema. Has fistula on left upper extremity
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
DISCHARGE
Vitals: 97.6 152/77 68 18 95 Ra
GEN: alert, AOx3. NAD.
HEENT: No OP lesions, MMM.
Neck: neck veins flat
Resp: Breathing comfortably on RA. No incr WOB, CTAB.
CV: RRR. S1/S2 with systolic murmur. 2+ radial and DP pulses
bilaterally.
Abd: Soft, NT, ND
MSK: ___ without edema. Has fistula on left upper extremity
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Pertinent Results:
ADMISSION:
___ 02:05AM BLOOD WBC-11.2* RBC-3.10* Hgb-9.9* Hct-30.7*
MCV-99* MCH-31.9 MCHC-32.2 RDW-14.1 RDWSD-50.6* Plt ___
___ 02:05AM BLOOD Neuts-91.5* Lymphs-3.0* Monos-4.2*
Eos-0.7* Baso-0.1 Im ___ AbsNeut-10.20* AbsLymp-0.34*
AbsMono-0.47 AbsEos-0.08 AbsBaso-0.01
___ 02:05AM BLOOD Plt ___
___ 02:05AM BLOOD Glucose-243* UreaN-24* Creat-3.7*# Na-137
K-3.9 Cl-90* HCO3-28 AnGap-19*
___ 02:05AM BLOOD ALT-14 AST-15 AlkPhos-59 TotBili-0.4
___ 02:05AM BLOOD Albumin-4.0 Calcium-9.7 Phos-2.9 Mg-2.1
___ 02:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:16AM BLOOD Lactate-4.1*
DISCHARGE:
___ 06:10AM BLOOD WBC-6.9 RBC-3.15* Hgb-10.4* Hct-31.7*
MCV-101* MCH-33.0* MCHC-32.8 RDW-14.1 RDWSD-50.9* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-190* UreaN-45* Creat-5.5*# Na-147
K-5.1 Cl-106 HCO3-25 AnGap-16
___ 06:10AM BLOOD Calcium-10.5* Phos-5.8* Mg-2.5
CXR ___:
Low lung volumes bilaterally. Suggestion of faint patchy
opacity bilaterally may represent atelectasis, however infection
cannot be excluded.
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ with ESRD on HD ___ and schizophrenia disorder presents
with AMS, dysuria, fevers x 2 days consistent with UTI. She had
outpatient Bactrim treatment but failed to improve and was
admitted for urosepsis.
#Urosepsis: Patient presented with dysuria, fevers, altered
mental status with a UA with >182 WBC. Urine cultures from
Atrius records grew out pseudomonas, resistant to ceftriaxone.
She was initially started on vancomycin and cefepime in the
setting of urosepsis and then narrowed to levofloxicin per
Atrius culture data for a total 7 day course to end on ___.
# Hypertension: Patient was unable to remove any fluid at HD
because of hypotension. Her amlodipine was restarted prior to
discharge in the setting of stable BPs.
CHRONIC ISSUES:
-------------------
# DMII: Insulin sliding scale while inpatient.
# Schizoaffective/bipolar disorder: Continued home psych regimen
including risperidone, benztropine, oxcarbazepine.
# ESRD on HD: Underwent HD while inpatient. Regular schedule is
___. Continued nephrocaps, low K/Phos/Na diet.
# Hypothyroidism: Continued home levothyroxine.
TRANSITIONAL ISSUES
[ ] Complete 7-day course of levofloxacin for UTI (last day
___
[ ] Re-check BP in clinic
[ ] Blood cultures pending at discharge and should be
followed-up in clinic
# CODE STATUS: Full
# CONTACT: husband ___ cell: ___ daughter ___
cell: ___
Attending attestation;
Patient seen and examined on day of discharge. Stable for
discharge home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 0.5 mg PO TID
2. OXcarbazepine 150 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. B complex with C#20-folic acid 1 mg oral DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. RisperiDONE 2 mg PO QAM
10. RisperiDONE 4 mg PO QPM
11. RisperiDONE 2 mg PO TID
12. QUEtiapine Fumarate 25 mg PO BID
Discharge Medications:
1. Levofloxacin 250 mg PO Q48H
RX *levofloxacin 250 mg 1 tablet(s) by mouth Every 48 hours Disp
#*1 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. B complex with C#20-folic acid 1 mg oral DAILY
4. Benztropine Mesylate 0.5 mg PO TID
5. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. OXcarbazepine 150 mg PO BID
8. QUEtiapine Fumarate 25 mg PO BID
9. RisperiDONE 4 mg PO QPM
10. RisperiDONE 2 mg PO TID
11. RisperiDONE 2 mg PO QAM
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Simvastatin 20 mg PO QPM
14.Rolling Walker
Date: ___
Rolling Walker
Dx: ___, R26.81
Prognosis: GOOD
Length of need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Urosepsis
SECONDARY DIAGNOSIS
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
You came to the hospital because you were confused and had pain
while urinating. This was because you had a urinary tract
infection. We treated you with antibiotics through the IV and
you got better! We then switched you to an oral antibiotic that
you will continue to take.
Please continue to take your antibiotic when you leave the
hospital and follow up with your doctors.
___ wish you the best,
Your care team at ___
Followup Instructions:
___
|
19658968-DS-9
| 19,658,968 | 22,024,310 |
DS
| 9 |
2178-10-27 00:00:00
|
2178-10-27 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dyazide / lisinopril
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Cardiac catheterization
History of Present Illness:
Patient is a ___ year old male with a history of CAD s/p DES to
the mid LAD in ___ for new onset and escalating angina
symptoms, hypertension who presented to ___ with
chest discomfort for the past 2 days. Patient describes that he
was sitting on the beach yesterday and noticed a substernal
burning/pressure sensation, which went away on its own after
___ minutes. Throughout the night and day earlier today, this
sensation returned multiple times, and did not go away with SL
Nitro. The sensation is associated with shortness of breath. He
states this is a similar sensation that he felt in ___ prior
to implantation of his stent. He has felt the chest discomfort
relatively infrequently since getting his stent. On arrival to
___, he had a normal ECG, normal troponin. His Hct was 23
(chronic, see below). He was started on aspirin, heparin gtt and
transferred to ___.
In the ED, initial vitals were 98.3 82 137/69 18 99% 2L NC. Labs
norable for PTT 149, Hct 24.2 last Hct 31.5 in our system, trop
< .01. ECG without any ischemic changes. He was pain free on
arrival. Heparin gtt was kept on. He required one dose of
morphine for ___ chest pain prior to arrival. Vitals on
transfer 98.0 78 124/65 18 99% 2L.
On arrival to the floor, patient describes a small residual
burning .___ below his left shoulder, but his discomfort is
much improved.
Per ___ records, patient's PCP has been working him up for
anemia. His Hct has been in the mid ___ for several months. He
has always had a mild anemia with Hgb ___, then was 8.6 in
___. Since starting plavix in ___, he has had multiple
episodes of epistaxis, constantly feeling "drained" since his
stent. His Hgb and Hct were as low as 7.7 and 24 in ___.
He states he can no longer cut the grass, can no longer work as
a ___. In ___, he saw Heme/Onc and had a BM biopsy which
was "suggestive" of early MDS but "not diagnostic." There was
also discussion of starting aranesp, but this was deferred.
Earlier this month, his PCP found that he had a + ___ with
speckled pattern. He had a mildly elevated TSH, so his PCP
checked him for thyroid autoantibodies, which were recently
negative.
On review of systems, he complains of general fatigue for the
last several months. He denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CAD RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
PCI: DES to mid-LAD in ___
3. OTHER PAST MEDICAL HISTORY:
- Anemia, Chronic
- + ___
- h/o bowel perforation secondary to colonoscopy ___ yrs ago)
- Schatzki's ring, dilated in ___
- Abnormal LFT's
- s/p tonsillectomy
- s/p left inguinal hernia repair
MEDICATIONS:
The Preadmission Medication list is accurate and complete
1. Amlodipine 5 mg PO DAILY
hold for sbp < 100
2. losartan-hydrochlorothiazide *NF* 50-12.5 mg Oral QD
hold for sbp < 100
3. Clopidogrel 75 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN anxiety
hold for sedation rr < 10
5. multivitamin with iron-mineral *NF* (pediatric
multivit-iron-min) Oral DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
ALLERGIES: Dyazide / lisinopril
SOCIAL HISTORY
Patient is a ___, married.
-Tobacco history: quit ___ yrs ago
-EtOH: 3 beers 5 days a week
-Illicit drugs: none
Social History:
___
Family History:
FAMILY HISTORY:
Brother died of MI in his late ___ or early ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98 161/79 79 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Soft bibasilar inspiratory crackles bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM - unchanged from above, except as below:
Lungs: CTAB
Extremities: R wrist radial access site is c/d/i
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-5.5 RBC-2.47*# Hgb-7.9*# Hct-24.2*
MCV-98 MCH-31.8 MCHC-32.5 RDW-17.2* Plt ___
___ 09:00PM BLOOD ___ PTT-149.0* ___
___ 09:00PM BLOOD Plt ___
___ 09:00PM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-135
K-3.4 Cl-103 HCO3-20* AnGap-15
___ 09:00PM BLOOD ALT-7 AST-30 AlkPhos-43 TotBili-0.2
___ 04:58AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.0
DISCHARGE LABS:
___ 08:15AM BLOOD WBC-3.7* RBC-2.95* Hgb-9.2* Hct-29.0*
MCV-98 MCH-31.1 MCHC-31.6 RDW-16.8* Plt ___
___ 08:15AM BLOOD ___ PTT-28.7 ___
___ 08:15AM BLOOD Glucose-133* UreaN-9 Creat-0.9 Na-138
K-3.6 Cl-103 HCO3-23 AnGap-16
___ 08:15AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
CARDIAC ENZYMES:
___ 09:00PM BLOOD cTropnT-<0.01
___ 04:58AM BLOOD CK-MB-2 cTropnT-<0.01
IMAGING:
___ CHEST (PORTABLE AP): IMPRESSION: No acute
cardiopulmonary process. Specifically, no finding to suggest
pneumothorax.
___: C. CATH:
LMCA: Very short
LAD: The LAD has a 40% stenosis in its origin. The stent in
the
LAD was widely patent. There was a 50% stenosis in the
mid-distal LAD . The diagonal branches had minimal lumen
irregularities.
LCX: The LCX had a smooth 50-60% stenosis in the mid LCx.
There
was a large ___ posterolateral branch that had minimal lumen
irregularities. The very distal portion of the ___
posterolateral branch had an 70-80% stenosis of prior to a short
branch. The distribution of the PL2 is small and unlikely to
cause rest pain.
RCA: Non dominant without focal stenoses.
Interventional details
There was marked tortuosity of the right subclavian artery
making
LCA engagement difficult.
Assessment & Recommendations
1.Intermediate coronary artery disease (50% mid LAD; 60% LCx;
80% very distal PLB)
2.Recommend maximal medical management
3.Stress nuclear study if pain persists to assess significant
of
distal ___ PL lesion
Brief Hospital Course:
Patient is a ___ year old male with a history of hypertension and
coronary artery disease s/p drug eluting stent to the mid LAD in
___ for new onset and escalating angina symptoms who
was transferred from ___ for unstable angina.
ACTIVE ISSUES:
#Chest pain/unstable angina: He continued to have substernal
chest pain after arrival to the floor which improved with
nitroglycerin sl. His EKG had no ischemic changes and serial
cardiac enzymes were negative. He was taken for cardiac cath
which showed 50% stenosis at mid LAD; 50-60% mid LCx lesion; 80%
very distal posterolateral branch. This distal PL branch
occlusion was thought unlikely to provoke rest angina. There
were no complications from the procedure. On hospital day 2, Mr.
___ angina resolved and he expressed desire to return home.
He was monitored to ensure that he was pain free for 24 hours
before discharge. For maximal medical management of his CAD, his
metoprolol was increased to 75mg daily because his HR was
persistently in the 80-90s.
CHRONIC ISSUES:
#Anemia: Mr. ___ has known anemia being followed by his PCP at
___. His Hct remained at baseline and transfusion was not
necessary on this admission.
#HTN: Patient was continued on his home medications, metoprolol
was increased to 75mg daily as above.
#Anxiety: Treated with home lorazepam PRN
#Code statis: FULL (confirmed)
#HCP: ___ (wife) ___
TRANSITIONAL:
-Stress nuclear study if pain persists to assess significance of
distal ___ PL lesion
-Follow up with PCP for anemia and HTN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide *NF* 50-12.5 mg Oral QD
hold for sbp < 100
2. Clopidogrel 75 mg PO DAILY
3. Lorazepam 0.5 mg PO HS:PRN anxiety
hold for sedation rr < 10
4. multivitamin with iron-mineral *NF* (pediatric
multivit-iron-min) Oral DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN anxiety
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. losartan-hydrochlorothiazide *NF* 50-12.5 mg Oral QD
7. multivitamin with iron-mineral *NF* (pediatric
multivit-iron-min) 0 tablet ORAL DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 50 mg 1.5 tablet extended release 24
hr(s) by mouth Daily Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with chest pain and underwent a cardiac
catheterization. Your cath showed mild blockages in some of
your coronary arteries, but no lesions that would be expected to
be causing your chest pain. Your prior stent was functioning
normally with no blockage.
Followup Instructions:
___
|
19659467-DS-13
| 19,659,467 | 20,332,418 |
DS
| 13 |
2178-12-28 00:00:00
|
2178-12-29 10:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pneumonia
pleural effusion
Major Surgical or Invasive Procedure:
chest tube placement ___
History of Present Illness:
___ is a ___ with PMHx of HTN and panic d/o who
presents with 2 weeks of fevers, chills and SOB, found to have a
large, L sided pleural effusion. The patient presents from his
PCP office for 2 weeks of fever a/w night sweats, cough,
pleuritic chest pain. At his PCP office he underwent CXR which
was notable for a large, L sided pleural effusion. Labs drawn at
that time revealed a WBC to 16k. The patient has no known TB
risk
factors, is not on immunosuppression, has no history of personal
malignancy. He denies IVDU.
He has not had any recent health care interactions, save for
cellulitis of his R great toe, which was treated with PO
antibiotics.
In the ED, initial VS were:
98.1 97 131/73 18 96% RA
Labs showed:
WBC 15.8, Plt 660, Hgb 11.3, albumin 2.4, pleural fluid studies
exudative by 2 test method, gram stain with 4+ GPCs
Imaging showed:
Large L sided pleural effusion
Patient received:
___ 21:22 IV Piperacillin-Tazobactam 4.5 g
___ 23:54 PO/NG MetroNIDAZOLE 500 mg
IP was consulted who performed a L sided thoracentesis and
placed
a L sided pigtail chest tube.
Transfer VS were:
98.1 93 110/58 21 92% RA
Past Medical History:
Hypertension
Panic disorder without agoraphobia with panic attacks full
remission
Social History:
___
Family History:
NC, no family history of pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.5 PO 133 / 74 98 18 95 2L
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: Absent lung sounds in LLL and LML, breath sounds
diminished but present in LUL; R lung fields CTA, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles. Chest tube to L lower chest with purulent drainage
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. 1+ pitting edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 97.7 BP 139/77 HR 81 RR 18 O2 93% RA
General: NAD, sitting upright in bed
HEENT: PERRL, EOMI, OP clear, MMM
Neck: no LAD
Lungs: Clear to auscultation on the R. Poor breath sounds L
lower
lung field. Mild crackles mid L lung field.
Chest: Chest tube in place over L back, dressing c/d/I, draining
serosanguinous fluid.
CV: RRR, no m/r/g.
Abdomen: non-tender, non-distended.
Ext: trace pitting edema bilateral ankles.
Neuro: A&Ox4
Pertinent Results:
ADMISSION LABS:
=============
___ 02:40PM BLOOD WBC-15.8* RBC-4.04* Hgb-11.3* Hct-35.7*
MCV-88 MCH-28.0 MCHC-31.7* RDW-14.5 RDWSD-46.5* Plt ___
___ 02:40PM BLOOD Neuts-82.8* Lymphs-7.4* Monos-8.0
Eos-0.5* Baso-0.3 Im ___ AbsNeut-13.08* AbsLymp-1.17*
AbsMono-1.26* AbsEos-0.08 AbsBaso-0.04
___ 02:40PM BLOOD ___ PTT-32.1 ___
___ 02:40PM BLOOD Glucose-104* UreaN-7 Creat-0.9 Na-139
K-4.6 Cl-95* HCO3-29 AnGap-15
___ 02:40PM BLOOD ALT-17 AST-30 AlkPhos-132* TotBili-0.6
___ 02:40PM BLOOD cTropnT-<0.01 proBNP-363*
___ 06:30AM BLOOD Calcium-7.5* Phos-4.5 Mg-2.3
___ 06:30AM BLOOD HIV Ab-NEG
___ 02:44PM BLOOD Lactate-1.6
PLEURAL FLUID LABS:
================
___ 08:06PM PLEURAL ___ RBC-___* Polys-98* Lymphs-0
___ Macro-2*
___ 08:06PM PLEURAL TotProt-4.4 Glucose-<2 Creat-0.7
LD(LDH)-6993 Amylase-15 Albumin-2.2 ___ Misc-BODY FLUID
RADIOLOGY
=========
CXR AP ___
IMPRESSION:
Comparison to ___. Stable position of the left
pigtail catheter.
An area of pleural thickening, pleural fluid and an intrapleural
air pocket is
visualized projecting over the left costophrenic sinus, and not
substantially
changed as compared to the previous image.
CXR AP ___
IMPRESSION:
Comparison to ___. The patient has received a
right-sided PICC
line. The course of the line is unremarkable, the tip of the
line projects
over the lower SVC. No complications, notably no pneumothorax.
The left chest tube and the left basolateral pleural air pocket
is stable.
CXR AP ___
FINDINGS:
Compared to the prior radiograph from ___, there
has been
interval improvement in a small left pleural effusion. There is
no evidence
of a pneumothorax. Adjacent consolidations appear unchanged
compared to the
prior exam which may again represent atelectasis versus
pneumonia. There is
no evidence of pneumothorax. The visualized right hemithorax is
unremarkable.
IMPRESSION:
Interval improvement small left pleural effusion and adjacent
consolidation,
which may be secondary to atelectasis versus pneumonia.
CXR AP ___
IMPRESSION:
Compared to chest radiographs ___.
Moderate to large left pleural effusion persists slightly
smaller if at all
compared to ___. Basal pigtail pleural drainage
catheter still in
place. Sharp angulation in the tube just inside the rib cage
may interfere
with drainage. Clinical correlation advised. No pneumothorax.
Severe left
lower lobe atelectasis persists.
Right lung clear of focal abnormalities. Heart size normal.
Mediastinal
venous engorgement developed on ___, unchanged.
CXR AP ___
IMPRESSION:
Compared to chest radiographs ___.
Large left pleural effusion has begun to reaccumulate despite
the left basal
pigtail pleural drainage catheter inserted on ___. Left
lower lobe is
largely collapsed. Right lung is clear. No right pleural
effusion. Left
heart border is obscured by pleural effusions are heart size is
indeterminate.
No pneumothorax.
CXR AP ___
FINDINGS:
AP portable upright view of the chest.
A pigtail chest tube is seen coiled in the medial left lung base
with interval
slight decrease in size of left pleural effusion, which remains
moderate to
large in size. Right lung remains clear. No detectable
pneumothorax.
IMPRESSION:
As above.
CXR AP ___
IMPRESSION:
Increased opacity throughout the left hemithorax with slight
mass effect
suggests an underlying effusion with probable component of
atelectasis.
Underlying consolidation would certainly be possible.
CT CHEST WO CONTRAST ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged portions
of the inferior
thyroid are unremarkable. There is no supraclavicular or
axillary
lymphadenopathy.
UPPER ABDOMEN: Visualized upper abdominal structures are
unremarkable, noting
that this study is not tailored for subdiaphragmatic evaluation.
MEDIASTINUM: There are numerous small to borderline mediastinal
lymph nodes
measuring up to 1 cm in short axis, likely reactive. There is
no mediastinal
mass.
HILA: There is no bulky hilar lymphadenopathy.
HEART and PERICARDIUM: The heart is normal in size. There is a
small
pericardial effusion.
PLEURA: There is a left basilar chest tube in place. There is
gas and a small
amount of complex fluid in the left pleural space. There is no
right pleural
effusion.
LUNG:
1. PARENCHYMA: Areas of consolidation in the left lower lobe,
and to a lesser
extent in the lingula and left upper ___ represent
atelectasis and/or
pneumonia. There the right lung is clear. There is no
suspicious nodule or
mass in the aerated lungs.
2. AIRWAYS: The central airways are patent.
3. VESSELS: There are no atherosclerotic calcifications of the
thoracic
aorta. There is no thoracic aortic aneurysm. The main
pulmonary artery is
normal in caliber, measuring 2.7 cm.
CHEST CAGE: There is no suspicious osseous lesion or acute
fracture.
IMPRESSION:
1. Left basilar chest tube in place. Small amount of gas and
complex fluid
in the left pleural space.
2. Areas of consolidation in the left lower lobe, and to a
lesser extent in
the lingula and left upper lobe, which may represent atelectasis
and/or
pneumonia.
3. Numerous small to borderline mediastinal lymph nodes, likely
reactive.
DISCHARGE LABS:
===============
___ 06:42AM BLOOD WBC-5.4 RBC-4.17* Hgb-11.2* Hct-37.3*
MCV-89 MCH-26.9 MCHC-30.0* RDW-14.3 RDWSD-47.1* Plt ___
___ 06:42AM BLOOD Glucose-73 UreaN-6 Creat-0.9 Na-144 K-4.1
Cl-103 HCO3-26 AnGap-15
___ 06:42AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ with PMHx of HTN and panic disorer who
presented with 2 weeks of fevers, chills and SOB, found to have
a left sided empyema. He underwent a thoracentesis with chest
tube placement by IP. His cultures grew strep anginosus
(___), which were sensitive to CTX. He was also seen by ID
who recommended adding on metronidazole. He had a PICC line
placed for long-term antibiotics. He was discharged with
follow-up with IP in 2 weeks, for possible CT scan with contrast
to clarify the need for possible decortication with thoracic
surgery.
ACUTE ISSUES:
===============
#Empyema
#Leukocytosis
Pt presented with 2 weeks of fevers/chills/increasing dyspnea on
exertion, but did not endorse cough otherwise. Diagnosed with
large pleural effusion at ___ office, transferred to ED and s/p
thoracentesis with chest tube placement ___ by IP. Pleural
fluid studies confirmed empyema (LDH 6993, pH 6.59, Glu <,
Protein 4.4. WBC 47K) with 4+ GPCs and 4+ PMNs, chest tube
draining frank pus. Initial WBC 12,000, CRP greater than 300,
HIV negative. Acid-fast stain, fungal culture negative.
Bacterial cultures grew strep anginosis, sensitive to CTX,
clinda, erythromycin. He underwent 2 rounds of intrapleural
medication. His chest tube was pulled when it drained ~90 cc
per 24 hours. ID was consulted, and he was treated with IV
ceftriaxone and p.o. metronidazole, for likely 3 week course
(___). Thoracic surgery was also consulted for possible
decortication given an air pocket. They recommended outpatient
follow-up with IP with a CT scan with contrast to evaluate the
need for decortication as an outpatient. He was discharged and
instructed to follow-up with IP in 2 weeks, as well as with ID.
#Elevated INR
INR 1.4 on admission. No history of liver disease, no
anticoagulants. He was given p.o. vitamin K, and his INR
decreased to 1.2. Also had a mixing study sent, it should be
followed up as an outpatient.
CHRONIC ISSUES:
===============
# Hypertension
No home meds. Monitored.
# Panic disorder
No events inpatient. Continued on home alprazolam.
TRANSITIONAL ISSUES:
====================
TRANSITIONAL ISSUES:
====================
[] Please ensure patient follows up with IP, thoracic surgery 2
weeks with repeat chest CT from discharge and follows up in ___
clinic.
[] Please ensure patient completes course of antibiotics
(ceftriaxone and metronidazole from ___ as per ID, until
___ as per IP). Please discuss the duration as ID recommends a
___nd IP is recommending a 4 week course.
[] Please monitor INR as patient had slightly elevated INR
during his admission with was thought to be nutritional as
improved with PO vitamin K. Please follow-up on results of
mixing study (inhibitor screen), sent on ___.
[] Please check weekly safety labs
CBC/diff
BUN/ creat
CPK
ALT, AST
CRP
Fax results to: ATTN: ___ CLINIC - FAX: ___
EMERGENCY CONTACT: ___
CODE STATUS: Full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV once a
day Disp #*21 Intravenous Bag Refills:*0
2. MetroNIDAZOLE 500 mg PO/NG Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*63 Tablet Refills:*0
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 mL IV PRN Disp #*250
Intravenous Bag Refills:*0
4. ALPRAZolam 0.5 mg PO TID:PRN anxiety
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
EMPYEMA/PARAPNEUMONIC EFFUSION
PNEUMONIA
SECONDARY DIAGNOSIS
==================
COAGULOPATHY
HYPERTENSION
PANIC DISORDER
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why you were admitted to the hospital:
-You were diagnosed with pneumonia, and your PCP performed ___
chest x-ray that showed you had fluid around your lungs.
-It was recommended that you go to the hospital to have this
fluid drained and to receive antibiotics.
What happened in the hospital:
-You had a procedure done to remove fluid from around your
lungs. The fluid showed that you had a severe infection around
your lungs.
-You had a chest tube placed to continue draining this fluid.
The chest tube was removed before you left the hospital.
-You were given IV antibiotics and had a PICC line placed into
your arm so that you can take IV antibiotics at home
-You were seen by our lung doctors, infectious disease doctors,
thoracic surgeons. The surgeons did not think that you needed
surgery for the fluid around your lungs, but recommended that
you have more imaging when you follow up in 2 weeks.
What to do when I leave the hospital:
-Continue taking your antibiotics as instructed (ceftriaxone and
metronidazole) from ___ - ___.
-Please follow-up with your appointments as listed below.
-If you develop worsening shortness of breath, fevers, or chills
please return to the emergency room.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
19659653-DS-29
| 19,659,653 | 28,551,481 |
DS
| 29 |
2187-03-19 00:00:00
|
2187-03-20 09:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Worsening lower extremity weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old handed woman with NMO who
presents
with worsening bilateral lower extremity weakness. Today, on
presentation she states that she was ready to be discharged from
rehab today and was feeling particularly weak. She was finding
that she could not stand as long with the aid of a walker and
that she was also unable to flex her legs at the hip with the
same strength as the prior day. She also described a painful
band-like sensation around the ankles and legs which she says
has
been consistent with her flares. She described no sensory loss.
She has no complaints of fevers, cough or dysuria (however she
has a suprapubic catheter).
She started Rituxan infusions on ___ and has
completed 4 infusions. She says she tolerated the first 2
infusions were fine. However after the ___ and ___ infusions she
started feeling like her legs were weaker. She also began having
numbness in her right ring and small finger that comes and goes.
She typically uses an electric wheelchair at home and uses a
walker to walk only with physical therapy. She also notes that
her right foot was floppy prior to her ___ admission but it
had improved.
Unfortunately this returned after the ___ and ___ Rituxan
infusions.
She was admitted recently from ___ to ___ for similar
complaints and was found to have a urinary tract infection and
was treated w/ IV Ceftriaxone for 3 days and a single dose of
tobramycin and then discharged to rehab in ___ where she
completed a 7-day course of cefpodoxime. Cultures from that
admission grew cephalosporin-sensitive E. coli. She had a
cervical and thoracic MRI which did not show any enhancement.
She
had seen ___ in the office yesterday (___) who felt
that she had increased lower extremity weakness and wished to
have her admitted in one week for IV steroids.
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.
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:
-Neuromyelitis optica, as above
-Mitral valve prolapse
-Hypertension
-Asthma
-Osteoarthritis, had required steroid injections to the
spine(well controlled recently)
-PMR, had been on prednisone and plaquinel in the past
-Depression
-Pneumonia
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced))
-Chronic diarrhea/?pancreatic insufficiency
-Adrenal insufficiency
-granulomatous Lung nodules
-renal cell carcinoma, left partial nephrectomy
Social History:
___
Family History:
Father died of lung cancer, grandmother died of colon
cancer.
Physical Exam:
Physical Examination on Admission:
Vitals: 98.3 56 127/63 16 99%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: multiple hyperpigmented lesions noted over arms.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone in bilateral lower
extremities. No pronator drift bilaterally. Occasional
non-rhythmic dorsiflexion of the left foot which the patient
states is only semi-voluntary. Delt Bic Tri WrE FFl FE IO IP
Quad Ham TA Gastroc
L 5 ___ ___ ___ 4- 4-
R 5 ___ ___ ___ 2 3
-Sensory: Decreased vibration and proprioception to the ankle
bilaterally. Intact pinprick and temperature throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
Admission Labs:
___ 05:10PM BLOOD WBC-6.6 RBC-3.81* Hgb-11.9* Hct-35.7*
MCV-94 MCH-31.1 MCHC-33.2 RDW-13.5 Plt ___
___:10PM BLOOD Neuts-53.0 ___ Monos-10.0
Eos-6.8* Baso-0.7
___ 05:43PM BLOOD ___ PTT-34.9 ___
___ 05:10PM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-144
K-4.3 Cl-104 HCO3-33* AnGap-11
___ 07:20AM BLOOD ALT-13 AST-14 LD(LDH)-185 AlkPhos-59
TotBili-0.3
___ 07:20AM BLOOD Albumin-4.0 Calcium-9.8 Phos-4.0 Mg-1.9
___ 05:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 05:10PM URINE Color-Straw Appear-Clear Sp ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Reports
EKG:
Sinus bradycardia. Findings are within normal limits. Compared
to the
previous tracing of ___ there is no significant diagnostic
change.
Rate PR QRS QT/QTc P QRS T
52 182 82 482/468 4 21 62
CXR: No acute intrapulmonary process
Brief Hospital Course:
Ms. ___ was admitted to the ___ Neurology Wards for
reports of lower extremity weakness. On admission, she described
how she had been doing well at her rehab facility for several
days, and actively engaging in rehabilitation efforts. She was
able to walk a few steps at a time, and her upper body strength
was also improving. However, At least ___ days prior to her
admission here, she started to experience a recurrence of lower
extremity heaviness and weakness, as well as a characteristic
band-like sensation around her ankles which for her is quite
typical for an NMO flare. She was seen by Dr. ___ day
prior to her admission in the clinic, who recommended an urgent
admission for IV steroids.
She presented to the ED the next day, and in the ED, she was
noted to have an examination as listed above which was
significantly worse than her prior discharge examination. She
was admitted to the floor, and received a routine set of serum
and urine chemistries as well as a chest X-ray, which revealed
no evidence of a toxic/metabolic/infectious process. She was
thus started IV steroid protocol (1g solumedrol IV x 3 days,
500mg IV solumedrol x 3 days, 250mg IV solumedrol x 3 days).
Her finger stick sugars remained elevated during this stay, and
this required uptitration of her insulin sliding scale. Given
her recurrent recent steroid use, we checked an A1c level which
is pending at the time of this summary. She did complain of an
intermittent cough which responded to routine symptomatic
treatment.
She was evaluated by our physical therapy team who recommended
continued rehabilitation. Our case managers were able to locate
a bed for Ms. ___ at ___, at which point, she was
discharged to this facility to complete two more doses of IV
steroids at this facility.
She was discharged on Prior to discharge, her neurological
examination was pertinent for normal mentation and cranial nerve
function without any visual findings. Her lower extremity
weakness was right > left, with weakness focused at the IP,
hamstring, TA, toe muscles, without any sensory loss.
Transitional Issues:
- She will follow up with her PCP and Dr. ___ at the
dates and times listed below.
- Please ensure that she is covered with insulin sliding scale
during the first few weeks following the completion of her
steroid course.
- To cover against the detrimental effects of long term high
dose steroids, please ensure that the patient receives Ca/Vit D
supplementation and BID zantac therapy.
Medications on Admission:
- Baclofen 10mg tid
- Creon tid with meals
- Paxil 20mg daily
- Ranitidine 150mg bid
- Tylenol PRN
- Calcium and vitamin D
- Fibercon bid
- Lamivudine 100mg daily
Discharge Medications:
1. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day): Administer
for one more month (End ___.
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily): Administer for one more month (End ___. Tablet(s)
8. Solu-Medrol 500 mg Recon Soln Sig: Two Hundred Fifty (250) mg
Intravenous once a day for 2 days: To receive two doses
___ and ___.
9. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2
times a day) as needed for constipation.
10. insulin regular human 100 unit/mL Solution Sig: As directed
Injection ASDIR (AS DIRECTED): Please check blood sugars and
cover with sliding scale insulin appropriately.
11. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation, anxiety.
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Neuromyelitis Optica
-Hypertension
-Asthma
-Osteoarthritis
-Polymyalgia rheumatica
-Depression
-Pneumonia
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced))
-Chronic diarrhea/?pancreatic insufficiency
-Adrenal insufficiency
-Granulomatous lung nodules
-Renal cell carcinoma, s/p left partial nephrectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neurology wards of the
___ your new complaints of
worsening leg weakness, which was discovered at your most
rehabilitation stay. For a presumed flare of your NMO
(neuromyelitis optica), you were treated with 9 days of
intravenous steroid therapy. During your steroid treatment, we
treated you with insulin therapy (to help control high blood
sugars that can come with steroid therapy), and also provided
you with regular physical therapy evaluations so as to preserve
your mobility during your hospitalization. Our physical
therapists felt that you would be a good candidate for continued
rehabilitation, and our case manager was able to find you a bed
in ___.
- Please continue to take all of your medications as prescribed
below. You will receive two more days of intravenous steroids at
your rehabilitation facility.
- Please make sure to follow up with your PCP as well as Dr.
___ the ___ of Neurology at the dates and times
listed below. Dr. ___ has promised to contact you when she
will return from her vacation, to set up an earlier appointment.
- Please make sure to come to the ED should you experience any
of the below listed symptoms
Followup Instructions:
___
|
19659653-DS-30
| 19,659,653 | 26,758,842 |
DS
| 30 |
2187-09-24 00:00:00
|
2187-09-24 11:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
lower extremity weakness
Major Surgical or Invasive Procedure:
___ Midline IV placement
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH significant for NMO
(followed by Dr. ___ imaging on prior admissions notable for
C4-T1 signal abnormality), who had no improvement on Rituxan
therapy, which was completed in ___ and who now presents
with worsening right greater than left lower extremity weakness
as well as tingling in her lower extremities and a band-like
sensation around her umbilicus. She says that this presentation
is consistent with prior exacerbations of her NMO. She last
ambulated with ___ 8 days ago and at that time, first noticed
that
she had difficulty raising her legs. She notes that for the past
5 days she has noticed right greater than left lower extremity
heaviness. She belives there has also been increased swelling of
her right greater than left lower extremity. Over this time, she
has noted increased difficulty lifting her right leg off the
ground to try to ambulate. She notes that she is able to
transfer
herself at home, but with increasing difficulty now. She notes
new tingling sensation from her feet to her hips and a painful
band-like sensation around her abdomen, by her umbilicus. She
has
a tight feeling (band-like) all over her right leg. She also
says
her feet feel heavy to put pressure on when standing.
She had a suprapubic catheter for a year, but this was removed
on ___. For the past 3 days she has noticed
increased difficulty urinating. She says it felt like she needed
to urinate, but was unable to. No definitive urinary urgency.
She
has had some urinary leakage. No bowel urgency or incontinence.
She does not note any current fevers, but says she completed a
14
day course of cipro yesterday for a UTI. Of note, during a prior
admission she was found to have an E. coli UTI (this was
sensitive to both cipro and cephalosporins).
Neuro ROS: Positive for increased lower extremity weakness and
tingling as per HPI. In addition, she notes she has has some
right arm numbness and burning sensation. For the past few days,
she has also been having throbbing headaches located in the
temples and occiput; these are relieved with Tylenol. She also
notes left greater than right eye blurry vision for the last few
days (she does not note any previous history of visual changes)
as well as left eye floaters. No loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. No difficulties producing or comprehending
speech.
General ROS: She did have dysuria at onset of UTI, but says this
is now improved with abx. No fever or chills. No cough,
shortness
of breath, chest pain or tightness, palpitations. No nausea,
vomiting, diarrhea, constipation or abdominal pain. No rash.
Past Medical History:
-Neuromyelitis optica, as above
-Mitral valve prolapse
-Hypertension
-Asthma
-Osteoarthritis, had required steroid injections to the
spine(well controlled recently)
-PMR (had been plaquinel; currently on prednisone)
-Depression
-Pneumonia
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced))
-Chronic diarrhea/?pancreatic insufficiency
-Adrenal insufficiency
-granulomatous Lung nodules
-renal cell carcinoma, left partial nephrectomy
Social History:
___
Family History:
Her father died of lung cancer. Her grandmother
died of colon cancer. Her older brother had a stroke.
Physical Exam:
ADMISSION EXAM
Vitals: Temp: 98.3 HR: 76 BP: 139/59 Resp: 18 O(2)Sat: 96
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, no oral lesions
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, II/VI systolic murmur
Abdomen: soft, nontender, nondistended, +BS
Extremities: edema R>L ___. Warm, well perfused.
Neurologic:
Mental Status: She is awake, alert, oriented to person, place
and
date. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Able to follow
both
midline and appendicular commands. Able to register 3 objects
and
recall ___ at 5 minutes. No evidence of apraxia or neglect.
Language: speech is clear, fluent and nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation (on color
field testing). No RAPD. No red desaturation. Funduscopic exam
revealed no papilledema.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk. Increased tone in ___ b/l. No pronator drift
bilaterally. No adventitious movements noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L ___ ___- 3+ 5- 5- 5- 5
R ___- 5- ___ 3+ 3+ 3+ 4
Sensory: Diminished light touch in R>L ___ (right is 50% compared
to left and both are decreased compared to UE). She has no
definitive sensory level, though would occasionally note a
change
in sensation around T9 (this was not reproducible). She has
severely impaired proprioception at great toe b/l and absent
vibration at great toe b/l.
DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
Plantar response was extensor bilaterally.
Coordination: No intention tremor or dysmetria on F-N or FNF.
RAMs intact b/l.
Gait: deferred
---
DISCHARGE EXAM:
Mental status and cranial nerves intact.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L ___ ___- ___ 5- 5
R ___ ___- 3 4+ 4 3+ 5-
Sensation decreased to vibration and proprioception at bilateral
great toes. Pinprick and cold intact throughout, no sensory
level.
Reflexes brisk and symmetric.
Pertinent Results:
___ 01:00PM BLOOD WBC-7.0 RBC-4.07* Hgb-12.5 Hct-38.3
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 Plt ___
___ 05:35AM BLOOD WBC-4.3 RBC-4.21 Hgb-12.8 Hct-39.7 MCV-94
MCH-30.3 MCHC-32.2 RDW-13.0 Plt ___
___ 01:00PM BLOOD Neuts-50.3 ___ Monos-8.9 Eos-2.1
Baso-0.5
___ 01:00PM BLOOD Plt ___
___ 05:35AM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-146*
K-3.5 Cl-106 HCO3-29 AnGap-15
___ 05:35AM BLOOD Glucose-282* UreaN-22* Creat-0.7 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-15
___ 05:35AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.0
___ 2:20 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML.
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-7.6 RBC-3.93* Hgb-12.2 Hct-36.7
MCV-93 MCH-31.0 MCHC-33.2 RDW-13.1 Plt ___
___ 05:00AM BLOOD Glucose-247* UreaN-25* Creat-0.8 Na-140
K-3.8 Cl-100 HCO3-32 AnGap-12
___ 05:00AM BLOOD Calcium-9.5 Phos-2.8 Mg-2.2
IMAGING:
LENIS ___:
No evidence of deep venous thrombosis in either lower extremity.
Brief Hospital Course:
___ W h/o neuromyelitis optica with recurrent transverse
myelitis p/w worsening leg weakness and band-like tightening
around her umbilicus. She initially thought that her symptoms
were due to having her suprapubic catheter manipulated and
having leg edema and thus "heaviness"; it wasn't until she had
the sensory changes around her abdomen that she decided to seek
medical care.
She was found to have significant paraparesis in upper motor
neuron pattern, and decreased vibration and proprioception with
brisk reflexes and upgoing toes, consistent with NMO flare.
She was treated with Methylprednisolone according to the ___
___ protocol for 9 days. She was treated for her UTI with
ceftriaxone. She also has a history of hepatitis B, and so was
treated with lamivudine during steroid course to avoid
reactivationof HBV. She should call Dr. ___ office to
determine when it is safe to stop lamivudine after the steroids
are complete.
She also required standing dose of insulin because of
hyperglycemia on steroids. Her Lantus dose was increased from 5
to 15 units on the day prior to discharge, and can be titrated
as needed in rehab setting.
She has had chronic issues with urinary incontinence, and failed
trial off of suprapubic catheter last week because of her NMO
flare. She has a Foley at discharge, which will be removed if
possible and voiding trial repeated. She should follow up with
urology.
The patient also complained of burning dysesthesias over right
C8-T1 dermatome areas, stemming from past NMO flare in that
location. She was started on gabapentin which helped, and the
dose can be titrated up slowly from 100 mg TID to ___ mg TID as
a start.
The patient's examintion did improve during her hospital course.
She was able to transfer without assistance, but still not able
to ambulate.
.
TRANSITIONAL CARE ISSUES:
[ ] ___ - Please continue therapy for maximal functional
recovery and assess for need for home services.
[ ] Neurology - Please reevaluate long-term immunosuppression
treatment plan.
Medications on Admission:
-Acetaminophen 1000 mg tid
-Calcium 600 + D
-Creon tid with meals
-Epivir HBV 100 mg daily
-Fibercon 625 mg bid
-Klor-Con 10 mEq bid
-Paxil 20 mg daily
-Senokot 8.6 mg daily
-Ascorbic Acid ___ mg bid
-Baclofen 15 mg bid and midday
-HCTZ 25 mg daily
-Polysaccharide iron complex ___ mg bid
-Prednisone
-Ranitidine 150 mg bid
-Zolpidem 5 mg qhs prn insomnia
Discharge Medications:
1. Baclofen 15 mg PO TID
2. Ascorbic Acid ___ mg PO BID
3. Creon 12 1 CAP PO TID W/MEALS
4. Hydrochlorothiazide 25 mg PO DAILY
5. Heparin 5000 UNIT SC TID
6. Paroxetine 20 mg PO DAILY
7. Ranitidine 150 mg PO BID
8. Senna 1 TAB PO DAILY
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
10. Potassium Chloride 10 mEq PO BID
11. Psyllium 1 PKT PO BID:PRN constipation
12. Gabapentin 100 mg PO TID
increase dose by 100 mg per day every 3 days to goal 300 mg TID
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
14. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
15. LaMIVudine 100 mg PO DAILY
while on IV steroids
16. MethylPREDNISolone Sodium Succ 500 mg IV DAILY Duration: 3
Days
Please administer in 500 cc D5W over ___ hours
17. MethylPREDNISolone Sodium Succ 250 mg IV DAILY Duration: 3
Days
Please administer in 250 cc D5W over ___ hours.
18. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
___ and Sub-Acute Care)
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Neuromyelitis optica (recurrent acute
transverse myelitis), Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: bilateral ___ weakness (IP 3, ham 4, right TA 3, left
TA 4, gastrocs 5)
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of WORSENING LEG WEAKNESS
resulting from a recurrent flare of NEUROMYELITIS OPTICA. To
treat this condition, we are giving you IV corticosteroids
(Methylprednisolone) for a ___s directed by your
Neurologist, Dr. ___.
We are changing your medications as follows:
1. please START gabapentin 100 mg three times daily, increase
dose by 100 mg per day every 3 days
2. please take lamivudine for the duration of your steroid
course, call Dr. ___ stopping this medication
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 medical
attention.
- worsening leg weakness, numbness, worsening bowel or bladder
symptoms, blurred vision or eye pain
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19659653-DS-32
| 19,659,653 | 22,640,334 |
DS
| 32 |
2188-01-01 00:00:00
|
2188-01-01 21:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape
Attending: ___
Chief Complaint:
right leg weakness and numbness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with PMH of neuromyelitis optica diagnosed ___
by
Dr. ___ imaging on prior admissions notable for C4-T1 signal
abnormality), s/p multiple admissions with courses of IV
steroids, IVIg, plasmapheresis and no response to rituximab in
___
recent admission with NMO flare ___ and recent
insurance prior authorisation issues regarding IVIg with recent
treatment on ___ with recurrent and significantly
disabling
leg weakness.
The patient had a recent admission to ___ ___ at which
time the patient had IV steroids with a 9-day intravenous taper
beginning with three days of 1000 mg intravenously daily,
reduced
over a total of nine days to which her acute leg weakness did
not
respond. She then had five days of plasmapheresis during which
she did experience improvement in the leg weakness. On ___,
for on-going prophylactic treatment, she received her first dose
of IVIG treatment for a total of 70 g of immunoglobulin on
___ prior to discharge. She also had complaints of urinary
retention during her last hospitalisation and urology were
consulted and she required straight catheterisation. She was
discharged with a urinary catheter. She had Botox injection to
her bladder on ___ and had her catheter removed on ___.
However, following removal of her catheter, although she was
able
to void, she endorsed that she was unable to completely empty
her
bladder and had significant frequency and urgency at times. She
denied dysuria, flank pain or fevers. She had recently been
treated with ciprofloxacin for a UTI on ___ although
previous cultures had been resistant to ciprofloxacin but not
ceftriaxone.
Plans were subsequently made for continued monthly IVIG
infusions, 1g/kg, This was not possible due to insurance issues.
Beginning on ___, the patient experienced a sense of tightness
in the right leg followed gradually by progressive weakness of
the right leg and increasing sensory sense of ligature. She had
IVIg on ___ and although this initially improved her symptoms,
since ___, her symptoms have again been worsening prompting
re-presentation for further treatment.
The patient notes worsening symptoms since ___ with
increase right>left leg weakness. Since discharge in ___
she has had great difficulty walking with her walker but has
been
able to stand with the walker and take a few shuffling steps but
she has noticed that her legs have been much heavier and with a
pressure sensation R>L, She denies pain but doe shave this
sensation of tightness/numbness in both legs which has worsened
over the past week. She also noticed new numbness in the ulnar
fingers of her right hand which she stated had recurred and
numbness/heaviness in her legs which has also worsened.
She otherwise has chronic right hip/lumbar pain which has not
changed and notes numbness in both buttocks and hips which is
also possibly worse. She has had difficulty with urinary
retention as above and has had difficulty controlling her urine
although she states that she can feel when micturating. She has
also noted constipation over the past 2 days and this is
somewhat
unusual for her. She took some docusate and has improved. She
stated that she can feel well on wiping. Otherwise, she notes
chronic tingling in both feet.
In the ED, she was noted to have lower extremity swelling R>L
and
Doppler U/S was negative for DVT. She currently notes a
bifrontal
and posterior neck headache which has been intermittent for the
past 1 week. She has been taking acetaminophen for this and has
not been associated with visual changes or nausea/vomiting. She
also notes a mild cough over the past 2 weeks.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence and no
bowel retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea or abdominal
pain. No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-Neuromyelitis optica, as above
-Mitral valve prolapse
-Hypertension
-Asthma
-Osteoarthritis, had required steroid injections to the
spine(well controlled recently)
-PMR (had been plaquinel; currently on prednisone)
-Depression
-Pneumonia
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced))
-Chronic diarrhea/?pancreatic insufficiency
-Adrenal insufficiency
-granulomatous Lung nodules
-renal cell carcinoma, left partial nephrectomy
Social History:
___
Family History:
- Her father died of lung cancer.
- Her grandmother died of colon cancer.
- Her older brother had a stroke.
Physical Exam:
Vitals: T:97.9 P:76 R:16 BP:133/63 SaO2:100% RA
General: Awake, cooperative, NAD, obese ___ female.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Mild tenderness in posterior neck not clearly in the midline.
Full range of motion.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, ESM loudest in aortic area.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. bdominal scars with left nephrectomy scar.
Extremities: Bilateral R>L ___ edema tomid shins and calf
asymmetry, right 1-2cm laregr than left, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted save keyloid scars over both
knee replacement scars.
Neurological examination:
- Mental Status:
ORIENTATION - Alert, oriented x 4
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty with 1 error.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3.5 to 2.5mm and brisk. VFF to confrontation.
Funduscopic exam reveals no papilledema, exudates, or
hemorrhages
specifically both discs are not pale or atrophic although there
are multiple pigmentary chanegs in the retina in general.
___ ___ bilaterally corrected.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, 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 with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 4 5 4 5 5 5
4
R 5* 5 ___ ___ ___ 5 4 5 3 4
4-
* pain limited
# difficult to asses, can't lift left leg off bed but on flexing
knee has pretty good power in right IP
- Sensory: She has decreased sensation to light touch, pinprick
and temperature in the right ulnar nerve distribution (negative
Tinel's on right) and both legs to just below the knees
circumferentially right worse than left (light touch abnoramlity
to distal thighs). Patient has decreased vibration to the ankles
bilaterally and decrased priorioception to the ankles
bilaterally. She possibly has decreased sensation in her
buttocks
but not clearly decreased to pinprick. Rectal examination
reveals
normal tone but some difficulty squeezing and normal perianal
sensation.
No deficits to light touch, pinprick, cold sensation, vibratory
sense, proprioception throughout in UE and ___. No extinction to
DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 4 3
R ___ 4 3
There was no evidence of clonus.
___ possible just present on left. Pectoral reflexes
present and clear crossed adductors bilaterally in legs with
spread.
Reflexes are very brisk in the UE with spread and even brisker
in
the legs with even more significant spread.
Plantars are extensor bilaterally more so on the left.
- Coordination: No intention tremor, normal finger tapping
sligght action tremor bilaterally on touching nose. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
- Gait: Not assessed.
Pertinent Results:
___ 08:20PM GLUCOSE-89 UREA N-21* CREAT-0.6 SODIUM-143
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-30 ANION GAP-11
___ 08:20PM estGFR-Using this
___ 08:20PM ALT(SGPT)-13 AST(SGOT)-26 ALK PHOS-68 TOT
BILI-0.2
___ 08:20PM ALBUMIN-3.9 CALCIUM-9.7 PHOSPHATE-3.3
MAGNESIUM-2.0
___ 08:20PM WBC-5.4 RBC-3.62* HGB-11.1* HCT-34.2* MCV-95
MCH-30.6 MCHC-32.4 RDW-13.5
___ 08:20PM NEUTS-42.2* LYMPHS-45.0* MONOS-8.0 EOS-4.1*
BASOS-0.7
___ 08:20PM PLT COUNT-308
___ 07:35PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 07:35PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 07:35PM URINE RBC-3* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-1
___ 07:35PM URINE WBCCLUMP-FEW
___ 06:00PM VoidSpec-GROSSLY HE
___ 06:00PM WBC-5.2 RBC-3.69* HGB-11.4* HCT-35.0* MCV-95
MCH-31.0 MCHC-32.7 RDW-13.5
___ 06:00PM NEUTS-44.5* ___ MONOS-8.6 EOS-4.8*
BASOS-1.1
___ 06:00PM PLT COUNT-296#
Lower Ext Ultrasound: No evidence of deep vein thrombosis
Brief Hospital Course:
___ with PMH of neuromyelitis optica diagnosed ___
by Dr. ___ imaging on prior admissions notable for C4-T1
signal abnormality), s/p multiple admissions with courses of IV
steroids, IVIg, plasmapheresis and recent admission with NMO
flare ___ presenting with recurrent leg weakness and
numbness since last admission but especially since ___. She
also has had urinary retention recently with a foley catheter
(out since ___ and has a positive UA.
NEURO: The patient was admitted to the general neurology
service. We started methylprednisilone for 3 days at 1 gram
daily followed by a 6 day taper. The patient reported almost
immediate increase in her strength. This continued to improve
through the treatment. On the final 2 days of the taper she
received daily IVIG treatment. She tolerated this well with no
adverse reactions.
ENDO:Her hospital course was complicated by very high blood
glucose levels while on steroids, up to the 400s. This was
treated with standing and sliding scale insulin. This improved
as the steroids were tapered off.
ID: She has a history of urinary retention which has resulted on
frequent urinary tract infections. Her urinalysis was positive
on admission and the culture grew enterococcus and coag psoitive
staph aureus. She completed 7 days of ceftriaxone. She also was
intermittently straight catheterized to decompress her bladder.
At the end of the hospital stay she required fewer straight
catheterizations. She expressed an interest doing this at home
herself to prevent future problems. She was taught in the
hospital and ___ was set up to help her with this initially at
home.
Transition of care: Ms. ___ will follow up with her
neurologist. She will have ___ to help with straight cath. She
will continue her usual physical therapy.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Tamsulosin 0.4 mg PO HS
2. Baclofen 15 mg PO TID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Creon 12 1 CAP PO TID W/MEALS
5. Paroxetine 20 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
7. Ranitidine 150 mg PO BID
8. Topiramate (Topamax) 25 mg PO DAILY
9. Zolpidem Tartrate 5 mg PO HS:PRN sleep
Discharge Medications:
1. Baclofen 15 mg PO TID
2. Creon 12 1 CAP PO TID W/MEALS
3. Hydrochlorothiazide 25 mg PO DAILY
4. Paroxetine 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
6. Ranitidine 150 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. Topiramate (Topamax) 25 mg PO DAILY
9. Zolpidem Tartrate 5 mg PO HS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neuromyelitis optica
urinary tract infection
Discharge Condition:
Alert and oriented. Face symmetric. No drift. Strength UE full.
R IP 4-, Quad 5, Ham 4+, TA 4-, Gas 4+ ___ 4- L IP 4+, Quad 4+,
Ham 4+, TA 4+, Gas 4+. Propriception intact.
Discharge Instructions:
You came to the hospital because of a flare of your NMO. You
received IV methylprednisilone for 3 days followed by a taper
and 2 days of IVIG. The strength in your right leg improved
almost immediately and has continued to improve so that it is
now nearly full strength.
We also found that you had a urinary tract infection, likely due
to urinary retention. You were treated with ceftriaxone for 7
days.
Please continue your usual medications and follow up with Dr.
___ as detailed below.
Followup Instructions:
___
|
19659653-DS-33
| 19,659,653 | 25,838,399 |
DS
| 33 |
2188-04-28 00:00:00
|
2188-04-29 20:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ right-handed woman with a history of
neuromyelitis optica diagnosed in ___ (followed by Dr. ___
who presents with worsening lower extremity weakness after
missing her dose of IVIG last week. She last received 55g IVIG
___ and ___, and was scheduled for her next monthly
infusion on ___. However the weather was bad that day and she
was unable to make it in. She was rescheduled for this ___
and thought she could make it until then, but over the weekend
she began to develop worsening lower extremity weakness. She
reports that when she awoke on ___ morning her legs felt
heavy and tight, and she had more difficulty than usual
transferring into her wheelchair. She is normally able to walk a
little around the house with a walker but has been unable to do
this at all for the last few days. She also began to develop
numbness and tingling in her legs, which she has had with
previous flares. This time however she also reports numbness in
the lower part of her torso, which she says she had once in the
past when she was first diagnosed but she has not experienced
this in a long time. She also had difficulty urinating for the
first time on ___ - she has had longstanding issues with
incomplete emptying and occasional incontinence (straight caths
herself intermittently at home), but says this was the first
time
she felt the urge to urinate but was unable to. She denies any
changes in bowel function or altered sensation in the perineal
region. Her leg weakness continue to progress through the
weekend, so she called Dr. ___ who advised her to come
into the ED.
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.
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:
-Neuromyelitis optica
-Mitral valve prolapse
-Hypertension
-Asthma
-Osteoarthritis, had required steroid injections to the spine
(well controlled recently)
-PMR (had been on plaquenil)
-Depression
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced)
-Chronic diarrhea/?pancreatic insufficiency on creon
-Adrenal insufficiency
-granulomatous lung nodules
-renal cell carcinoma, left partial nephrectomy
Social History:
___
Family History:
Her father died of lung cancer. Her grandmother died of colon
cancer. Her older brother had a stroke.
Physical Exam:
Vitals: 98.9 60 143/62 18 100% ra
General: Awake, pleasant and cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, +systolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-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.
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.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 4 5 5- 5- 5 5- 5-
R 5 ___ ___- 3 5 4 3 5 4 4
-Sensory: Reports decreased sensation to pinprick over RLE from
mid-shin down. Intact sensation to pinprick over LLE. Sensation
intact to pinprick over b/l UE. +Sensory level anteriorly at T5
extending down to groin, where sensation returns. Vibration and
proprioception are impaired at b/l great toes.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3 + clonus
R 3 3 3 3 3 + clonus
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Deferred
DISCHARGE EXAMINATION:
AF VSS
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 4- 5 5- 4 5 5- 5-
R 4+ 4+ ___ ___ 5 4 4- 5 4 4
Pt with some R upper extremity weakness, mostly in C5
distribution. RLE weakness slightly improved, LLE weakness
unchanged from admission. Patient feels at baseline.
Pertinent Results:
ADMISSION LABS:
___ 08:15PM BLOOD WBC-5.2 RBC-3.81* Hgb-11.0* Hct-34.7*
MCV-91 MCH-28.9 MCHC-31.8 RDW-14.4 Plt ___
___ 08:15PM BLOOD Neuts-36.2* Lymphs-53.2* Monos-8.2
Eos-1.9 Baso-0.5
___ 08:15PM BLOOD Glucose-114* UreaN-26* Creat-0.8 Na-142
K-3.9 Cl-105 HCO3-26 AnGap-15
___ 07:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.8
URINARLYSIS:
___ 08:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
___ 08:15PM URINE RBC-3* WBC-6* Bacteri-FEW Yeast-NONE
Epi-1
MICROBIOLOGY:
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM NEGATIVE ROD #2. <10,000 organisms/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
___ yo RH woman with PMH of NMO diagnosed in ___ (followed by
Dr. ___ who presents with difficulty transferring and sense
of worsening BLE weakness and tingling/numbness after missing
her monthly IVIg. It was thought to be due to her missing dose
of IVIg and after discussion with her outpatient neurologist,
Dr. ___ was made to increase her IVIg to 70 gram/day
x2 days as her previous dose was thought to be not lasting long
enough between treatments. Patient received her IVIg in the
hospital without events. As patient felt improved and back at
baseline, she was discharged home.
As her urinalysis was borderline positive, she was treated with
antibiotics (ceftriaxone) but it grew out e coli (___) that
was similar to her past urine culture, raising question of
colonization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 15 mg PO TID
2. Hydrochlorothiazide 25 mg PO DAILY
3. Creon 12 1 CAP PO TID W/MEALS
4. Paroxetine 20 mg PO DAILY
5. Potassium Chloride 10 mEq PO BID
6. Ranitidine 150 mg PO BID
7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
8. Acetaminophen 1000 mg PO Q8H:PRN pain
9. Ascorbic Acid ___ mg PO TID
10. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
11. FiberCon *NF* (calcium polycarbophil) 625 mg Oral QHS prn
constipation
12. Poly-Iron *NF* (polysaccharide iron complex) 150 mg iron
Oral BID
13. Senna 1 TAB PO DAILY:PRN constipation
14. Topiramate (Topamax) 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Baclofen 15 mg PO TID
3. Creon 12 1 CAP PO TID W/MEALS
4. Paroxetine 20 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Senna 1 TAB PO DAILY:PRN constipation
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
8. Ascorbic Acid ___ mg PO TID
9. FiberCon *NF* (calcium polycarbophil) 625 mg Oral QHS prn
constipation
10. Poly-Iron *NF* (polysaccharide iron complex) 150 mg iron
Oral BID
11. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
12. Hydrochlorothiazide 25 mg PO DAILY
13. Topiramate (Topamax) 25 mg PO DAILY
14. Potassium Chloride 10 mEq PO BID
15. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 1
Days
Start ___
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*2 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: neuromyelitis optica, urinary tract infection
Secondary Diagnosis: hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
you were admitted to the hospital with worsening weakness of
legs after missing your scheduled doses of IVIg. You were given
increased doses of IVIg in the hospital and your urinary tract
infection was also treated with antibiotics.
Your symptoms improved with treatment and you worked with
physical therapist and felt that you were similar to your
baseline.
Followup Instructions:
___
|
19659653-DS-39
| 19,659,653 | 27,840,326 |
DS
| 39 |
2191-11-16 00:00:00
|
2191-11-16 09:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape
Attending: ___.
Chief Complaint:
Worsening leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ RH F w PMHx of NMO (followed by Dr.
___ who presents to ___ ED with several weeks of
worsening leg weakness. Neurology is consulted for
recommendations regarding further evaluation and treatment.
Ms. ___ reports that she has been having weakness and
tightness in her legs for approximately three weeks. She notes
that her flares are usually precipitated by UTIs. She states
that
with treatment of the UTI, the flare resolves or aborts. She
reports that she was diagnosed with a UTI several weeks ago, but
despite abx treatment, her symptoms have not improved. She
believes this indicates that she is having a "true" NMO flare.
Ms. ___ reports that her symptoms are mainly in the legs.
She
reports that both legs feel "tight" and heavy, as if there are
"bands or a cast" around them. She notes that the entire RLE
feels "tingly and numb" and she has the sensation that it is
swollen. She notes some numbness in her R ___ and ___ digits
over
the last several days, but otherwise denies symptoms in the
BUEs.
She states that the leg symptoms are very bothersome and have
been interrupting her sleep and limiting her mobility (difficult
for her to use the walker). She feels that the RLE is weak and
that she is "dragging it." Overall, she feels that her symptoms
have been progressive since onset, though she does not that she
has "good days and bad days."
On ROS, she reports urinary frequency (perhaps related to UTI)
and what sounds like chronic urge incontinence. She has been
incontinent recently, though states that usually at home she can
"make it to the bathroom in time." Additionally, she complains
of
a dull bifrontal HA that feels like "tension" for the past week.
She denies chest pain, abdominal pain, or SOB.
Ms. ___ was last seen in Dr. ___ on ___. The
examination from that visit is as follows: "Right discomfort to
pressure appears to maximize over the area of the right
trochanteric bursa. Extraocular movements unremarkable, grimace
symmetric. Power testing shows fairly symmetric interossei, EDC
and wrist extensors. Proximal arm power ___. Psoas ___,
hamstrings ___, anterior tibialis
movement in the right bracing, ___ on the left without bracing.
Pinprick is intact over the feet, lower legs and thighs
bilaterally."
Past Medical History:
-Devic's Neuromyelitis optica
-RCC, left partial nephrectomy
-Hepatitis B
-Steroid-induced hyperglycemia
-Mitral valve prolapse
-Hypertension
-Asthma
-Left sciatica
-Osteoarthritis
-Bilateral knee replacement
-Depression
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced)
-Chronic diarrhea/?pancreatic insufficiency on creon
-Adrenal insufficiency
-Granulomatous lung nodules
Social History:
___
Family History:
-Father and paternal grandmother with rheumatoid arthritis
-Daughter w/ BREAST CANCER
-MGM Deceased at ___ w/COLON CANCER
-Sister, brother, mother: HYPERTENSION HYPERLIPIDEMIA
-daughter with hypertension.
Physical Exam:
=== ADMISSION EXAM ===
PHYSICAL EXAMINATION:
VS T97.3 HR63 BP115/52 RR18 Sat100RA
GEN - overweight AA woman, pleasant and cooperative
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - obese, soft, NT, ND
EXTR - s/p B/L knee surgery
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
months backwards. Recalls a coherent history. Structure of
speech
demonstrates fluency with full sentences, and normal prosody. No
paraphasic errors. Intact repetition, naming, reading, and
comprehension. No evidence of apraxia or neglect.
CN - [II] PERRL 3->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, fatigable end-gaze nystagmus bilaterally. Normal
saccades. [V] V1-V3 without deficits to light touch or PP
bilaterally. [VII] No facial movement asymmetry with forced
eyelid closure or volitional smile. [VIII] Hearing intact to
voice. [IX, X] Palate elevation symmetric. No dysarthria. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline
with
full ROM.
MOTOR - Normal bulk and tone. No pronation, mild downward drift
of RUE. No tremor or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 ___ 5 4 5* 5
R 5 5 4+ 5 ___ 4 ___ 5* 5
*Significant give way weakness, though appears grossly full
power
SENSORY - Reports "dullness" to LT over RUE. Reports decreased
sensation to PP over R ___ and ___ digits, reports allodynia
over
medial aspect of R palm to PP. Reports stocking pattern of PP
loss to the level of the knees B/L.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 0 0
R 2+ 2+ 2+ 0 0
Plantar response flexor bilaterally.
COORD - No dysmetria with finger to nose. Good speed and intact
cadence with rapid alternating movements.
GAIT - Deferred.
=== DISCHARGE EXAM ===
Unchanged except as noted below.
MOTOR -
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
L 5 5 5 5 5 4+ 5 5 5 5 5
R 5 5 4+ 5 5 4- 4+ 4 4- 5 4
SENSORY - Dullness to LT over bilateral lower extremities to
level of mid-calf -- 80% of normal on Left, 30% of normal on
right. Normal sensation in bilateral hands.
Pertinent Results:
=== SELECTED LABS ===
___ 05:00PM BLOOD WBC-3.4* RBC-3.84* Hgb-10.9* Hct-36.2
MCV-94 MCH-28.4 MCHC-30.1* RDW-13.4 RDWSD-46.0 Plt ___
___ 05:00PM BLOOD Neuts-35.4 ___ Monos-11.7
Eos-0.3* Baso-0.3 Im ___ AbsNeut-1.21* AbsLymp-1.78
AbsMono-0.40 AbsEos-0.01* AbsBaso-0.01
___ 05:15AM BLOOD ___ PTT-39.2* ___
___ 05:00PM BLOOD Glucose-105* UreaN-19 Creat-0.7 Na-141
K-3.7 Cl-100 HCO3-31 AnGap-14
___ 05:47AM BLOOD WBC-3.9* RBC-3.60* Hgb-10.3* Hct-33.7*
MCV-94 MCH-28.6 MCHC-30.6* RDW-13.1 RDWSD-44.7 Plt ___
___ 05:47AM BLOOD Glucose-403* UreaN-20 Creat-0.7 Na-133
K-3.4 Cl-95* HCO3-27 AnGap-14
___ 05:15AM BLOOD ALT-10 AST-22 LD(LDH)-210 CK(CPK)-185
AlkPhos-79 TotBili-0.3
___ 05:47AM BLOOD ALT-11 AST-20 AlkPhos-74 TotBili-0.4
___ 05:00PM BLOOD Calcium-10.0 Phos-3.4 Mg-1.7
___ 05:15AM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.1 Mg-1.7
___ 05:47AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.9
___ 05:15AM BLOOD CRP-4.2
___ 11:50PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 11:50PM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-0
___ 11:50PM URINE Color-Straw Appear-Clear Sp ___
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a history of DM2,
HTN, pancreatic insufficiency, RCC s/p L partial nephrectomy,
and Devic's neuromyelitis optica who presents to ___ ED with
several weeks of worsening leg weakness and sensory changes,
likely NMO flare due to similarity to prior episodes. It was
preceded by a UTI (which is common for her), though this had
been treated with amoxicillin prior to her presentation. Her UA
was negative. Admitted per outpatient neurologist Dr. ___
___ for a 9 day IV steroid course. Her symptoms have improved
somewhat during the first 4 days of treatment - though with more
obvious improvements in sensation (initially stocking
distribution to proximal thighs, now mid-calf). She has been
able to ambulate herself using a walker with stand-by assistance
only, and she subjectively feels her strength is improving. Her
right leg is more affected than her left in both strength and
sensory symptoms. We did not re-image her spine due to poor
tolerance previously. A Foley catheter was placed per patient
preference and in keeping with prior episodes, as she would have
episodes of functional incontinence due to her weakness. She
received her two monthly doses of IVIG for her NMO (___)
while she was admitted.
- The entire course of IV methylprednisolone is 1g Q24H x 3
days, 500mg x 3 days, 250mg x 3 days. She received 3 doses of 1g
___ early AM, ___ late ___, ___ ___, started 500mg (___-)
- Continue IV methylprednisolone 500mg QPM until ___, decrease
to 250mg QPM (___).
- Continue ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Immune Globulin Intravenous (Human) 75 g IV 2 DAYS PER MONTH
2. Mycophenolate Mofetil 1500 mg PO BID
3. Baclofen ___ mg PO TID
4. Indapamide 1.25 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. methenamine hippurate 1 gram oral BID
7. nizatidine 150-300 mg oral QHS
8. Omeprazole 20 mg PO BID
9. PARoxetine 40 mg PO DAILY
10. Ascorbic Acid ___ mg PO BID
11. Aspirin 81 mg PO EVERY OTHER DAY
12. Vitamin D ___ UNIT PO DAILY
13. Docusate Sodium 100 mg PO DAILY
14. Gabapentin 100-300 mg PO TID
15. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
16. Calcium Carbonate 750 mg PO BID
17. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. MethylPREDNISolone Sodium Succ 500 mg IV Q24H Duration: 3
Doses
___
2. MethylPREDNISolone Sodium Succ 250 mg IV Q24H Duration: 3
Doses
___
3. Baclofen 20 mg PO BID
4. Baclofen 10 mg PO Q24
5. Gabapentin 300 mg PO QHS
6. Gabapentin 100 mg PO BID
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Ascorbic Acid ___ mg PO BID
9. Aspirin 81 mg PO EVERY OTHER DAY
10. Calcium Carbonate 750 mg PO BID
11. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
12. Docusate Sodium 100 mg PO DAILY
13. Immune Globulin Intravenous (Human) 75 g IV 2 DAYS PER
MONTH
14. Indapamide 1.25 mg PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO DAILY
16. methenamine hippurate 1 gram oral BID
17. Mycophenolate Mofetil 1500 mg PO BID
18. nizatidine 150-300 mg oral QHS
19. Omeprazole 20 mg PO BID
20. PARoxetine 40 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Devic's NMO Flare
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. ___,
You were admitted to the hospital for symptoms of leg weakness
and numbness, consistent with your prior episodes of NMO flare.
You urine was checked and you did not have an urinary infection.
You were started on an IV steroid taper, and will be go to rehab
where you will complete the 9 day course. You also received
your monthly doses of IVIG while you were admitted.
- Continue the IV steroids as prescribed.
- Continue all of your other home medications.
It was a pleasure taking care of you!
Your ___ Neurology Team
Followup Instructions:
___
|
19659653-DS-40
| 19,659,653 | 25,746,353 |
DS
| 40 |
2191-11-21 00:00:00
|
2191-11-26 09:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape
Attending: ___.
Chief Complaint:
Inadequate care at rehab
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a history of DM2,
HTN, pancreatic insufficiency, ___ s/p L partial nephrectomy,
and Devic's neuromyelitis optica who returns to ___ after
recent discharge for NMO flare.
She was admitted from ___ for several weeks of worsening
leg weakness and sensory changes, that was preceded by UTI
treated with amoxicillin. Her UA was negative on this admission.
She was started on IV steroids and planned for a 9 day taper, 1g
___, 500mg ___, 250mg ___. During her
admission
her symptoms improved somewhat during the first 4 days of
treatment - though with more obvious improvements in sensation
(initially stocking
distribution to proximal thighs, now mid-calf). She was
able to ambulate herself using a walker with stand-by assistance
only, and she subjectively felt her strength is improving. Her
right leg is more affected than her left in both strength and
sensory symptoms. She was not re-imaged due to poor
tolerance previously. A Foley catheter was placed per patient
preference and in keeping with prior episodes, as she would have
episodes of functional incontinence due to her weakness. She
received her two monthly doses of IVIG for her NMO (___)
while she was admitted.
Unfortunately, after discharge to ___, the ___ did not know how
to access her port and steroids were not given ___. A
peripheral IV was placed ___ and she did get her
steroids ___ 9pm. On ___, during the day she felt
increased leg weakness and sensory change but this has been
improving after her dose of steroids. This AM, on ___, she
accidentally DC'ed her peripheral IV. She often gets
hyperglycemic with her steroid courses and she was not ordered
for FSG. When she felt jittery, she asked for a fingers stick
and
it has been elevated in 260s-270s without treatment with sliding
scale. She was told that insulin was "not in her orders" and
therefore did not receive any glycemic coverage. Her family
became very distressed at this inadequate treatment and
volitionally removed her from her rehab to come to our ED.
On discharge ___, her exam was notable for:
"MOTOR -
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [___]
L 5 5 5 5 5 4+ 5 5 5 5 5
R 5 5 4+ 5 5 4- 4+ 4 4- 5 4
SENSORY - Dullness to LT over bilateral lower extremities to
level of mid-calf -- 80% of normal on Left, 30% of normal on
right. Normal sensation in bilateral hands.
No reflexes in patellar or ankle bilaterally."
Previously when seen in clinic in ___, she had "Psoas ___,
hamstrings ___, anterior tibialis movement in the right bracing,
___ on the left without bracing." with no sensory deficits.
Past Medical History:
-Devic's Neuromyelitis optica
-RCC, left partial nephrectomy
-Hepatitis B
-Steroid-induced hyperglycemia
-Mitral valve prolapse
-Hypertension
-Asthma
-Left sciatica
-Osteoarthritis
-Bilateral knee replacement
-Depression
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced)
-Chronic diarrhea/?pancreatic insufficiency on creon
-Adrenal insufficiency
-Granulomatous lung nodules
Social History:
___
Family History:
-Father and paternal grandmother with rheumatoid arthritis
-Daughter w/ BREAST CANCER
-MGM Deceased at ___ w/COLON CANCER
-Sister, brother, mother: HYPERTENSION HYPERLIPIDEMIA
-daughter with hypertension.
Physical Exam:
====================================================
ADMISSION PHYSICAL EXAMINATION
====================================================
VS 97.8F, HR 72, 161/66 RR 16 100% on RA
GEN - overweight AA woman, pleasant and cooperative
HEENT - NC/AT, mildly dry mucous membranes
RESP - normal WOB
ABD - obese, soft, NT, ND
EXTR - s/p B/L knee surgery
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
months backwards. Recalls a coherent history. Structure of
speech demonstrates fluency with full sentences, and normal
prosody. No paraphasic errors. Intact repetition, naming,
reading, and comprehension. No evidence of apraxia or neglect.
CN -
[II] PERRL 3->2 brisk. VF full to number counting.
[III, IV, VI] EOMI, fatigable end-gaze nystagmus bilaterally.
[V] V1-V3 without deficits to light touch or PP
bilaterally.
[VII] No facial movement asymmetry with forced eyelid closure or
volitional smile.
[VIII] Hearing intact to voice.
[IX, X] Palate elevation symmetric. No dysarthria.
[XI] SCM/Trapezius strength ___ bilaterally.
[XII] Tongue midline with full ROM.
MOTOR -
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 3 5 4+ 5 5
R 5 5 5 5 5 2 4+ 3 3 5
SENSORY - Decreased light touch and pinprick over right leg
laterally more than medially compared to the left leg. No
deficits in her UE.
REFLEXES -
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 0
R 3 3 3 3 0
Plantar response flexor bilaterally.
COORD - No dysmetria with finger to nose.
GAIT - Deferred.
=========================================================
DISCHARGE PHYSICAL EXAMINATION
=========================================================
Unchanged from admission.
Pertinent Results:
___ 05:00PM BLOOD WBC-5.4 RBC-3.90 Hgb-11.0* Hct-35.6
MCV-91 MCH-28.2 MCHC-30.9* RDW-13.1 RDWSD-43.3 Plt ___
___ 04:47AM BLOOD WBC-6.1# RBC-3.62* Hgb-10.3* Hct-32.8*
MCV-91 MCH-28.5 MCHC-31.4* RDW-13.2 RDWSD-43.8 Plt ___
___ 05:00PM BLOOD Neuts-68.8 ___ Monos-11.5
Eos-0.0* Baso-0.0 Im ___ AbsNeut-3.72# AbsLymp-1.03*
AbsMono-0.62 AbsEos-0.00* AbsBaso-0.00*
___ 05:00PM BLOOD Glucose-340* UreaN-21* Creat-0.8 Na-132*
K-3.4 Cl-91* HCO3-32 AnGap-12
___ 04:47AM BLOOD Glucose-267* UreaN-20 Creat-0.8 Na-134
K-2.8* Cl-92* HCO3-35* AnGap-10
___ 01:20PM BLOOD K-3.6
Imaging:
CXR ___: No acute intrathoracic process.
Brief Hospital Course:
Ms. ___ was readmitted ___ after an admission for NMO
flare. She had been discharged with plan to continue IV steroid
taper, which was not administered at OSH. On arrival, we
restarted the steroid taper and finished the planned course
prior to discharge.
Urinalysis on admission was abnormal, and in the setting of
recent (___) urine culture which grew >100,000 cfu/mL of both
E. coli and proteus mirabilis, of which the E. coli had multiple
resistances, including to ceftriaxone, she was treated with
ampicillin-sulbactam (to which both previous bacteria had been
susceptible), however on the day of discharge her urine culture
returned without infection, and antibiotics were stopped.
Additionally, she developed diarrhea on ___, after
antibiotics were started. C.difficile PCR was sent and was
negative. This was therefore favored to represent
antibiotic-associated diarrhea, and it improved with Imodium.
She additionally developed hypokalemia after having multiple
loose stools, which improved and was stabilized with improvement
in stool volume on Imodium prior to discharge.
==================
Transitional Issues:
- consider resistant organisms with future UTIs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO EVERY OTHER DAY
4. Baclofen 20 mg PO BID
5. Baclofen 10 mg PO Q24
6. Docusate Sodium 100 mg PO DAILY
7. Gabapentin 300 mg PO QHS
8. Gabapentin 100 mg PO BID
9. Indapamide 1.25 mg PO DAILY
10. Mycophenolate Mofetil 1500 mg PO BID
11. Omeprazole 20 mg PO BID
12. PARoxetine 40 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
15. MethylPREDNISolone Sodium Succ 500 mg IV Q24H
16. MethylPREDNISolone Sodium Succ 250 mg IV Q24H
17. Calcium Carbonate 750 mg PO BID
18. MetFORMIN (Glucophage) 500 mg PO DAILY
19. methenamine hippurate 1 gram oral BID
20. nizatidine 150-300 mg oral QHS
21. Immune Globulin Intravenous (Human) 75 g IV 2 DAYS PER MONTH
Discharge Medications:
1. LOPERamide 2 mg PO QID:PRN Loose stools
RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth every 4
hours as needed Disp #*30 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Ascorbic Acid ___ mg PO BID
4. Aspirin 81 mg PO EVERY OTHER DAY
5. Baclofen 20 mg PO BID
6. Baclofen 10 mg PO Q24
7. Calcium Carbonate 750 mg PO BID
8. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral TID W/MEALS
9. Docusate Sodium 100 mg PO DAILY
10. Gabapentin 100 mg PO BID
11. Gabapentin 300 mg PO QHS
12. Immune Globulin Intravenous (Human) 75 g IV 2 DAYS PER
MONTH
13. Indapamide 1.25 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO DAILY
15. methenamine hippurate 1 gram oral BID
16. Mycophenolate Mofetil 1500 mg PO BID
17. nizatidine 150-300 mg oral QHS
18. Omeprazole 20 mg PO BID
19. PARoxetine 40 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neuromyelitis optica flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after receiving inadequate
treatment for your NMO flare at the rehab. We continued treating
you with steroids, and you received your last dose of steroids
today.
You also were found to have a UTI on admission, and we are
treating you with an antibiotic. Take it as directed.
Followup Instructions:
___
|
19659653-DS-42
| 19,659,653 | 23,896,986 |
DS
| 42 |
2194-01-01 00:00:00
|
2194-01-07 20:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape / latex
Attending: ___.
Chief Complaint:
Weakness and Parasthesias
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with history of neuromyelitis
optica restricted to the cord who presents with several days of
weakness and sensory change in her legs. Neurology consulted
given possibility of NMO flare.
At Physical therapy on ___, her L knee felt somewhat 'funny'.
___, after her routine IVIg administration, she could
tell 'something just wasn't right'. Late ___, she
noted a band-like sensation around toes that gradually moved up
her legs. Currently, there is a band of tightness and tingling
that is largely felt over anterior thighs, and circumferentially
around the lower legs. Yesterday morning there was no abnormal
sensation above the knees, and today it progressed to involve
her thighs.
She also notes incrased leg heaviness and weakness. She is still
able to walk, but finds it is much more difficult to do so than
it is normally. For example, normally she drags her R foot and
wears an AFO, but she now feels like she is also dragging her
left foot. She becomes fatigued more quickly, and overall feels
more tired over this time period.
She also has had increased frequency of nocturnal leg spasms
during this time period.
Ms. ___ last NMO flare was approx ___ years ago. She has
been maintained on stable regimen of IVIg and mycophenolate
mofetil since that time.
She often has increase in weakness when she gets UTIs. This is
different from typical exacerbations with UTIs because the
timecourse has been somewhat slower, she has the band of
tightness around her legs, and she does not have the change in
urine odor and sleepiness that typically accompany her UTIs.
Chronic residual deficits include paraparesis, R weaker than L,
chronic tingling bilateral feet and lower legs to knee, R more
intense than left and small area of nubmness R ulnar aspect of
hand/fingers.
She has spastic bladder with chronic intermittent straight cath
several times per day (occ spont void but doesn't empty), and
ambulates with rolling walker and AFO, though uses wheelchair
rarely.
Of note, with prior steroid administration, she has had
hyperglycemia.
Her baseline neurologic exam per ___ clinic note by Dr.
___: "Extraocular movements unremarkable, grimace symmetric.
Power testing right/left, interossei ___ EDC ___ wrist
extensors ___ biceps, triceps and deltoid full; psoas ___
hamstrings ___ anterior tibs braced/9; lateral peroneals
braced/10; quadriceps ___. Diminished vibratory sense in the
right foot, reconstitutes at the ankle, word is symmetric.
Pinprick is intact in the lower extremities. She arises fairly
briskly with minimum pressure on the arms and shoulders to a
standing position and can adjust her posture to an erect one.
Ambulation is mildly broad-based and somewhat stiff, but
accomplished and she denies much in the way of (right shoulder)
pain."
Past Medical History:
-Neuromyelitis optica
-RCC, left partial nephrectomy
-Hepatitis B
-Steroid-induced hyperglycemia
-Mitral valve prolapse
-Hypertension
-Asthma
-Left sciatica
-Osteoarthritis
-Bilateral knee replacement
-Depression
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced)
-Chronic diarrhea/?pancreatic insufficiency on creon
-Adrenal insufficiency
-Granulomatous lung nodules
Social History:
___
Family History:
-Father and paternal grandmother with rheumatoid arthritis
-Daughter w/ BREAST CANCER
-MGM Deceased at ___ w/COLON CANCER
-Sister, brother, mother: HYPERTENSION HYPERLIPIDEMIA
-daughter with hypertension.
Physical Exam:
ADMISSION:
Vitals: T: 96.0 HR: ___ BP: ___ RR: 18 SaO2: 100%
RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to exam. Speech is fluent
with normal grammar and syntax. No paraphasic errors.
Comprehension intact to complex commands. Normal prosody.
-Cranial Nerves: Gaze conjugate. EOMI. Face symmetric. No
dysarthria.
- Motor: Normal bulk, difficult to assess tone. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 2 2* 2* 4- 4- 3
R 5 ___ ___ 2* 2 2 0 2 2
*both muscles are this strong, but this muscle is slightly
stronger than the contralateral side.
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 3 2 3 2 3 +
R 3 2 3 2 3 +
L appears slightly more brisk throughout.
With achilles reflex testing, she has spread to involve
adductors bilaterally.
Plantar response was extensor bilaterally.
-Sensory: Proprioception intact to medium movements of R ankle,
maximal movements of L ankle. Sensory level to PP R thorax at
approx level of around T6-T8. On R, sensation decreased to PP
mid medial thigh, and circumferentially below the knee, and is
intact anterior, lateral and posterior thigh. Additionally there
is decrease to PP R lateral hand and fingers, stated chronic and
unchanged per pt.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
========================================
DISCHARGE:
Vitals: T 97.7, BP 72 / 87, HR 52, RR 18, ___ 100
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: wam, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to converse
without difficulty. Attentive to exam. Speech is fluent with
normal grammar and syntax. No paraphasic errors. Comprehension
intact to complex commands. Normal prosody.
- Sensory: Complaining of numbness and tingling to just above
the knees, but markedly improved compared to admission.
-Strength:
IP Quad Ham TA ___
L 5- ___ 5
R 4 5 4+ 4 5
Pertinent Results:
___ 07:25AM BLOOD ___ PTT-50.0* ___
___ 07:25AM BLOOD Glucose-344* UreaN-25* Creat-0.9 K-3.6
Cl-96 HCO3-25 AnGap-14
___ 07:25AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.7
Brief Hospital Course:
Pt had no acute events while inpt.
___ through ___, pt received methylprednisolone 1000 mg IV q
24 hours. She did show intermittent hyperglycemia up to 350s;
treated with sliding scale insulin; ___, insulin lispro
increased to 4 units prn w/ meals and added glargine 15 units at
bedtime; had slightly improved blood glucose control w/ this
regimen; no hypoglycemia.
We held paroxetine to decrease likelihood of mood changes w/
steroid therapy.
She had no other adverse effects related to steroid therapy.
She was evaluated by physical therapy, who deemed her to be
slightly below baseline functional status due to b/l ___ weakness
w/ NMO flare.
___, she was stable for transfer to ___ to
continue physical therapy and to continue steroid therapy.
Recommended steroid course:
methylprednisolone 500 mg daily from ___ to ___
methylprednisolone 250 mg daily from ___ to ___
Also check glucose q 6 hours and adjust insulin regimen as
needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Baclofen 10 mg PO QHS:PRN Muscle Spasms
3. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP WEEKLY
4. Indapamide 1.25 mg PO DAILY:PRN leg swelling
5. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral BID
6. Mycophenolate Mofetil 1500 mg PO BID
7. Nitrofurantoin (Macrodantin) 100 mg PO QHS
8. Omeprazole 20 mg PO BID:PRN heartburn
9. PARoxetine 40 mg PO DAILY
10. Potassium Chloride 20 mEq PO BID:PRN hand cramping
11. Pravastatin 20 mg PO QPM
12. Repaglinide 0.5 mg PO TID:PRN large meal
13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
14. Ascorbic Acid ___ mg PO BID
15. Aspirin 81 mg PO EVERY OTHER DAY
16. Calcium Carbonate 300 mg PO BID
17. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
4. Heparin 5000 UNIT SC BID
5. Glargine 15 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
6. MethylPREDNISolone Sodium Succ 500 mg IV Q24H Duration: 3
Days
7. MethylPREDNISolone Sodium Succ 250 mg IV Q24H Duration: 3
Days
8. Ramelteon 8 mg PO QHS:PRN sleep
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Omeprazole 20 mg PO BID
while on steroids
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
12. Ascorbic Acid ___ mg PO BID
13. Aspirin 81 mg PO EVERY OTHER DAY
14. Baclofen 10 mg PO TID
15. Baclofen 10 mg PO QHS:PRN Muscle Spasms
16. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP WEEKLY
17. Calcium Carbonate 300 mg PO BID
18. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral BID
19. Indapamide 1.25 mg PO DAILY:PRN leg swelling
20. Mycophenolate Mofetil 1500 mg PO BID
21. Nitrofurantoin (Macrodantin) 100 mg PO QHS
22. Potassium Chloride 20 mEq PO BID:PRN hand cramping
23. Pravastatin 20 mg PO QPM
24. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Neuromyelitis Optica spectrum disorder
Discharge Condition:
improved, stable
Discharge Instructions:
Pt will be discharged to ___ to continue physical
therapy. Steroid therapy will be continued as per D/C medication
list.
Followup Instructions:
___
|
19659653-DS-43
| 19,659,653 | 22,713,342 |
DS
| 43 |
2194-01-25 00:00:00
|
2194-01-25 16:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Vicodin / acetaminophen-codeine / Atenolol / ProAir HFA / Sulfa
(Sulfonamide Antibiotics) / adhesive tape / latex
Attending: ___
Chief Complaint:
new onset bilateral arm weakness in the setting of a urinary
tract infection
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ yo woman with history of neuromyelitis
optica restricted to the spinal cord, DMII who presented to the
ED with new arm weakness; neurology consulted given possibility
of NMO flare. Patient reports that since her discharge from
___, she has been doing really well with physical therapy at
___ from this past ___ through
___. On ___ she noticed she was "fatigued"
and slower, but the physical therapist didn't didn't notice
anything different about her performance. This fatigue
progressed on ___ and ___. She was discharged home on
___, and felt very tired. The fatigue continued to progress
on ___ and ___, she thought it was related to her
elevated blood sugars from the steroids she had received in
rehab; her sugars were in the 300s, 400s at rehab. On ___
(___) she contacted ___, and some changes were made to her
regimen on ___, but her sugars remained in the 200s. On
___, patient felt like she had a UTI and contacted her
PCP to set up an appointment. She became concerned about her
upper extremities, which she says "just don't feel as strong".
She reports that she experienced similar symptoms in her arms
once before in ___ during her initial NMO flare. This scared
her today, which is why she presented to the ED. She also
endorses intermittent blurry vision in both eyes
Notably, the patient does often see an increase in her weakness
when she has a UTI, which she describes as a sense of
generalized fatigue. She feels that she has a UTI currently,
which she thinks could be because she may have straight cathed
more frequently than she should have. She feels her current
presentation is different from the weakness induced by a UTI
because she has never before experienced weakness of her arms.
Patient was recently admitted to the general neurology service
from ___ for several days of weakness and sensory changes
in her legs concerning for NMO flare. She received
methylprednisolone 1000mg IV qday ___, and discharged to
___ rehab on ___ with methylprednisolone 500 mg
daily from ___ to ___ methylprednisolone 250 mg daily from
___ to ___. Prior to this recent admission, her last flare
was in ___, and has been maintained on IVIG and mycophenolate
mofetil since that time. She receives two days of IVIG monthy,
last received at the beginning of ___ and she will have her
next dose on ___. She has been able to get up
to walk using her walker, but feels limited by her fatigue so
she mostly used her chair during the day.
Chronic residual deficits include paraparesis, R weaker than L,
chronic tingling bilateral feet and lower legs to knee, R more
intense than left and small area of nubmness R ulnar aspect of
hand/fingers. She has spastic bladder with chronic intermittent
straight cath several times per day (occ spont void but doesn't
empty), and ambulates with rolling walker and AFO, though uses
wheelchair rarely.
Endorses lightheadedness, nausea, constant sensation of cold
Denies vomiting, chest pain, SOB
Past Medical History:
-Neuromyelitis optica
-RCC, left partial nephrectomy
-Hepatitis B
-Steroid-induced hyperglycemia
-Mitral valve prolapse
-Hypertension
-Asthma
-Left sciatica
-Osteoarthritis
-Bilateral knee replacement
-Depression
-___ esophagitis
-Fungal gastritis
-Anemia
-Leukopenia (drug induced)
-Chronic diarrhea/?pancreatic insufficiency on creon
-Adrenal insufficiency
-Granulomatous lung nodules
Social History:
___
Family History:
-Father and paternal grandmother with rheumatoid arthritis
-Daughter w/ BREAST CANCER
-MGM Deceased at ___ w/COLON CANCER
-Sister, brother, mother: HYPERTENSION HYPERLIPIDEMIA
-daughter with hypertension.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 98.9 HR 99 BP 124/78 RR 22 SaO2 100% 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: breathing comfortably on room air
Cardiac: good peripheral perfusion
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: skin breakdown in skin folds
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to examiner. 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:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. No red desaturation.
V: Facial sensation intact to light touch in V1-V3 to light
touch and pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4+* 5 4+ ___ 2 2* 2* 4- 1 4- 3
R 4+* ___ ___ 2 2 0 1 2 1
*patient reporting pain when testing the deltoids from recent
insulin shots.
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 3 2 3 1 3 + -
R 3 2 3 1 3 + -
With achilles reflex testing, she has spread to the patella
bilaterally.
Plantar response was extensor on the left, mute on the right.
-Sensory: Proprioception intact 50% of the time at the toes
bilaterally. Sensory level around T8 on the left, T6 on the
right
back. Intact sensation to pinprick in the bilateral upper
extremities. In the lower extremities, pinprick intact on the
left thigh, decreased pinprick in the calf and foot. On the
right, decreased pinprick in the thigh and calf and foot.
Patient
feels that this is her normal sensory exam.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
DISHCARGE PHYSICAL EXAMINATION
24 HR Data (last updated ___ @ 853)
Temp: 98.3 (Tm 98.9), BP: 109/60 (99-131/52-72), HR: 56
(56-66), RR: 22 (___), O2 sat: 99% (98-99), O2 delivery: ra
General: Awake, friendly, NAD
HEENT: NC/AT, no scleral icterus noted, PERRL 2 --> 1 mm
Neck: Supple
Pulmonary: breathing comfortably on room air, lungs clear to
auscultation
Cardiac: good peripheral perfusion
Abdomen: non-distended
Extremities: No ___ edema.
Skin: Skin breakdown in skin folds, per nursing, still
producing
occasional bloody discharge
Neurologic:
-----------
-Mental Status: Attentive to examiner. Normal prosody.
There were no paraphasic errors. Speech was not dysarthric. Able
to follow both midline and appendicular commands. Recalls
details
of her family and past interactions with ease.
-Cranial Nerves: pupils ERRL 2 mm --> 1 mm , No facial droop,
facial musculature symmetric.
- Motor: Normal bulk. No tremor or asterixis.
Upper extremities ___
___ ___ w/ exception of ___ L IP, ___ L Quad, and ___ L TA.
- DTRs: deferred
- ___: deferred
- Coordination: deferred
- Gait: deferred (patient has been mobile with nursing
assistance/walker)
Pertinent Results:
Admission Labs
===============
___ 01:30AM BLOOD WBC-6.2 RBC-4.01 Hgb-11.4 Hct-36.2 MCV-90
MCH-28.4 MCHC-31.5* RDW-13.4 RDWSD-44.1 Plt ___
___ 01:30AM BLOOD Neuts-55.8 ___ Monos-11.4
Eos-0.6* Baso-0.2 Im ___ AbsNeut-3.47 AbsLymp-1.97
AbsMono-0.71 AbsEos-0.04 AbsBaso-0.01
___ 01:30AM BLOOD ___ PTT-29.7 ___
___ 01:30AM BLOOD Glucose-401* UreaN-22* Creat-1.0 Na-134*
K-4.4 Cl-95* HCO3-25 AnGap-14
___ 01:30AM BLOOD ALT-10 AST-20 AlkPhos-77 TotBili-0.4
Important Interval Labs
=========================
Mycophenolic Acid: 12.3mct/mL
Discharge Labs
===============
___ 08:30AM BLOOD WBC-2.9* RBC-3.10* Hgb-8.9* Hct-28.8*
MCV-93 MCH-28.7 MCHC-30.9* RDW-14.5 RDWSD-48.8* Plt ___
___ 05:06AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-145
K-3.7 Cl-106 HCO3-29 AnGap-10
___ 05:06AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.5*
Imaging
========
___ MRI C and T spine
IMPRESSION:
1. Evaluation is suboptimal due to motion artifact.
2. Multiple focal areas of signal abnormality are seen within
the cervical
spinal cord which do not enhance and are unchanged since
___.
3. Abnormal signal seen throughout most levels in the thoracic
cord which are
not particularly well assessed due to motion. No associated
enhancement
visualized. Cord signal abnormality had been seen to a similar
extent on
patient's most recent non motion degraded exam in ___.
4. Mild cervical spondylosis.
RECOMMENDATION(S): Management of Incidental Renal Cyst
Completely
Characterized on CT or MRIBosniak I or II- No further workup
___ Renal US
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 11.4 cm Left kidney: 11.6 cm. A simple cyst is
identified within the interpolar region of the left kidney
measuring 1.3 x 1.4 x 1.6 cm. The bladder is decompressed.
IMPRESSION:
No hydronephrosis.
Brief Hospital Course:
Ms. ___ is a ___ yo F with a history of NMO restricted to the
spinal cord (well controlled since ___, and diabetes type II,
who represented after recent treatment for NMO flare after
several days of worsening bilateral arm weakness in the setting
of a UTI and PNA
Issues addressed:
--------------------
#NMO recrudescence
#UTI
#PNA: Upon admission patients weakness was below baseline with
increased sensory symptoms. UA and CXR were consistent with
infection and she was started on ceftriaxone and azithromycin
for 5 day course. MRI spine w/ and w/out was negative for active
demyelination. Her symptoms improved with treatment of UIT and
PNA, therefore she was not given additional immunosuppression.
She was continued on home mycofenolate.
#Varicella Zoster: Patient was noted to have crusting vesicular
rash on nose and upper lip. She was seen by dermatology who
agreed that this was consistent with VZV shingles. Due to V2
involvement ophthomology saw her and confirmed that there was no
ocular involvement. She was initially treated with IV acyclovir
per dermatology recommendations until lesions crusted over. She
was then transitioned to PO but started to develop pancytopenia
which was felt due to acyclovir (discussed below). After
discussions with ID and dermatology it was felt safe to stop
acyclovir after 6 days due to possibility of myelosuppression
and low risk benefit ratio to prevent post herpetic neuralgia as
lesions had already been present for >1 week prior to treatment.
Patient has not received shingles vaccine.
___: While on IV acyclovir patient developed a rapidly rising
creatinine from baseline of 0.8 to 1.7. She was bolused with
fluids and continued on high maintenance. Renal was consulted
and felt that this likely represented acute kidney injury from
IV acyclovir despite getting IV fluids. Patient continued to
have good urine output and creatinine trended down to baseline
with IV fluids. Creatinine remained stable off IV fluids.
#Pancytopenia: During admission patient initially developed
worsening thrombocytopenia and slowly downtrending anemia.
Initially felt that this likely represented delusional in the
setting of high volume fluids for her AK I. There was no
evidence of hemolysis on labs, no history or evidence of
bleeding. Eventually patient also developed pancytopenia with
worsening lymphopenia. Felt that this was likely due to the
acyclovir, causing myelosuppression. After discussion with ID
and dermatology felt that the risks outweighed the benefits for
continuing acyclovir and this was stopped. CBC with differential
was monitored and she was discharged with an ANC of 0.93. After
discussing with her outpatient Neurologist decided to reduce
mycofenolate as this could be causing pancytopenia as well.
Myclfenolate level was checked and was high at 12.5. She was
continued on reduced dose of mycofenolate. She will follow-up
with her PCP on ___ with repeat CBC with differential to
ensure that all cell lines are coming up after stopping
acyclovir.
#Prurigo nodules, eczematous dermatitis: Patient was seen by
dermatology who recommended 2 weeks of betamethasone cream.
#Type II diabetes: Patient was seen by ___ during admission.
She was re-started on Prandin 1mg at breakfast and 0.5mg with
dinner. She was discharged on Lantus 12units with lunch. She
will have ___ at home to help monitor blood sugars.
Transitional Issues
=====================
[]Please re-check CBC with diff on ___ at PCP
appointment to ensure that counts are recovering
[] Please re-check Magnesium on ___ and replete as
needed
[] Please monitor blood glucose
[] Please give patient Shingles vaccine (must be Shingrix since
patient is immunocompromised from taking CellCept)
[] Discharged with home ___, and ___ for wound care
[] Consider referral to dermatology for rash
[] Continue Betamethasone till ___ (2 week course)
[] Patient discharged an reduced dose of mycofenolate (1000mg
BID)
[] Patient didn't receive IVIG during admission. She will follow
up with Dr. ___ as an outpatient.
#Contact: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO EVERY OTHER DAY
3. Baclofen 10 mg PO TID
4. Mycophenolate Mofetil 1500 mg PO BID
5. Omeprazole 20 mg PO BID
6. Pravastatin 20 mg PO QPM
7. Vitamin D ___ UNIT PO DAILY
8. Indapamide 1.25 mg PO DAILY:PRN leg swelling
9. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral BID
10. Calcium Carbonate 300 mg PO BID
11. Ascorbic Acid ___ mg PO BID
Discharge Medications:
1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID Duration: 14
Days
RX *betamethasone, augmented 0.05 % Apply small about to rash
twice a day Refills:*0
2. Glargine 12 Units Lunch
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL AS DIR
12 Units before LNCH; Disp #*1 Vial Refills:*0
3. Magnesium Oxide 400 mg PO BID Duration: 2 Days
4. Repaglinide 1 mg PO DAILY ac breakfast
RX *repaglinide 1 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
5. Repaglinide 0.5 mg PO DINNER ac dinner
RX *repaglinide 0.5 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
7. Ascorbic Acid ___ mg PO BID
8. Aspirin 81 mg PO EVERY OTHER DAY
9. Baclofen 10 mg PO TID
10. Calcium Carbonate 300 mg PO BID
11. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral BID
12. Indapamide 1.25 mg PO DAILY:PRN leg swelling
13. Mycophenolate Mofetil 1500 mg PO BID
14. Omeprazole 20 mg PO BID
15. PARoxetine 40 mg PO DAILY
16. Pravastatin 20 mg PO QPM
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
NMO recrudescence
UTI
PNA
VZV shingles
___
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why were you admitted?
- You were having worsening weakness and numbness.
What happened while you were here?
- You had imaging that showed you were not having an NMO flare
- You were treated with antibiotics for a pneumonia and UTI
- You were noted to have shingles on your nose and you were
given acyclovir for this.
- You had a kidney injury from the acyclovir, but this improved
with fluids
- You also had low blood counts we think from the acyclovir or
from your mycofenolate. Acyclovir was stopped and your counts
improved.
What should you do when you get home?
- Please follow-up with your neurologist and continue your
regular/monthly NMO treatments.
- Get a shingles vaccine from your PCP at your convenience to
prevent further recurrence.
- Continue using betamethasone cream on your arms and abdomen
until ___
- Please continue to take lantus 12 units with lunch. This will
likely be decreased as your sugars improve
- Your blood counts will need to be re-checked as an outpatient
to ensure they still trending up
All the best,
Your Neurology Care Team
Followup Instructions:
___
|
19659879-DS-15
| 19,659,879 | 20,099,821 |
DS
| 15 |
2196-10-17 00:00:00
|
2196-10-18 15:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever and fatigue
Major Surgical or Invasive Procedure:
TEE
___ placement ___
History of Present Illness:
___ with mild to moderate mitral and aortic regurgitation
presenting with fevers, fatigue, malaise, and bacteremia.
Patient was in his usual state of health 10 days prior to
admission when he experienced acute-onset shaking, chills,
headache, anorexia, and fever. Patient denied nausea, vomiting,
and diarrhea. Ibuprofen provided minimal symptomatic relief.
Patient denied any associated pain other than his headache.
Symptom onset typically occurred at the same time every evening
and persisted throughout the night. 7 days prior to admission,
he was seen at the ___ and was diagnosed with a
viral infection. Percocet was given for pain control but
headaches continued. Symptoms persisted and 2 days PTA he
recorded highest temperature of 101.1 F. The day prior to
admission he was seen by his PCP, ___, and blood
cultures came back positive for gram-positive cocci in chains
the following day. The patient then drove to ___ for work-up
after referral by his PCP. Of note, he denied arthralgias,
myalgias, and rashes. He denied recent antibiotic use, travel,
exposure to wooded areas, recent dental procedures, and known
percutaneous lacerations.
In the ED, physcial examination revealed a pleasant, alert, and
oriented man. His speech was fluent speech without
lateralization. He had a ___ harsh, late systolic murmur. No
diastolic murmur was appreciated. He was without rashes. Vital
signs in the ED demonstrated a T 98.5, BP 151/66, P 74, RR 18,
and O2 sat 100% on RA. CXR revealed mild right basal atelectass
but was without acute cardiopulmonary pathology. He was
diagnosed with bacteremia with possible endocarditis He was
started on Vancomycin and sent to the floor.
Past Medical History:
- mild to moderate mitral and aortic regurgitation
- gastritis with iron deficiency anemia
- GERD
- basal cell carcinoma plus multiple precancerous nevi s/p
resection
- arthritis
- dysuria
- L knee ___ cyst s/p resection
- lactose intolerance
- wisdom teeth s/p removal x3
Social History:
___
Family History:
He has no family history of cardiac disease. His father has HTN.
His daughter has GERD and migraines.
Physical Exam:
Admission Physical Examination:
- Gen: AOx3, WDWN, NAD
- HEENT: sclera anicteric and noninjected, MMM, clear oropharnyx
- Neck: supple, JVP not elevated, no LAD or thyromegaly
- CV: RRR, normal S1 and S2, no S3, S4 at LUSB, ___
crescendo-decrescendo diastolic murmur at RUSB, ___ holosystolic
murmur at apex, no rubs or gallops
- Resp: CTABL, no WRR
- Abd: soft, NDNT, no guarding or rebound tenderness, no
hepatosplenomegaly, BS+
- GU: no Foley
- Ext: WWP, no edema or skin lesions
- ___: no petechiae, ___ nodes, ___ lesions
- Neuro: cranial nerves II-XII symmetric and intact, language
and speech intact, U/LEs with intact and symmetric strength and
sensation, patient able to get out of bed and walk without
difficulty
- Pysch: normal mood and affect
Discharge Physical Exam:
Vitals- 98.5 141/73 80 16 99%RA
General - Alert, oriented, no acute distress, interactive
HEENT - Sclera anicteric, MMM, oropharynx clear, no meningeal
signs
Neck - supple, JVP not elevated, no LAD
Lungs - Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV - Regular rate and rhythm, normal S1 + S2, loud ___
holosystolic murmur heard best at the apex, radiating to the
back.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin: no rash, no nail changes
Pertinent Results:
Admission labs:
___ 01:46PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:46PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:46PM SED RATE-37*
___ 01:46PM PLT COUNT-207
___ 01:46PM NEUTS-80.6* LYMPHS-11.9* MONOS-6.5 EOS-0.8
BASOS-0.2
___ 01:46PM WBC-8.2 RBC-4.73 HGB-13.0* HCT-40.5 MCV-86
MCH-27.4 MCHC-32.1 RDW-15.3
___ 01:46PM FERRITIN-103
___ 01:46PM ALT(SGPT)-22 AST(SGOT)-19 ALK PHOS-68 TOT
BILI-0.5
___ 01:46PM estGFR-Using this
___ 01:46PM UREA N-14 CREAT-1.0 SODIUM-139 POTASSIUM-3.8
CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
___ 01:46PM GLUCOSE-88
Discharge labs:
___ 09:05AM BLOOD WBC-8.3 RBC-4.36* Hgb-12.0* Hct-36.1*
MCV-83 MCH-27.5 MCHC-33.1 RDW-15.1 Plt ___
___ 09:05AM BLOOD Glucose-96 UreaN-9 Creat-0.9 Na-139 K-4.2
Cl-102 HCO3-29 AnGap-12
___ 08:00AM BLOOD ALT-23 AST-27 AlkPhos-58 TotBili-0.2
___ 09:05AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2
___ 01:46PM BLOOD Ferritn-103
___ 06:10AM BLOOD CRP-58.2*
___ 09:05AM BLOOD Vanco-17.1
___ 12:40PM BLOOD Lactate-1.0
CXR: revealed mild right basal atelectass but was without acute
cardiopulmonary pathology.
TTE ___:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is a moderate resting left
ventricular outflow tract obstruction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
There is systolic anterior motion of the mitral valve leaflets.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: No echo evidence of endocarditis or abscess seen.
Moderate symmetric LVH with near-hyperdynamic left ventricular
systolic function and systolic anterior motion of the mitral
valve - consequently there is a moderate left ventricular
outflow tract gradient during systole. Mild aortic
regurgitation.
TEE ___: Overall left ventricular systolic function is
normal (LVEF>55%). The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Mild to moderate
(___) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is mild mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. There is brief
systolic anterior motion of the mitral valve leaflets with a
late systolic jet of mild (1+) mitral regurgitation. There is no
pericardial effusion.
IMPRESSION: No valvular vegetations seen. Mild mitral valve
prolapse and brief systolic anterior motion of the mitral valve.
Mild mitral regurgitation.
CT ABD/PELVIS ___: IMPRESSION: 1. No evidence of underlying
abscess or abnormal fluid collection to suggest source of
infection.
2. Small hiatal hernia. Splenomegaly of uncertain etiology.
3. Equivocal mild prominence of the left atrium, which is only
partially
visualized. This is difficult to characterize on this exam.
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram
Stain-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STREPTOCOCCUS MITIS/ORALIS}; Aerobic Bottle Gram Stain-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STREPTOCOCCUS MITIS/ORALIS}; Aerobic Bottle Gram Stain-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS MITIS/ORALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS MITIS/ORALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS MITIS/ORALIS}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
___ URINE URINE CULTURE-FINAL
Blood Culture, Routine (Final ___:
STREPTOCOCCUS MITIS/ORALIS. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = <= 0.12 MCG/ML.
CEFTRIAXONE Susceptibility testing requested by ___
___ (___) ON ___.
CEFTRIAXONE = 0.38 MCG/ML, Sensitivity testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS MITIS/ORALIS
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- =>8 R
PENICILLIN G---------- 1 I
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Brief Hospital Course:
___ with mild to moderate mitral and aortic regurgitation and
admitted for a 10-day history of fevers (Tm of 101.1), fatigue,
and malaise who was found to have bacteremia at ___ clinic day
PTA.
.
# Strep viridans bactermia: Found to have positive blood
cultures drawn at ___ office and sent to ED, where he was
started on vancomycin. TTE and TEE were negative for
vegatations, serial blood cultures were drawn until negative. ID
was consulted for input on duration of treatment in patient with
known valvular disease without evidence of vegetation. Patient
remained afebrile after first few doses of antibiotics and was
hemodynamically stable throughout his admission. He was
discharged with ___ line for 4 week total course of antibiotics
- vancomycin 1500mg q12h- to be followed by OPAT.
.
.
# Headache: Initially presented with headache and mild neck
stiffness without meningeal signs, no mental status changes and
resolved with tylenol. Very low suspicion for meningitis and so
imaging was deemed unnecessary at that time. Headache resolved
and patient was asymptomatic. No neurological changes throughout
his admission.
.
.
# Valvular heart disease: Longstanding history of mild mitral
and aortic regurgitation. Last ECHO in ___ revealed fair
functional exercise capacity without 2D echocardiographic
evidence of inducible ischemia to achieved workload.
.
.
# Insomnia: Stable, continued on home medication- Zolpidem
Tartrate 10 mg PO QHS sleep
.
.
# GERD: Continued on home medication - Omeprazole 20 mg PO QD.
.
Transitional Issues:
- follow up with PCP for resolution, incidental findings on CT:
Small hiatal hernia. Splenomegaly of uncertain etiology.
- follow up with OPAT as detailed in discharge planning
- follow up with cardiology
Medications on Admission:
- Oxycodone-Acetominophen 5 mg-325 mg Q6H PO:PRN pain
- Omeprazole 20 mg PO BID
- Zolpidem 10 mg PO QHS PO:PRN insomnia
- Aspirin 81 mg PO QD
- ___ signature adults 50+ mature multi 1 TAB PO QD
- Saw ___ 1 TAB PO QD
Discharge Medications:
1. Outpatient Lab Work
ICD 9: Bacteremia
Qweek CBC, Chem 7, ALT/AST and vancomycin trough for duration of
vancomycin therapy. Fax lab results to ___
R.N.s at ___. Questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___.
2. Omeprazole 20 mg PO BID
3. Zolpidem Tartrate 10 mg PO HS
4. Aspirin 81 mg PO DAILY
5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
6. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 750 mg 1500 mg IV every 12 hours Disp #*94 Bag
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Strep viridans bacteremia
Secondary diagnosis: mitral valve regurgitation, aortic valve
regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for evaluation of positive blood
cultures which showed that you have bateria in your blood. You
had imaging to look at your heart and heart valves which was
negative, and this is reassuring. You were given antibiotics and
your fevers and blood cultures cleared. You had a PICC line
placed and you will infuse vancomycin twice a day for a total of
4 weeks of antibiotics.
You will have your blood monitored every week. Results should be
faxed to the number detailed on the prescription and below.
Followup Instructions:
___
|
19659930-DS-11
| 19,659,930 | 28,898,877 |
DS
| 11 |
2164-03-11 00:00:00
|
2164-04-29 14:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / morphine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy with lysis of adhesions
History of Present Illness:
___ is a ___ w/ hx of DM, ?COPD, remote ex-lap for
self-inflicted stab wound w/ no bowel resection, and ventral
hernia repair w/ mesh, who is presenting here to the ED w/ a <1
day hx of worsening diffuse abd pain and distension. He says he
has had similar sx before ___ yr ago and had a SBO which was
managed at ___ non-operatively w/ NGT. He does not remember the
last time he passed gas, last BM was yesterday ~4pm. He notes
that the pain started after dinner yesterday. He also endorses
sweats, chills, and h/a. Had one episode of NBNB emesis this
morning. He denies f, lightheadedness and/or dizziness, chest
pain, SOB, blurry vision, difficulty urinating, new myalgias,
new arthralgias, or skin changes; ROS is o/w -ve except as noted
before. He is from ___ and presented to an OSH there, and had a
NGT placed and a CT was obtained showing high grade SBO, for
which we were consulted, and he was txfr'ed here for further
management. His labs show WBC 19.7, up from ~15 at OSH, and
lactate 3.1. On review w/ radiology here, CT shows SBO, no
closed loop.
Past Medical History:
Prior DMII
Hyperlipidemia
HTN
Migraine Headaches
Depression
COPD
"Blacking out and losing time"
Prior discectomy of L4/L5 by report
Prior ex lap after self stabbing suicide attempt in late ___
Hepatitis C, patient unsure of details
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS - 98.1 93 152/91 18 95% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress
Abd - soft, moderate to severe distension, periumbilical ttp w/
guarding, no rebound
Discharge Physical Exam:
VS: T: 98.2 PO BP: 155/82 L Lying HR: 64 RR: 20 O2: 94% Ra
GEN: A+Ox3, NA D
CV: RRR
PULM: CTA b/l
ABD: abdomen soft, mildly distended, non-tender to palpation.
Midline surgical incision with staples, well-approximated, no
s/s infection
EXT: no edema b/l
Pertinent Results:
___ 05:16AM BLOOD WBC-7.1 RBC-3.72* Hgb-11.2* Hct-32.7*
MCV-88 MCH-30.1 MCHC-34.3 RDW-14.6 RDWSD-45.9 Plt ___
___ 06:01AM BLOOD WBC-6.9 RBC-3.56* Hgb-10.4* Hct-30.7*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.0 RDWSD-44.3 Plt ___
___ 05:59AM BLOOD WBC-7.1 RBC-3.97* Hgb-12.0* Hct-34.4*
MCV-87 MCH-30.2 MCHC-34.9 RDW-13.9 RDWSD-43.8 Plt ___
___ 08:25AM BLOOD Neuts-76.6* Lymphs-13.9* Monos-7.8
Eos-0.6* Baso-0.3 Im ___ AbsNeut-15.09* AbsLymp-2.74
AbsMono-1.54* AbsEos-0.11 AbsBaso-0.05
___ 05:16AM BLOOD Plt ___
___ 05:59AM BLOOD Plt ___
___ 05:16AM BLOOD Glucose-111* UreaN-9 Creat-0.7 Na-142
K-4.0 Cl-100 HCO3-25 AnGap-17
___ 06:01AM BLOOD Glucose-118* UreaN-11 Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-22 AnGap-16
___ 05:59AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-141
K-3.7 Cl-102 HCO3-21* AnGap-18
___ 08:25AM BLOOD ALT-20 AST-43* AlkPhos-112 TotBili-0.4
___ 08:25AM BLOOD Lipase-21
___ 05:16AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.6
___ 06:01AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8
___ 05:59AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
___ 08:37AM BLOOD Lactate-3.1*
___ Portable Abdomen:
1. Oral contrast is seen within the small bowel and large
bowel. Several
loops of dilated small bowel which measure up to 3.7 cm noted.
Findings may represent ileus versus developing partial small
bowel obstruction.
2. Gastric tube terminates in the proximal body of the stomach.
The side hole terminates just below the gastroesophageal
junction. Advancement by 5-10 cm is recommended.
Brief Hospital Course:
Mr. ___ is a ___ w/ hx of DM, COPD, remote history of
exploratory laparotomy for self-inflicted stab wound without
bowel resection, and ventral hernia repair w/ mesh, who
presented to the ___ ED this admission with worsening diffuse
abdominal pain and distension. He initially presented to an OSH
in ___ and had a CT scan which showed a high-grade bowel
obstruction. He had a NGT placed there and was transferred to
___. His labs showed WBC 19.7, up from ~15 at OSH, and
lactate 3.1. On review w/ radiology at ___, the CT scan
confirmed a SBO, but no closed loop. On HD1, he was taken to
the operating room by Acute Care Surgery and underwent
exploratory laparotomy with extensive lysis of adhesions. A
Prevena wound vac was placed. An epidural was placed in the OR
by the Acute Pain Service (APS) for pain control. After
remaining hemodynamically stable in the PACU, the patient was
transferred to the surgical floor to await return of bowel
function and for pain control.
The patient received IVF for hydration and he remained NPO with
NGT in place. On POD #1, the patient's NGT fell out, then was
replaced and repositioned. On POD #4, the patient self d/c'd
the NGT and it was replaced. The pravena wound vac was removed.
On POD #6, the patient had a bowel movement. NGT was removed
and he was started on a regular diet which he tolerated. APS
removed the epidural and he received oxycodone and acetaminophen
for pain control.
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.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Benzonatate 100 mg PO TID:PRN cough
3. Soma (carisoprodol) 350 mg oral TID:PRN
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Mirtazapine 15 mg PO QHS
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. QUEtiapine Fumarate 100 mg PO QHS
11. QUEtiapine Fumarate 400 mg PO BID
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Voltaren-XR (diclofenac sodium) 75 mg oral DAILY:PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
5. Benzonatate 100 mg PO TID:PRN cough
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q6H:PRN
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Mirtazapine 15 mg PO QHS
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. QUEtiapine Fumarate 400 mg PO BID
13. QUEtiapine Fumarate 100 mg PO QHS
14. TraZODone 100 mg PO QHS:PRN insomnia
15. Voltaren-XR (diclofenac sodium) 75 mg oral DAILY:PRN
16. HELD- Soma (carisoprodol) 350 mg oral TID:PRN This
medication was held. Do not restart Soma until you are no longer
taking oxycodone as taking both medications together can lead to
drowsiness
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a small bowel obstruction
and you were taken to the operating room where you underwent an
exploratory laparotomy with lysis of adhesions (bands of scar
tissue). After surgery, you initially had a tube placed in your
nose and into your stomach to allow your bowels to decompress.
You had oral contrast and a repeat abdominal x-ray which showed
the contrast had moved all the way through your bowels,
indicating that you have good return of bowel function. The tube
was removed and your diet was advanced to a regular diet which
you tolerated well.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19659930-DS-12
| 19,659,930 | 22,363,459 |
DS
| 12 |
2164-03-23 00:00:00
|
2164-03-23 12:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / morphine
Attending: ___.
Chief Complaint:
Surgical Site Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ w/ hx of recent hospitalization ___ -
___ for SBO s/p ex-lap/LOA ___ who is presenting here to the
ED w/ a ~1 wk hx of abd pain and drainage from incisional wound.
He noted abd pain and distention starting ~1 wk, and several
days later noted some drainage from the wound. He has been
tolerating a reg diet w/o n/v. He has not had a BM in one week
but is passing gas. ROS is diffusely +ve including f/c/s, SOB,
and h/a's. He presented to an OSH was txfr'ed here for further
management, for which we were consulted. Labs showed WBC 17.2,
and a CT A/P was obtained which showed an abd wall fluid
collection just below stapled incision, and no e/o of SBO. ___
of the inferior-most staples were removed and the wound was
opened, expressing ~10cc of pus - the wound was swabbed, sent
for cx, and packed w/ gauze.
Past Medical History:
PMH:
Prior DMII
Hyperlipidemia
HTN
Migraine Headaches
Depression
COPD
"Blacking out and losing time"
Prior discectomy of L4/L5 by report
Prior ex lap after self stabbing suicide attempt in late ___
Hepatitis C, patient unsure of details
PSH:
remote ex-lap for self-inflicted stab wound w/ no bowel
resection, ventral hernia repair w/ mesh, b/l knee surgery,
multiple back surgeries, ex-lap with lysis of adhesions
Social History:
___
Family History:
No family history of colon cancer
Physical Exam:
Vital Signs - Temp 98.9 BP 110/84 HR 87 RR 16 O2 sat 94% on
room air
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no respiratory distress
Abd - soft, mild distension, minimal tenderness, no rebound or
guarding, midline stapled vertical incision s/p ___ staples
removed from w/ inferior most aspect with minimal serosanguinous
drainage, packed w/ gauze
Ext - no leg swelling observed b/l
Pertinent Results:
___ 06:20AM BLOOD WBC-7.2 RBC-4.07* Hgb-12.1* Hct-35.6*
MCV-88 MCH-29.7 MCHC-34.0 RDW-14.1 RDWSD-44.9 Plt ___
___ 10:02PM BLOOD WBC-17.2* RBC-4.43* Hgb-12.8* Hct-38.6*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.1 RDWSD-45.2 Plt ___
___ 06:20AM BLOOD ___ PTT-27.7 ___
___ 06:20AM BLOOD Glucose-147* UreaN-13 Creat-0.8 Na-140
K-4.1 Cl-99 HCO3-25 AnGap-16
------------------
CT A/P ___
COMPARISON: Outside hospital CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous 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. There is no peripancreatic stranding.
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. Sub centimeter hypodensities bilaterally too
small to characterize. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. Oral contrast extends the level of the cecum. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: There is a vertical postsurgical incision along
the anterior abdominal wall. Along the inferior aspect of this
incision there is a gas and fluid containing collection that
measures 1.6 x 3.0 x 4.3 cm collection which does not appear to
extend intra-abdominally. Ventral abdominal wall hernia repair
material is noted.
IMPRESSION:
1. No evidence of small-bowel obstruction.
2. 4.3 x 3.0 x 1.6 cm subcutaneous gas and fluid collection
subjacent to the inferior aspect of the vertical abdominal
incision. No evidence of intra-abdominal extension.
Brief Hospital Course:
___ is a ___ year-old man with a recent hospitalization
for a small bowel obstruction for which he underwent an ex-lap
and lysis of adhesions on ___ who presented to the ___
on ___ with drainage from his midline abdominal incision.
He was initially treated with IV antibiotics and the inferior
portion of his incision was opened by removing several staples
to allow for drainage. He tolerated this well and had gauze
packed into the area daily. On HD#1 the patient was advanced to
a regular diet, and IV fluids were discontinued. On HD#2 the
patient was tolerating a regular diet, pain was well controlled
on an oral pain regimen, and they had regular flatus/BMs. His
incision no longer appeared infected after the wound was opened,
thus, antibiotics were discontinued. The patient was discharged
from the hospital in stable condition to home with ___ services
for daily wound care on HD#2 with follow up in clinic in ___
weeks.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. - (Prescribed by Other Provider)
BENZONATATE - benzonatate 100 mg capsule. 1 capsule(s) by mouth
three times a day - (Prescribed by Other Provider)
DICLOFENAC SODIUM - diclofenac ER 100 mg tablet,extended release
24 hr. 1 tablet(s) by mouth once a day - (Prescribed by Other
Provider)
METFORMIN [GLUCOPHAGE] - Glucophage 1,000 mg tablet. 1 tablet(s)
by mouth once a day - (Prescribed by Other Provider)
MIRTAZAPINE - mirtazapine 15 mg tablet. 1 tablet(s) by mouth
once
a day - (Prescribed by Other Provider)
QUETIAPINE - quetiapine 400 mg tablet. 1 tablet(s) by mouth
twice
a day - (Prescribed by Other Provider)
TRAZODONE - trazodone 100 mg tablet. 1 tablet(s) by mouth once a
day - (Prescribed by Other Provider)
Medications - OTC
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth as needed for constipation - (Prescribed by Other
Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing/SOB
4. Bisacodyl 10 mg PO BID:PRN Constipation - First Line
5. Docusate Sodium 100 mg PO BID
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
7. Mirtazapine 15 mg PO QHS
8. QUEtiapine Fumarate 400 mg PO BID
9. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Skin and soft tissue infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You came here with a skin and soft tissue infection of your
incisional wound. We put you on antibiotics here with good
effect. You should continue your dressing changes at home. ___
services have been arranged to help you with this.
You should plan to follow up with our surgery clinic in ___
weeks. Please call our office at ___ to set up an
appointment.
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.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
Followup Instructions:
___
|
19660235-DS-33
| 19,660,235 | 25,703,384 |
DS
| 33 |
2178-10-25 00:00:00
|
2178-10-25 15:25:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Dicloxacillin
Attending: ___.
Chief Complaint:
hemorrhoids, dehydration
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter placed ___
History of Present Illness:
Mr. ___ is a ___ with history of stage IV chronic kidney
disease, HIV, hepatitis B cirrhosis complicated by
hepatocellular carcinoma status post liver transplant in ___,
type 2 diabetes mellitus, and pulmonary embolus/deep venous
thrombosis on long-term warfarin anticoagulation, now with
recently diagnosed metastatic rectal squamous cell carcinoma who
presents to the ER with painful hemorrhoids, anorexia and
dehydration. He states that for the past 2 days, he has been in
terrible pain from his hemorrhoids with little relief from
Oxycodone. The pain is ___ and worse when having a bowel
movement; it has caused him to not be able to eat or drink well.
He went to his Rad/Onc apt on the day of admission and was sent
to the ER. Vitals in the ER: Pain 10 T 98.1 60 117/49 18 100%.
He received 2L NS, Morphine 4mg IV which provided relief. Exam
showed very large external hemorrhoids, and condylomas. no
evidence of bleeding. Guaic negative.
.
REVIEW OF SYSTEMS:
(+) Per HPI + chills/shakes with pain
(-) Denies fever, recent weight loss or gain. Denies headache,
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, change in abdominal pain. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Noted mass in inguinal region, right > left, in ___
-PET CT ___ with new FDG-avid bilateral bulky inguinal
adenopathy, increased activity in anus and rectum
-Excisional lymph node biopsy on ___ with metastatic
squamous cell carcinoma, p63 positive and CK5-6 positive
- S/P 10-day total antibiotic course with Levofloxacin
concluding ___ for superinfected necrotic inguinal lymph
node with possible
overlying cellulitis
- Hx of acute enteritis on the basis of suggestive findings on
outside hospital CT abdomen/pelvis and resolved with
conservative management during admission in early ___
PAST MEDICAL HISTORY:
1. HIV/AIDS diagnosed in ___, on HAART
2. History Hep B cirrhosis and HCC status post liver transplant
___.
3. History of DVT and PE in ___, on coumadin
4. Chronic kidney disease stage IV.
5. Neuropathy.
6. Basal cell carcinoma with Mohs surgery
7. Type 2 diabetes mellitus.
8. BPH
9. HSV
10. Hypercholesterolemia.
11. Nephrolithiasis s/p surgical removal in the early ___ and
lithotripsy x3 in the ___, and again in ___
12. Pancytopenia
13. HPV
14. Hypogonadism
Social History:
___
Family History:
Mother- colon cancer in her ___, diabetes mellitus
Father- brain tumor in his ___
Sister- cancer of unknown primary
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98 bp 112/59 HR 88 RR 16 SaO2 98 RA
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, slightly tender, ND, bowel sounds resent
EXT: normal perfusion
SKIN: warm, dry
GU: per ER: large external hemorrhoids, and condylomas
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS: 98.1 119/58 54 20 97%RA
GENERAL: NAD, AA O x 3
HEENT: EOMI, PERRL, MMM
NECK: supple without lymphadenopathy. JVP not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: CTAB. No wheezing, rhonchi or crackles. Stable inspiratory
effort without labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses,
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 05:42PM GLUCOSE-118* LACTATE-1.7 NA+-134 K+-4.1
CL--104 TCO2-21
___ 05:16PM GLUCOSE-120* UREA N-59* CREAT-4.6*#
SODIUM-136 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-19* ANION
GAP-21*
___ 05:16PM ALT(SGPT)-19 AST(SGOT)-31 ALK PHOS-58 TOT
BILI-0.6
___ 05:16PM ALBUMIN-4.1
___ 05:16PM WBC-2.3* RBC-2.52* HGB-8.1* HCT-23.8* MCV-94
MCH-32.1* MCHC-34.0 RDW-16.4*
___ 05:16PM NEUTS-70.5* LYMPHS-15.5* MONOS-6.4 EOS-7.1*
BASOS-0.5
___ 05:16PM PLT COUNT-102*
___ 05:16PM ___ PTT-49.5* ___
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-1.1* RBC-2.69* Hgb-8.6* Hct-25.8*
MCV-96 MCH-31.9 MCHC-33.2 RDW-16.9* Plt ___
___ 07:15AM BLOOD Neuts-71.6* Lymphs-15.4* Monos-4.8
Eos-8.1* Baso-0
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-100 UreaN-21* Creat-2.5* Na-139
K-4.3 Cl-110* HCO3-23 AnGap-10
___ 07:15AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.0
___ 05:42PM BLOOD Glucose-118* Lactate-1.7 Na-134 K-4.1
Cl-104 calHCO___
ABDOMINAL ULTRASOUND:
FINDINGS:
In the right inguinal region there is a 3.6 x 2.8 x 2.6 cm
hypoechoic mass with central increased echogenicity which was
previously biopsied. This finding is consistent with a lymph
node most likely with metastatic
involvement. No discrete fluid collections are identified.
Overlying skin thickening is consistent with cellulitis as has
been documented previously.
IMPRESSION:
Right inguinal lymphadenitis with infected, likely necrotic
lymph node.
Appearance is not significantly changed from recent comparison.
No drainable fluid collection.
Brief Hospital Course:
Mr. ___ is a ___ with history of stage IV chronic kidney
disease, HIV, hepatitis B cirrhosis complicated by
hepatocellular carcinoma status post liver transplant in ___,
type 2 diabetes mellitus, and pulmonary embolus/deep venous
thrombosis on long-term warfarin anticoagulation, now with
recently diagnosed metastatic rectal squamous cell carcinoma who
presents to the ER with painful hemorrhoids, anorexia, and
dehydration.
# Hemorrhoids without evidence of thrombosis: The patient was
treated symptomatically with SITS baths and preparation H. His
pain was managed with IV morphine and PO narcotics.
# History of pulmonary embolus/deep venous thrombosis with
current coagulopathy (INR 6) with rectal bleeding: Patient's
Coumadin was held and patient started on heparin drip given
supratherapeutic INR on admission, risk of DVT/PE and plan to
start ___. Patient remained off coumadin and with heparin drip
until completion of ___. The patient was restarted on coumadin
after completion of ___ and before discharge with a lovenox
bridge.
# Metastatic anal SCC: Patient received ___ continuous infusion
via peripherally inserted central catheter from ___. A
peripherally inserted central catheter was inserted on this
hospital stay ___, with initiation of second infusion
___. His XRT dose to date on admission was 1620 cGy of 5580
cGy total planned to the pelvic region. He continued his
radiation treatments while inpatient.
# Anemia: Secondary to inflammation with ___ colonoscopy
showing diffuse angioectasias, ___ EGD with gastritis/
duodenitis, and known
hemorrhoids. Patient's baseline hematocrit is around 27. He was
transfused on the floor to maintain hgb ideally at or above 9
per rad/onc physician. He was continued on his PPI.
# Hepatitis B cirrhosis complicated by hepatocellular carcinoma
status post liver transplant: Continued mycophenolate mofetil
and Tacrolimus with level monitoring as needed. Patient received
HBIG monthly, next on ___.
# Acute on Chronic kidney injury: with baseline Cr of 3.3-3.4;
patient met to discuss possibility of kidney transplantation the
week of admission. He received 2L IVF in the ER and was given 1L
NS at 100 cc/hr for treatment of prerenal etiology. Cr returned
to baseline post IVF.
#HIV: Continued on home darunavir, emtricitabine/tenofovir,
raltegravir,
and ritonavir
#Pancytopenia: secondary to chemotherapy, transfused as needed
ANC on admission was greater than 1000.
#Diabetes mellitus 2: steroid-induced, continued on home insulin
#Depression: continued on home escitalopram.
#Peripheral neuropathy: Continued on home pregabalin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dapsone 100 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Mycophenolate Mofetil 250 mg PO BID
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Pregabalin 50 mg PO BID
8. Raltegravir 400 mg PO BID
9. RiTONAvir 100 mg PO BID
10. Temazepam 15 mg PO HS:PRN insomnia/anxiety
11. Warfarin 5 mg PO DAILY16
5mg MO-SAT, 4mg on SUN
12. Loperamide 2 mg PO QID:PRN diarrhea
13. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
60 mcg/0.3 mL Injection q2-3 weeks
14. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
15. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q72H
16. fenofibrate *NF* 145 Oral daily
17. Hepatitis B Immun Globulin (HepaGam B) 10,000 UNIT IV Q3MO
18. Tacrolimus Suspension 0.25 mg PO QTUES
19. Pantoprazole 40 mg PO Q24H
20. Docusate Sodium 100 mg PO BID
21. Senna 1 TAB PO BID:PRN constipation
22. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Dapsone 100 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q72H
5. Escitalopram Oxalate 20 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Glargine 10 Units Breakfast
8. Mycophenolate Mofetil 250 mg PO BID
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth Q4H:PRN Disp
#*90 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
11. Pregabalin 50 mg PO BID
12. Raltegravir 400 mg PO BID
13. RiTONAvir 100 mg PO BID
14. Senna 1 TAB PO BID:PRN constipation
15. Tacrolimus Suspension 0.25 mg PO QTUES
16. Temazepam 15 mg PO HS:PRN insomnia/anxiety
17. Aranesp (polysorbate) *NF* (darbepoetin alfa in polysorbat)
60 mcg/0.3 mL Injection q2-3 weeks
18. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
19. Loperamide 2 mg PO QID:PRN diarrhea
20. Enoxaparin Sodium 50 mg SC Q24H Duration: 7 Days
RX *enoxaparin 40 mg/0.4 mL 40mg Sub Q daily Disp #*7 Syringe
Refills:*0
21. Hepatitis B Immun Globulin (HepaGam B) 10,000 UNIT IV Q3MO
22. Preparation H(pe, witch ___ *NF* (phenylephrine-witch
___ 1 Appl TP QID:PRN hemorrhoids Reason for Ordering: Please
substitute formulary med and I will cosign
RX *phenylephrine-witch ___ [Hemorrhoidal] 0.25 %-50 % topical
QID:PRN Disp #*1 Box Refills:*0
23. Warfarin 5 mg PO DAILY16
5mg MO-SAT, 4mg on SUN
24. fenofibrate *NF* 145 Oral daily
25. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*24 Capsule Refills:*0
26. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Anal squamous cell carcinoma
Acute on chronic kidney disease
History of pulmonary embolism and deep venous thrombosis
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 ___ oncology service for management of
your anal squamous cell carcimoma and hemorrhoids. For this, you
received chemotherapy via a peripherally inserted central
catheter starting ___ for a total of 4 days. You received
topical treatment to alleviate pain from your hemorrhoids. You
also had some kidney dysfunction from dehydration on admission,
and for this you received intravenous fluids with improvement in
your kidney function to baseline. While in the hospital you
received and completed your second cycle of chemotherapy and
continued radiation therapy.
Followup Instructions:
___
|
19660649-DS-13
| 19,660,649 | 21,844,592 |
DS
| 13 |
2188-12-31 00:00:00
|
2188-12-31 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
symptomatic AAA
Major Surgical or Invasive Procedure:
EVAR (___)
Intubation (___)
Cardiac catheterization (___)
Placement of an Intra-aortic Balloon Pump (___)
History of Present Illness:
___ w/ h/o HTN, chronic low back pain who presented to an OSH
with a multiple day history of worsening lower back pain in
addition to fevers, chills, nausea, vomiting and diarrhea. His
family reports that his stools have been very dark but he has
had no BRBPR. On arrival to the OSH ED he was noted to be
febrile to 101.9, tachycardic and have soft blood pressures.
While in the ED
his back pain worsened and he began to complain of suprapubic
abdominal pain. CT A/P was obtained and noted a 5.5 x 6 cm
saccular infrarenal AAA. He was also noted to have a RUL opacity
on CXR and was started on Levaquin for CAP. Because of his new
abdominal pain and unstable vital signs in the setting of large
AAA he was transferred to ___ via medflight for further care.
In the ED he alert and answers questions. His main complaints
were of low back pain. His family notes that he has lost 20 lbs
over the last several months and that he complains of abdominal
pain after meals from time to time. He has no lower extremity
claudication symptoms. He was taken directly from the ED to the
OR for repair of his aneurysm.
Past Medical History:
- Hypertension
- Asthma
- Interstitial lung disease of unclear etiology
- Asthma
- Abdominal aortic aneurysm
Social History:
___
Family History:
Father with significant heart disease.
Physical Exam:
EXAM ON ADMISSION:
=====================
Vitals: 100.9 127 ___ 20 94 4L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, suprapubic TTP, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pulses: fem pop DP ___
EXAM ON DISCHARGE:
=====================
GEN: elderly man appears comfortable lying in bed on NC 6 LPM
HEENT: mild dry MM
Neck: no JVD
CV: RRR, ___ murmur throughout precordium, systolic
Lungs: Tachypneic, coarse crackles b/l throughout lung fields
GU: Foley in place
Extremities: WWP, palp pulses distally
Pertinent Results:
LABS ON ADMISSION:
===================
___ 11:11PM BLOOD WBC-13.0* RBC-4.05* Hgb-12.6* Hct-40.2
MCV-99* MCH-31.1 MCHC-31.3 RDW-14.1 Plt ___
___ 11:11PM BLOOD ___ PTT-35.2 ___
___ 11:11PM BLOOD Glucose-130* UreaN-23* Creat-0.7 Na-137
K-4.4 Cl-110* HCO3-21* AnGap-10
___ 11:11PM BLOOD ALT-17 AST-39 CK(CPK)-194
___ 11:11PM BLOOD CK-MB-14* MB Indx-7.2* cTropnT-0.32*
___ 11:11PM BLOOD Albumin-2.4* Calcium-9.2 Phos-3.7 Mg-1.3*
LABS ON DISCHARGE:
==================
___ 05:26AM BLOOD WBC-24.4* RBC-3.42* Hgb-10.4* Hct-32.8*
MCV-96 MCH-30.5 MCHC-31.8 RDW-14.5 Plt ___
___ 07:40PM BLOOD Neuts-86.5* Lymphs-6.5* Monos-5.4 Eos-1.2
Baso-0.3
___ 05:26AM BLOOD Plt ___
___ 05:26AM BLOOD Glucose-161* UreaN-53* Creat-1.2 Na-138
K-3.7 Cl-97 HCO3-34* AnGap-11
___ 06:00PM BLOOD CK-MB-3 cTropnT-0.15*
STUDIES:
==========
Imaging
High resolution non-contrast CT chest (___)
Mild acute CHF produces mild pulmonary edema and trace right and
small left pleural effusions. Moderate UIP pattern pulmonary
fibrosis. Pulmonary hypertension. Small hiatal hernia.
___ Echo
The left atrium is moderately dilated. The left atrium is
elongated. The right atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. There is mild to
moderate regional left ventricular systolic dysfunction with
septal dyskineis. Overall left ventricular systolic function is
mildly depressed (LVEF = 40 %). The right ventricular cavity is
moderately dilated with normal free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There is moderate to
severe aortic valve stenosis (valve area 1.0- 1.1 cm2). Mild to
moderate (___) aortic regurgitation is seen. The mitral valve
leaflets are severely thickened/deformed. The study is
inadequate to exclude significant mitral valve stenosis, but
mean gradients appeared normal. Mild to moderate (___) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. Severe [4+] tricuspid regurgitation is seen.
There is no pericardial effusion. Surgeons were notified at the
time of the exam.
___ Echo
IMPRESSION: Normal left ventricular global systolic function.
Mildly dilated right ventricle with septal flattening c/w
pressure/volume overload. Moderate aortic stenosis. Severe
pulmonary hypertension.
___ CT Chest
IMPRESSION:
Mild acute CHF produces mild pulmonary edema and trace right and
small left pleural effusions.
Moderate UIP pattern pulmonary fibrosis.
Pulmonary hypertension.
Small hiatal hernia.
___ Echo
IMPRESSION: Dilated and mildly hypokinetic right ventricle with
evidence of pressure overload. Grossl preserved left ventricular
systolic funciton. No pericardial effusion.
___ Cath
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
___ Echo
IMPRESSION: Suboptimal image quality. Severe aortic stenosis.
Low-normal global left ventricular systolic function. Dilated
and hypokinetic right ventricle. Mild aortic regurgitation.
Severe pulmonary hypertension.
___ CT Chest
IMPRESSION:
Interval worsening of diffuse bilateral ground-glass opacities
which are
likely due to worsening edema.
Stable pulmonary fibrosis.
Stable pulmonary hypertension with Swan-Ganz catheter in place
terminating in a left lower lobe pulmonary artery.
Interval resolution of trace right and decreased now small left
pleural
effusions.
Brief Hospital Course:
___ y/o gentleman with h/o HTN, pulmonary disease of unclear
etiology, and AAA s/p endovascular repair complicated by
hypotension and NSTEMI presents to the CCU after cardiac cath
demonstrated 3VD with cath complicated by V fib arrest now
extubated s/p aggressive diuresis with improved oxygen
saturations.
# Acute hypoxic respiratory failure: Patient presented from the
cath lab requiring FIO2 of 100% and initial Po2 of 68. CXR with
interval worsening of pulmonary edema and elevated PCWP on RHC.
The cause may be multifactorial, relating to an infectious
process vs pulmonary edema vs acute worsening in his chronic
interstitial pulmonary process. Patient s/p aggressive diuresis
with multiple Lasix boluses with initial improvement. Have
diuresed with some improvement despite PCWP of 8. Patient was
treated initally with Levaquin for CAP and subsequently for HCAP
with Vanc and Cefepime. Patient was seen by pulmonary who
recommended treatment of underlying lung disease with
methylprednisolone 125 q8hr and standing albuterol and duonebs.
His O2 was weaned to high flow nasal cannula but he would
desaturate with any movment. Per palliative care recs, patient
was started on low dose morphine during activity for subjective
SOB. Ultimately, given goals of care, he was transitioned back
to levofloxacin PO and prednisone PO.
# Resolved cardiogenic shock: Patient s/p Vfib arrest in cath
lab requiring brief episode of CPR and cardioversion. An IABP
was placed and had removal of the IABP on ___ with small
hematoma. He was aggressively diuresed with improvement in
volume status. His O2 requirement decreased from non-rebreather
and CPAP to high flow nasal cannula.
# CAD/NSTEMI: likely demand type in the setting of 3 vessel CAD.
Patient is not a candidate for CABG given his underlying lung
disease. He was placed on ASA 81, plavix 75, Atorvastatin 80mg,
Captopril 6.25 q8h and Metop 12.5 mg PO Q6HPRN.
#Severe AS: Noted on echo it is unclear that his pulmonary
status will be amenable to surgical correction. We were unable
to measure a gradient in the cath lab. TTE on ___ showed
severe AS (area <1.0cm2). Mild (1+) AR. Patient was not a
candidate for surgical intervention.
#Severe pulmonary hypertension: TEE showed RV dilation with EF
___, TR gradient significant with Echo today with Dilated and
mildly hypokinetic right ventricle with evidence of pressure
overload. The cause likely secondary to precapillary PAH from
chronic pulmonary disease vs elevated left sided filling
pressures. A PA cath was placed to titrate meds and better
assess volume status. Pulmonary consult suggested the cause was
underlying Interstitial Lung Disease and started him on a course
of prednisone.
#AAA: Patient received an EVAR of his symptomatic aortic
abdominal aneurysm. During the operation the patient had
significant hypotension which was not related to bleeding via
image confirmation. He had no fullnessin his abdomen and his
hematocrit was stable. At this time he also had some EKG changes
on his monitor. A intraop transesophageal echo was performed,
which showed RV dilated and hypokenesis, severe TR, and overall
left ventricular systolic function depression (LVEF = 40 %).
Troponin was elevated at 0.32-0.43-0.45-0.27. Please see ___
report for further details. Please see op report for further
details about the EVAR.
TRANSITIONAL ISSUES
===================
- Continue prednisone taper as detailed in medications
- Continue levofloxacin for pneumonia (1 more dose on ___ to
complete course)
- Approximately 85% O2 saturation with O2 support up to 6 L by
NC is OK for him. Has left and right groin sites that were C/D/I
on discharge.
- Consider hospice care
CODE STATUS (See MOLST form for details)
===========
- DNR/DNI
- Would NOT want to be rehospitalized if his condition
deteriorates
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH QID:PRN wheeze
2. Cyclobenzaprine 10 mg PO HS
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Lisinopril 20 mg PO DAILY
5. Naproxen 375 mg PO Q12H:PRN pain
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. PredniSONE 40 mg PO DAILY Duration: 7 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
6. PredniSONE 30 mg PO DAILY Duration: 7 Days
Start: After 40 mg tapered dose
7. PredniSONE 20 mg PO DAILY Duration: 7 Days
Start: After 30 mg tapered dose
8. PredniSONE 10 mg PO DAILY Duration: 7 Days
Start: After 20 mg tapered dose
9. Cyclobenzaprine 10 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Naproxen 375 mg PO Q12H:PRN pain
12. Senna 8.6 mg PO BID:PRN constipation
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Lisinopril 5 mg PO DAILY
15. Morphine Sulfate (Oral Soln.) 5 mg PO Q2H:PRN SOB, 30
minutes prior to moving around
RX *morphine 10 mg/5 mL 2.5 mL by mouth Q2H:PRN Refills:*0
16. Docusate Sodium 100 mg PO BID
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
18. Levofloxacin 750 mg PO Q48H
One more dosage to be given ___. That is the final dose.
19. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
20. Heparin 5000 UNIT SC TID
21. Albuterol Inhaler 1 PUFF IH QID:PRN wheeze
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
1. Infra-renal Abdominal Aortic Anuerysm
2. Non-ST Elevation Myocardial Infarction
3. Hospital-Acquired Pneumonia
4. Interstitial Lung Disease
5. Severe Aortic Stenosis
6. Cardiogenic Shock
7. Acute Hypoxic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for repair of an abdominal aortic aneurysm.
Your surgery was complicated by a concern for heart problems, so
you were seen by the cardiology team. After an echocardiogram
showed high blood pressure in your pulmonary blood vessels, the
cardiology team performed a catheterization of your coronary
arteries to check for coronary artery disease. This procedure
showed some blockages in your coronary arteries. During this
procedure, your heart was beating abnormally, and you had to be
resuscitated. Your blood pressure was low, so a device
(intra-aortic balloon pump) was placed and medications were
started to help with this. Your lung function was also
compromised, and the pulmonary team diagnosed you with
Interstitial Lung Disease. You were started on steroids for this
condition. During this hospitalization, you were also treated
for a pneumonia.
We also discussed your goals for your health and you decided to
focus on your comfort and avoid further invasive diagnostics and
procedures, acknowledging that your disease proccesses are
likely to be life threatening in the short term. You filled out
a MOLST form indicating you would not want to undergo CPR or
resuscitation and that you do not want to be rehospitalized.
Please follow-up with your doctors as below.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19660773-DS-6
| 19,660,773 | 23,308,248 |
DS
| 6 |
2182-08-01 00:00:00
|
2182-08-01 12:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / adhesive tape
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with the past medical history
of MS, borderline ovarian tumor s/p resection who presents with
weakness and leukocytosis. She initially presented to ___ with
inability to move BUE and fevers. Pt states that she has been
feeling fatigued over the past 1 month. She always has some
fatigue due to MS, but has been worse than usual. On ___, she
had sudden onset, over the course of ___ mins, weakness in all
extremities, but worse in UEs. No radicular pain or
parasthesias. At the same time, she also had a fever and
therefore presented to OSH ED. At ___ ED, was found to have
fever to 101.2. Workup showed WBC 21, ESR 44. OSH CXR and UA was
negative (no WBC or bacteria checked) and she underwent a CTA
head, CT chest for further evaluation which was unrevealing. Flu
swab was neg. She was given 2g IV CTX for lyme coverage at ___.
She was transferred to ___ for further evaluation.
On arrival to ___ ED, vitals
98.4 70 106/51 18 96% RA. She remained afebrile during ED
course. She noted improvement in her weakness and denied URI
symptoms, cough, odynophagia, chest pain, dyspnea, back pain,
abdominal pain, F/C/N/V/D, UTI symptoms. She has been taking her
medication regularly as prescribed. On exam, she had a foley in
place (placed at OSH as unable to transfer to bathroom), with
baseline strength exam. She also was noted to have erythematous
blanching rash over dorsum of foot to ankle; mildly warm but no
TTP. Labs showed WBC 20.4, normal chem panel, and UA with 8 WBC,
few bacteria, sm leuk. In the ED, she received atenolol 25, MVI,
ascorbic acid, modafinil 100mg, doxycycline 100mg, dalampridine,
vit D.
On arrival to the floor, pt states that her strength is back at
baseline. She reported the above history. She added that she has
no vision change, SOB, CP, abdominal pain, n/v, diarrhea, new
rash (states rash on heel/ankle is stable/chronic), or urinary
symptoms. She denies recent rash, myalgias, neck stiffness,
arthralgias, headache. She states that she has had chronic UTIs
due to incomplete bladder emptying from MS, but this has
resolved with once daily macrobid which she is currently on. She
currently has no changes in urinary symptoms.
She also notes that she has been undergoing treatment for lyme
disease with doxycycline, dx by PCP based on blood work. She
started taking this on ___.
ROS: Pertinent positives and negatives as noted in the HPI.
Otherwise a 10-point ROS was reviewed and is negative.
Past Medical History:
PMH: MS, HTN, UTI
PSH: none
Gyn: no abnl pap, no STI
OB: SVD x2
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.6 PO BP: 113/66 HR: 74 RR: 18 O2 sat: 99% O2 delivery:
RA
GENERAL: Alert and in no apparent distress sitting up wheelchair
EYES: Anicteric, EOMI
ENT: MMM
CV: Heart regular, no murmur, no JVD
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
SKIN: No rashes
NEURO: Alert, oriented, conversant. 4+/5 ankle plantar flexion
bilaterally, ___ doriflexion on left. ___ right
PSYCH: calm, cooperative, normal affect
Pertinent Results:
ADMISSION LABS:
================
___ 06:17AM BLOOD WBC-20.4* RBC-4.29 Hgb-11.9 Hct-36.7
MCV-86 MCH-27.7 MCHC-32.4 RDW-14.0 RDWSD-43.2 Plt ___
___ 06:17AM BLOOD Neuts-82.6* Lymphs-8.1* Monos-7.7
Eos-0.8* Baso-0.3 Im ___ AbsNeut-16.84* AbsLymp-1.65
AbsMono-1.56* AbsEos-0.17 AbsBaso-0.06
___ 06:17AM BLOOD Glucose-92 UreaN-15 Creat-0.5 Na-141
K-4.2 Cl-105 HCO3-25 AnGap-11
___ 06:17AM BLOOD ALT-14 AST-21 AlkPhos-82 TotBili-0.3
___ 06:17AM BLOOD Lipase-35
___ 06:17AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.9 Mg-2.0
.
.
NOTABLE LABS WHILE INPATIENT:
================
___ 07:35AM BLOOD ___
___ 07:10AM BLOOD ALT-15 AST-18 LD(LDH)-173 CK(CPK)-107
AlkPhos-80 TotBili-0.2
___ 07:35AM BLOOD TSH-4.1
___ 07:35AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
.
.
MICRO:
===============
___ 6:17 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
.
IMAGING:
===============
Final Report
EXAMINATION: ___ CLINIC BRAIN AND ___ PROTOCOL WANDW/O
CONTRAST
INDICATION: ___ year old woman with primary progressive multiple
sclerosis
presenting with acute weakness. Assess for new lesion
suggestive of true
relapse multiple sclerosis.
TECHNIQUE: BRAIN:
Sagittal 3D FLAIR imaging was performed along with axial T1
weighted, T2
weighted, FLAIR, gradient echo, and diffusion imaging. The 3D
FLAIR images
were re-formatted in axial and coronal orientations. Axial
MPRAGE and axial T1
weighted imaging were performed after administration of 7 mL of
Gadavist
intravenous contrast, and MP RAGE images were re-formatted in
sagittal and
coronal orientations.
CERVICAL SPINE:
Sagittal T1 weighted, T2 weighted, and IDEAL images were
performed with axial
gradient echo and T2 weighted images. Following intravenous
gadolinium
administration, sagittal and axial T1 weighted images were
obtained.
COMPARISON: ___ noncontrast head CT from an outside
facility
___ brain MRI from an outside facility
FINDINGS:
BRAIN:
There are innumerable foci of high T2 signal in the subcortical,
deep, and
periventricular white matter of the cerebral hemispheres,
including confluent
callosal and radiating pericallosal lesions, consistent with the
known
multiple sclerosis. Differences in patient head position, as
well as
differences between MR scanners and sequence parameters, are the
likely cause
for overall increased signal intensity of the lesions on the 3D
FLAIR
sequence of the present study compared to the ___ study.
However, the
distribution and extent of the lesions does not appear
significantly changed.
A right posterior frontal subcortical lesion on images 6:128 and
600:446 is
not definitively identified on the prior study. No other
definite new
supratentorial lesion is seen. Many of the lesions demonstrate
low signal
intensity on T1 weighted images, consistent with black holes.
The T2 hyperintense lesion between the right middle cerebellar
and right
cerebellar hemisphere on images 600:364, 6:109 is stable.
Bilateral T2
hyperintensity in the central midbrain appears new.
Postcontrast images are slightly limited by motion artifact. No
evidence for
contrast enhancing lesions or lesions with slow diffusion.
There are T2 shine
through associated with a chronic right frontal subcortical
lesion on image
550:22.
Thinning of the corpus callosum is unchanged. Ventricles and
sulci are stable
in size.
No evidence for an enhancing mass, acute infarction, or
intracranial blood
products. Major arterial flow voids are preserved. Dural
venous sinuses
appear patent.
There is mild mucosal thickening in the ethmoid air cells.
CERVICAL SPINE:
Motion artifact on both sagittal and axial T2 weighted images
limits
evaluation of spinal cord signal. No focal demyelinating lesion
separate from
artifact is definitively identified. No evidence for pathologic
intrathecal
contrast enhancement.
Vertebral body heights are preserved. Minimal retrolisthesis of
C5 on C6.
Minimal anterolisthesis of T1 and T 2. No evidence for
suspicious bone marrow
signal abnormalities.
C2-C3: No spinal canal or neural foraminal narrowing.
C3-C4: No spinal canal narrowing. Moderate right and mild left
neural
foraminal narrowing by uncovertebral and facet osteophytes.
C4-C5: No spinal canal narrowing. No significant neural
foraminal narrowing.
C5-C6: Mild retrolisthesis, broad-based right paracentral disc
protrusion with
overlying endplate osteophytes, and infolding of the ligamentum
flavum, cause
mild narrowing of the spinal canal, right more than left,
without spinal cord
contact. Severe right and moderate to severe left neural
foraminal narrowing
by uncovertebral and facet osteophytes.
C6-C7: Broad-based left paracentral disc protrusion with
overlying endplate
osteophytes, and infolding of the ligamentum flavum, cause mild
narrowing of
the spinal canal, left more than right, without spinal cord
contact. Mild
right and severe left neural foraminal narrowing by
uncovertebral and facet
osteophytes.
C7-T1: No spinal canal narrowing. Moderate left neural
foraminal narrowing by
uncovertebral and facet osteophytes.
There are multiple bilateral nodules in the partially visualized
thyroid
gland, up to 1.4 cm on the left on sagittal images ___.
There is intraglandular ductal dilatation in the left
submandibular gland, as
well as dilatation of the partially visualized extra glandular
left
submandibular duct, series 16, images ___.
IMPRESSION:
1. Extensive supratentorial demyelinating disease. A right
posterior frontal
subcortical lesion appears new. Otherwise, no significant
change in the
supratentorial compartment compared to ___, allowing for
differences in
technique and patient head position.
2. Stable right middle cerebellar peduncle T2 hyperintense,
presumably
demyelinating lesion. New bilateral T2 hyperintensity in the
central
midbrain.
3. Stable thinning of the corpus callosum.
4. Extensive motion artifact limits evaluation of spinal cord
signal for focal
demyelinating lesions. No clear evidence for focal lesions
separate from
artifacts.
5. No evidence for intracranial or cervical contrast-enhancing
lesions.
6. Mild spinal canal narrowing at C5-C6 and C6-C7. Severe right
C5-C6,
moderate to severe left C5-C6, and severe left C6-C7 neural
foraminal
narrowing.
7. Multiple nodules in the partially visualized thyroid gland,
up to 1.4 cm.
8. Dilatation of the intra glandular left submandibular ducts
and of the
partially visualized extra glandular left submandibular duct.
RECOMMENDATION(S):
1. If clinically warranted, the left submandibular gland and
duct could be
further assessed for sialoliths by CT.
2. No further evaluation is recommended for thyroid nodules
smaller than 1.5
cm. Since the thyroid is only partially visualized on this
exam, and size of
the visualized nodules approaches 1.5 cm, ultrasound could be
considered.
"Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings
include: Abnormal lymph nodes (those displaying enlargement,
calcification,
cystic components and/or increased enhancement) or invasion of
local tissues
by the thyroid nodule." ___, et al, "Managing Incidental
Thyroid Nodules
Detected on Imaging: White Paper of the ACR Incidental Findings
Committee". J
___ ___ 12:143-150.
Final Report
EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman with MS and worsening weakness.//
Please
determine if weakness is secondary to relapse vs progression vs
pseduorelapse.
Please determine if weakness is secondary to relapse vs prog
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique,
followed by axial T2 imaging. This was followed by sagittal and
axial T1
images obtained after the uneventful intravenous administration
of 7 mL of
Gadavist contrast agent.
COMPARISON: No prior imaging of the thoracic spine.
FINDINGS:
Diffusely atrophic cord. Mild central T2 signal abnormality
versus artifact
upper thoracic cord may be sequela of chronic demyelination. No
enhancement.
There is mildly exaggerated kyphosis of the thoracic spine.
Alignment is
otherwise unremarkable. A T1 and T2 hyperintense lesion, which
enhances
following administration of contrast in the anterior aspect of
the T5
vertebral body is compatible with a hemangioma. Otherwise, the
marrow is
within normal limits.
There is no significant spinal canal or neural foraminal
narrowing.
Bilateral thyroid nodules are incompletely evaluated. Few
benign simple
hepatic cysts. Indeterminate 1.5 cm enhancing lesion right
hepatic lobe was
better characterized on MRI ___. Linear T2
hyperintense lesion at
the right lung base likely represents atelectasis (series 7,
image 15).
Exophytic simple right renal cyst. Small right pleural
effusion.
IMPRESSION:
1. Significant diffuse cord atrophy, may be sequela of chronic
demyelination.
No focal lesions or cord enhancement.
2. Minimal degenerative changes.
3. Partially visualized thyroid nodules are incompletely imaged
and
characterized. If not previously performed recommend ultrasound
for further
evaluation.
4. Indeterminate right hepatic lobe lesion, better evaluated on
MRI ___
Brief Hospital Course:
# Fever & Leukocytosis
The patient presented with fever and leukocytosis to 20. On
thorough ROS, she has no localizing symptoms, and her
leukocytosis has resolved with conservative management. She
reiterated that the only symptoms she was experiencing prior to
___ was subacute to chronic fatigue. Infectious work-up was
unrevealing. Her leukocytosis recurred in setting of initiation
of high-dose steroids, but was not accompanied by fever or any
other concerning symptoms. Her PCP had obtained ___ Lyme Western
Blot. This showed reactive 23 and 41 KD IgM. Only 66 KD IgG was
positive.ID team was consulted at the request of the Neurology
team, as the medication for MS that she takes is known to be
immunosuppressive. Low suspicion for tick-borne disease,
neuro-Lyme, or any other serious underlying infection. Suspect
this was likely a viral illness of some sort, self-limited. ID
team advised checking Hep B panel, Strongy Ab, and Quant-gold.
Hep B panel was pan-negative. Strongy and Quant are pending at
time of discharge.
# Acute on chronic weakness
# MS ___ vs true relapse
She was continued on her home medications for MS. ___ the
Neurology consult team, in discussion with the patient's primary
Neurologist, decided to treat with 3 days of high-dose steroids
(___). She will need ongoing close Neuro follow-up as
outpatient. She was discharged to rehab. On outpatient
ocrelizumab infusions, next due ___
# Lyme disease
Doxycycline was stopped on ___, after she completed a total 14
day course of doxy for possible Lyme disease. As above, we had
low suspicion for Lyme disease. Her tick-borne disease panel at
___ returned negative.
# Thyroid nodules: partially/incompletely visualize on MRI
___ on ___. Would advise non-urgent ultrasound (as
outpatient) if not previously done. ___ TSH: wnl
# Palpitations: Atenolol was reduced to 12.5 mg BID given HR
persistently in the ___
Transitional issues:
[ ] Strongyloides and Quant are pending at time of discharge.
[ ] needs Hep B vaccination series (start as outpatient, when
not getting high dose steroids)
[ ] Would advise non-urgent ultrasound (as outpatient) if not
previously done
Ms. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO BID
2. Baclofen 10 mg PO QHS
3. Multivitamins 1 TAB PO DAILY
4. dalfampridine 10 mg oral BID
5. biotin 100 mg/gram oral TID
6. Calcium Carbonate 1500 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Ascorbic Acid ___ mg PO TID
9. Vitamin D 4000 UNIT PO DAILY
10. Vitamin E 400 UNIT PO DAILY
11. Modafinil 100 mg PO DAILY
12. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Ramelteon 8 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Nightly Disp
#*30 Tablet Refills:*3
2. Atenolol 12.5 mg PO BID
3. Ascorbic Acid ___ mg PO TID
4. Baclofen 10 mg PO QHS
5. biotin 100 mg/gram oral TID
6. Calcium Carbonate 1500 mg PO BID
7. dalfampridine 10 mg oral BID
8. Modafinil 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 4000 UNIT PO DAILY
12. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
# Fever
# Leukocytosis
# Weakness - possible MS flare
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 fever, elevated white
blood cell count, and increased weakness. The fever and
elevated white blood cell count, often a marker of inflammation,
resolved without any specific intervention. Your weakness
persisted. Imaging of your brain and spinal cord was not fully
explanatory of the cause and an evaluation for infectious causes
was also not revealing. The Neurology team recommended treating
this as a possible flare of MS, with high-dose steroids. ___
received 3 days of high dose steroids (___).
Also, the ID team evaluated ___ and recommended stopping
doxycycline on ___, because at that point ___ had received a
full course of treatment (2 weeks) for possible Lyme disease.
Your tick-borne illness panel that was performed at ___
___ returned negative for Lyme, Babesia, and Anaplasma. We
do not think it is likely that ___ had Lyme disease or any other
tick-borne illness as the cause of your presenting symptoms.
It was a pleasure caring for ___ and we wish ___ the best.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
19661445-DS-4
| 19,661,445 | 21,323,786 |
DS
| 4 |
2130-11-05 00:00:00
|
2130-11-05 17:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Timoptic Ocudose
Attending: ___.
Chief Complaint:
CC: brbpr, ___
REASON FOR MICU: serial h/h
Major Surgical or Invasive Procedure:
Colonoscopy on ___.
History of Present Illness:
This is an ___ M with PMH atrial fibrillation on eliquis,
CABG, who was referred in by his PCP for abrupt onset explosive
diarrhea and rectal bleeding this morning. Patient notes he had
6 episodes of explosive bowel movements since 7:30am. While in
his PCP's office, he c/o that he was not feeling well and had
mild associated lightheadedness and dizziness. He denies any
prior history of melena or hematochezia.
Patient did take his eliquis this morning which he was started
on a few months ago for atrial fibrillation.
Patient denies taking any NSAIDs and can't recall the last time
he had a colonoscopy. No record of colonoscopy in BI records.
Atrius records show:
Colonoscopy ___ (___), diverticulosis and hemorrhoids.
Colonoscopy ___ (___), diverticulosis and hemorrhoids.
Of note, patient recently had video oropharyngeal swallowing
videofluoroscopy on ___ for dysphagia/aspiration requiring
administration of barium.
In the ED, initial vitals:
11:06 0 97.5 80 143/82 12 94% RA
He had ___ further episodes of brpbr in ED.
Blood pressures were as low as 103/63.
Labs were notable for Creat 1.4 (Creat 1.41 on ___, h/h
11.6/36.1 (10.___/34.3 in ___, lactate 2.8, trop <0.01 X 1
CTA abd/pelvis was notable for contrast seen on portal venous
phase in a segment of the sigmoid colon could represent slow
venous oozing secondary to diverticulosis and extensive colonic
diverticulosis with large 4.8cm sigmoid diverticulum.
Patient was given 40mg IV protonix and typed and crossed for 4
units.
On transfer, vitals were:
Today 14:02 91 143/82 20 96%
On arrival to the MICU, patient states he feels well and is
joking with the MICU staff.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, constipation, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Hypercholesterolemia
CABG ___
Cardiac cath ___: 3VD with total occlusion of LAD, left
circumflex and RCA; LIMA graft to LAD patent, SVBG to OMG
patent, and SVBG to RCA patent
Cancer of prostate s/p radiation
Psoriatic arthritis
History of total left hip replacement X 2 c/b septic joint
Glaucoma
Cataracts bilaterally
Renal insufficiency
Anemia
Gout
Esophageal reflux
Keratosis, actinic
Claudication, intermittent
Squamous cell carcinoma of right anterior scalp
Psoriasis
Hiatal hernia
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
___ esophagus with high grade dysplasia, Dr. ___
___ concentric left ventricular hypertrophy (LVH)
Essential hypertension
Atrial fibrillation with RVR; started apixiban ___ s/p
electrocardioversion in ___
Pulmonary fibrosis determined by high resolution computed
tomography ___
Social History:
___
Family History:
No family history of GIB
Father: deceased; ___ years old - MI
Mother: deceased; ___ years old - DM, Heart diease
2 siblings with ALS - deceased; 1 sibling with heart disease,
deceased
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: T98.2 HR74, sinus BP 156/101 RR14 96%RA
GENERAL: Alert, oriented, conversing appropriately, smiling,
pleasant
HEENT: appears pallorous, dry mm, OP clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: moving all extremities without difficulty
ACCESS: ___ PIV
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.2 146/89 86 18 99 RA
GENERAL: Alert, oriented, conversing appropriately, smiling,
pleasant.
HEENT: MMM, OP clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: moving all extremities without difficulty
Pertinent Results:
ADMISSION LABS:
===============
___ 12:00PM BLOOD WBC-11.2* RBC-3.76* Hgb-11.6* Hct-36.1*
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.7 RDWSD-50.8* Plt ___
___ 12:00PM BLOOD Neuts-83.2* Lymphs-9.3* Monos-6.1
Eos-0.6* Baso-0.4 Im ___ AbsNeut-9.34* AbsLymp-1.04*
AbsMono-0.68 AbsEos-0.07 AbsBaso-0.04
___ 12:00PM BLOOD ___ PTT-35.7 ___
___ 12:00PM BLOOD Glucose-94 UreaN-28* Creat-1.4* Na-141
K-4.4 Cl-103 HCO3-29 AnGap-13
___ 12:00PM BLOOD ALT-13 AST-20 AlkPhos-127 TotBili-0.6
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD Albumin-3.9 Calcium-9.9 Phos-3.0 Mg-1.8
___ 03:12PM BLOOD Lactate-2.8*
PERTINENT IMAGING/STUDIES
==========================
___ Colonoscopy:
Diverticulosis of the sigmoid colon
Erythema and edematous in the colon
Blood in the colon
No large masses were noted, but the prep was poor with blood and
stool, and inadequate for colon cancer screening.
Otherwise normal colonoscopy to cecum
___ CTA ABD/PELVIS
1. No evidence of arterial bleeding. Contrast seen on portal
venous phase in a segment of the sigmoid colon could represent
slow venous oozing secondary to diverticulosis.
2. Extensive colonic diverticulosis with a large 4.8 cm sigmoid
diverticulum with mild diverticulitis.
3. Large hiatal hernia with herniation of nearly the entire
stomach into the thorax.
4. Cholelithiasis.
MICROBIOLOGY
=============
___ BLOOD CULTURE PENDING
DISCHARGE LABS:
===============
___ 10:15AM BLOOD WBC-10.9* RBC-3.41* Hgb-10.8* Hct-33.1*
MCV-97 MCH-31.7 MCHC-32.6 RDW-15.2 RDWSD-52.9* Plt ___
___ 10:15AM BLOOD Glucose-144* UreaN-16 Creat-1.3* Na-138
K-3.7 Cl-100 HCO3-26 AnGap-16
___ 10:15AM BLOOD Calcium-10.0 Phos-2.4* Mg-1.8
Brief Hospital Course:
Mr. ___ is an ___ M with PMH atrial fibrillation on Apixaban
and aspirin, CABG, who was referred in by his PCP for abrupt
onset explosive diarrhea and rectal bleeding on ___ concerning
for ___. Colonoscopy showed actively bleeding diverticulosis;
no further bleeding post-procedure after he was restarted on his
anticoagulation.
# Diverticulosis, ? of diverticulitis on CT abdomen: Patient had
had multiple episodes of bright red blood per rectum, concerning
for ___. Given prior colonoscopies showing diverticula, patient
underwent CTA which did show on slow venous phase GI bleeding
and extensive diverticulosis with possible small section of
inflammation/diverticulitis. Patient was given IVF, and patient
had active type and screen. Serial crits stable. GI consulted.
He had no clinical evidence of diverticulitis on exam or by
history: no abdominal pain, no fever, no nausea. His WBC were
intermittantly elevated during the hospitalization. GI team did
not feel that he had clinical diverticulitis. A colonoscopy was
done on ___ showing actively bleeding diverticula. He was
restarted on his anticoagulation and monitored for over 24 hours
without further any bleeding.
# Leukocytosis: Of note, the patient's WBC count, which was
intermittantly elevated throughout the hospiatalization, was
10.9 on the day of discharge. He did not have any infectious
signs or symptoms. His abdominal exam was normal. He had no
pain, nausea, or fever. As above, he was not felt to have
clinical evidence of diverticulitis given this reassuring
examination and as he was without complaints. He was given
instructions that should he develop any abdominal pain, nausea,
or fever he should call for a PCP evaluation ___ given the
radiographic concern for possible diverticulitis on his
admission CT scan as above.
# CAD s/p CABG in ___: Patient's aspirin was held in the
setting of ___ initially and then restarted, and patient was
continued on home statin.
# Atrial Fibrillation with RVR: patient's home apixiban and
metoprolol was held in the setting potential hypotension and
bleeding. His apixaban was restarted after bleeding appeared to
be resolved. His metoprolol was restarted on ___.
# History of total left hip replacement x 2 c/b septic joint:
Patient was continued on home penicillin.
# Psoriatic arthritis: Methotrexate continued as outpatient.
Consider stopping if relative anemia is persistent.
# Glaucoma: Patient was continued on home bimatoprost to the
right eye.
# Gout: Patient was continued on home febuxostat
# HTN: Metoprolol and Quinapril were restarted on ___.
Transitional Issues:
[] 12 mm hypodense lesion in the pancreatic body. The standard
follow up recommendation is MRCP in 6 months.
[] On Apixaban 2.5 mg BID, per age and renal function, normal
dosing would be 5 mg BID.
[] If the patient develops any signs or symptoms of
diverticulitis, recommend immediate evaluation at ___'s office
or ED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. bimatoprost 0.01 % ophthalmic QHS apply to right eye
2. Apixaban 2.5 mg PO BID
3. Omeprazole 20 mg PO BID
4. Ranitidine 300 mg PO BID
5. Quinapril 10 mg PO DAILY
6. Febuxostat 40 mg PO DAILY
7. econazole 1 % topical BID:PRN
8. Desonide 0.05% Cream 1 Appl TP APPLY BID IN GROIN
9. FoLIC Acid 1 mg PO DAILY
10. Penicillin V Potassium 500 mg PO Q6H
11. Aspirin 81 mg PO DAILY
12. Methotrexate 7.5 mg PO QSUN
13. Metoprolol Tartrate 25 mg PO BID
14. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
15. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. bimatoprost 0.01 % ophthalmic QHS apply to right eye
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. Desonide 0.05% Cream 1 Appl TP APPLY BID IN GROIN
6. FoLIC Acid 1 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 20 mg PO BID
9. Penicillin V Potassium 500 mg PO Q6H
10. Quinapril 10 mg PO DAILY
11. econazole 1 % topical BID:PRN
12. Febuxostat 40 mg PO DAILY
13. Methotrexate 7.5 mg PO QSUN
14. Ranitidine 300 mg PO BID
15. Simvastatin 10 mg PO QPM
16. Outpatient Physical Therapy
Dx: Balance deficits. Please eval and treat.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower Gastrointestinal Bleeding
Diverticulosis
Secondary:
Atrial Fibrillation
Chronic Kidney Disease
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted because you had an episode of bleeding. You
had a colonoscopy which showed a condition called
diverticulosis. Diverticula can sometimes bleed. You were
monitored on your anticoagulation with no further bleeding.
It is likely that you will not have any further bleeding. If you
do have further bleeding, please go to the Emergency Room and
ask for a "stat CTA." This is a test to try and see exactly
where the bleeding is coming from.
If you develop any abdominal pain, fevers, chills, or nausea,
please call your primary care doctor because these are all
symptoms of diverticulitis. If you develop this conditions, you
will need to start taking antibiotics right away, so it will be
important to get evaluated by your doctor within 24 hours. If
your doctor cannot see you or the office is closed, we recommend
that you return to the emergency department for evaluation.
Please follow-up with your primary care physician and continue
your medications as listed below.
It was a pleasure taking care of you,
-Your ___ Team
Followup Instructions:
___
|
19661562-DS-11
| 19,661,562 | 28,246,187 |
DS
| 11 |
2142-08-03 00:00:00
|
2142-08-03 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bees / sensitive to pain meds and sedation / dairy
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
___ - Placement of percutaneous cholecystostomy tube
___ - ERCP
History of Present Illness:
Ms. ___ is a pleasant ___ on palliative ___ with
pembrolizumab and DF/HCC ___ who p/w fevers and abdominal
pain.
she was admitted ___ for sepsis from cholangitis c/b
Citrobacter Freundii bacteremia and Acinetobacter baumannii
bacteremia and more recently admitted with colitis where she was
found to have c.diff and possible cholecystitis c/b surrounding
fluid collections possible biloma with plan for endoscopic
drainage on ___.
Last night started having increasing abdominal pain
(specifically
"gallbladder pain again" and fevers 100.6F). Her ___ nurse came
today thought she had orthostatic hypotension so sent to ___. She was febrile at ___ spoke to her
oncologist who stated she should come here for further imaging
and admission. She was given Zosyn at ___. In our ED, she
was found to have temp of 99.9F, BP dipped to 84/49, HR 98,
99.9F
max. She received NS, Vanc, Zosyn. ERCP notified re CT findings
c/f cholecystitis and infected bilomas.
We were notified from ___ that 1 aerobic culture bottle is
growing GNR. On arrival to 8S, pt is anxious about not feeling
well, about avoiding readmissions, and the overall plan.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___ presented with 6 weeks of abdominal bloating,
heaviness, postprandial upper and lower abdominal discomfort
starting in ___. Ultrasound showed a 4 x 3 x 2 cm pancreatic
body mass as well as a 1.3 cm mass in the left lobe of the
liver.
-___ MRI at ___ revealed a 3.5x2.4x3.8cm pancreatic body
mass with encasement of the splenic vein and celiac axis with a
suspicious liver lesion in segment II. ___ was 2509
- ___ EUS demonstrated a mass in the body of the pancreas
with invasion of the splenic vein and a 2 cm mass in the liver.
FNA of the pancreatic and liver masses revealed moderately
differentiated and poorly differentiated adenocarcinoma
consistent with a pancreatic cancer origin.
- ___ consented to HALO3 trial but screen failed with HA low
status.
- ___: C1D1 gemcitabine/nab-paclitaxel.
- ___: C1D8 held for neutropenia, move to D1/d15 schedule
- ___: C2D1 gem/nab (D1/D15)
- ___ CT showed progression of disease , C3D1 held
- ___: port placement
- ___: C1D1 FOLFIRINOX
- ___: C2D1 FOLFIRINOX
- ___: CT showed decreased size of pancreatic mass to
5.1x2.5cm from 6.6x3.3cm in ___
- ___: C3D1 FOLFIRINOX. C3D15 HELD for thrombocytopenia.
- ___: C4D1 FOLFIRINOX (full dose)
- ___: C5D1 FOLFIRINOX
- ___: CT showed stability of pancreatic mass compared to
___
- CancerNext genetic testing returned negative
- ___: C5D15 FOLFIRI (oxali held for neuropathy), no
neulasta.
- ___: Screen failed for Bioline DFCI ___ because CT
showed response to FOLFIRINOX: hepatic mets difficult to see,
pancreatic mass decreased in size to 3.6x1.6cm compared to 5cm
on
prior ___
- ___: C6D1 FOLFIRI
- ___ C6D22 FOLFIRI (q3 week treatment plan). CA ___ up to
668 from 513 on ___.
- ___ CT Torso concerning for new hepatic metastasis,
discussed DF/___ Protocol ___, ___, which is a Phase II
trial of COQ10 given as a continuous infusion and she declined
because the pump would be burdensome. We then recommended
gem/cis, she was considering a trial with Dr. ___ at
___.
- ___. CA ___ from 1689 on ___, bili was rising up
to 5.3 on ___ and she was admitted ___, underwent ERCP
and EUS with biopsy. A pancreatic duct stent was placed, and a
stent was placed across a stricture in the common hepatic duct.
-___ Readmitted with worsening abdominal pain and
fever, found to have polymicrobial GNR bacteremia with a
presumed
biliary source, a distended gallbladder with concern for
possible
cholecystitis. ERCP was done ___ and no occlusion was found,
sludge was removed. CT abd/pelvis ___ showed progression in
her pancreatic head mass, multiple new liver metastases,
distended gallbladder, and concern for peritoneal carcinomatosis
with moderate ascites and omental nodularity. She was seen by
palliative care for her abdominal pain which was controlled on
discharge with oral dilaudid. She was discharged on a course of
cipro to complete ___ - she saw Dr. ___ with surgery, he did not offer
surgery for her gallbladder but offered a percutaneous biliary
drain if she is not improving. Had ongoing abdominal pain and
oral dilaudid was refilled
-___ - consented for Bioline trial, began screening,
gallbladder pain was reduced. Screening CT ___ showed ? of
contained perforation of the gallbladder, but elected for
conservative management given improvement in symptoms.
Screening
labs were adequate except HCT and PTT
-___ - ___
PAST MEDICAL HISTORY (per OMR):
GERD
IBS
restless leg syndrome
s/p hysterectomy, BSO
s/p appendectomy
Social History:
___
Family History:
Mother: UC and polyps
Cancers in the family: relative with breast cancer
Physical Exam:
ADMISSON PHYSICAL EXAM:
=======================
VITAL SIGNS: 98.5 PO 91 / 59 101 19 99 RA
General: NAD, restless in bed
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, mild TTP epigastric area
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
DISCHARGE PHYSICAL EXAM:
========================
VITAL SIGNS: ___ 0508 Temp: 98.8 PO BP: 104/58 HR: 91 RR:
18
O2 sat: 93% O2 delivery: RA Dyspnea: 1 RASS: 0 Pain Score: ___
General: cachectic female, emotional but in no acute distress
HEENT: MMM, no OP lesions
CV: RRR, NL S1S2, no MRG
PULM: CTAB
ABD: BS+, soft, moderate TTP in RUQ area, no rebound, perc tube
drain covered and draining, c/d/i
LIMBS: WWP, edematous left hand, intermittent twitching
SKIN: No rashes on the extremities
NEURO: Grossly normal
Pertinent Results:
ADMISSION LABS:
================
___ 08:00PM BLOOD WBC-15.4* RBC-2.61* Hgb-8.2* Hct-24.1*
MCV-92 MCH-31.4 MCHC-34.0 RDW-13.9 RDWSD-46.5* Plt Ct-77*#
___ 08:00PM BLOOD Neuts-92.2* Lymphs-3.5* Monos-2.0*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.18* AbsLymp-0.54*
AbsMono-0.30 AbsEos-0.01* AbsBaso-0.03
___ 08:00PM BLOOD Plt Ct-77*#
___ 07:20AM BLOOD ___ PTT-29.6 ___
___ 08:00PM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-131*
K-4.0 Cl-95* HCO3-21* AnGap-15
___ 08:00PM BLOOD Lipase-8
___ 08:00PM BLOOD ALT-351* AST-456* AlkPhos-419*
TotBili-1.1
___ 08:00PM BLOOD Albumin-3.0*
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:06PM BLOOD Lactate-1.5
RELEVANT STUDIES/IMAGING:
=========================
CT abd/Pelvis w/ Con ___:
1. Compared to ___, overall unchanged appearance of
metastatic pancreatic cancer, as detailed above.
2. Re-demonstration of perforated cholecystitis with mildly
bigger fluid collections in the right upper quadrant likely
representing bilomas.
3. No gastrointestinal obstruction.
CT abd/pelv w/ con ___. Interval development of an irregular, tubular, branching
hypodense structure along the anterior right portal vein with
associated wedge-shaped peripheral hypodensity involving
primarily segment 8 within the right hepatic lobe, findings
highly concerning for biloma and hepatic ischemia. Coexistent
infection cannot be excluded. 2. Relatively similar appearance
of
hypodense areas in the left hepatic lobe, also likely reflective
of bilomas. 3. Re-demonstration of hepatic metastases and
pancreatic head adenocarcinoma with vascular invasion and
high-grade stenoses of the celiac axis, SMA, main portal vein,
and portal splenic confluence, better depicted on prior CTA of
the pancreas. 4. CBD stent now appears to be nearly completely
occluded though pneumobilia is present in the left lobe. Degree
of mild to moderate intrahepatic biliary duct dilatation
elsewhere in the liver (apart from the biloma) is similar. 5.
Re-demonstration of perforated cholecystitis with slight
interval
increase in size of adjacent pericholecystic fluid collection.
Interval resolution of the previously noted periduodenal fluid
collection. 6. Slight interval increase in small right pleural
effusion. 7. Near complete resolution of previously noted fluid
collection in the left rectus femoris muscle. 8. Interval
development of large colonic stool load.
U/S guided per chole ___
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into
the
gallbladder. More than 20 cc of purulent fluid were aspirated
with samples was sent for microbiology evaluation. No immediate
postprocedure
complication.
ERCP ___
Grade B esophagitis seen.
Mild extrinsic compression was seen at the duodenal sweep.
A duodenoscope was used for the procedure
The scout film showed metal stent in the RUQ.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with a 0.035in guidewire.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Contrast injection revealed evidence of stricture and adjacent
extravastion, 1-2cm above the upper edge of the previous SEMS,
at the level of CHD suggesting possible leak/perforation.
The sphincterotome was exchanged for a balloon.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation.
A small amount of sludge was successfully removed.
A 10mm x 60mm Wallflex biliary Rx fully covered metal stent (ref
___, lot ___ was placed across the leak.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically. The quality of the fluoroscopic images was
good. Otherwise normal ercp to third part of the duodenum
RELEVANT LABS:
==============
___ PF4 Heparin Antibody: Negative
___ 04:53AM BLOOD calTIBC-130* ___ Hapto-261*
Ferritn-2865* TRF-100*
___ 04:53AM BLOOD TSH-1.8
___ 05:26AM BLOOD Vanco-18.0
___ 08:06PM BLOOD Lactate-1.5
MICROBIOLOGY:
=============
___ 7:22 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 8:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
Piperacillin/Tazobactam test result confirmed by ___
___.
Cefepime test result confirmed by ___.
Ertapenem REQUESTED BY ___ ___ (___) ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS:
================
___ 05:27AM BLOOD WBC-12.2* RBC-2.50* Hgb-7.5* Hct-22.0*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.5 RDWSD-46.5* Plt Ct-51*
___ 05:27AM BLOOD Neuts-81.0* Lymphs-8.3* Monos-9.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.86*# AbsLymp-1.01*
AbsMono-1.18* AbsEos-0.01* AbsBaso-0.03
___ 05:27AM BLOOD ___ PTT-26.7 ___
___ 05:27AM BLOOD Glucose-121* UreaN-9 Creat-0.5 Na-133*
K-3.7 Cl-97 HCO3-25 AnGap-11
___ 05:27AM BLOOD ALT-249* AST-169* LD(LDH)-237
AlkPhos-494* TotBili-1.5
___ 05:27AM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.9 Mg-2.3
Brief Hospital Course:
SUMMARY:
=====================
___ on palliative ___ with pembrolizumab and DF/HCC ___
who presented with fevers, RUQ pain and Enterobacter bacteremia
from a biliary source. A percutaneous cholecystostomy drain was
placed and an ERCP was done showing progression of disease.
Given her illness severity and infection, she was no longer a
candidate for her study drug and discharged home.
# Enterobacter Bacteremia
# Contained Gallbladder Perforation: Enterobacter bacteremia and
sepsis from biliary source. She is s/p ___ drainage with
percutaneous cholecystostomy placement on ___, s/p ERCP with
new stent placement and concern for friable ducts. She was
treated initially with vanc/zosyn and switched to vanc/meropenem
based on sensitivities. She will complete a 2 week course of
ciprofloxacin (last day: ___
# Anemia
Likely anemia of chronic disease in addition to malnutrition;
c/f
blood loss during ERCP. Hb 7.1. Smear with occasional tear
drops,
no schistocytes. Did not require red cell transfusion.
# Pancreatic Cancer
Her current status is a contraindication to palliative trial as
noted above.
1. PAIN REGIMEN:
- MS ___ 15mg q12h, Dilaudid ___ PO q4h PRN
- Lidocaine patch, heat packs for back pain
- APAP PRN headache
- FYI: DO NOT TREAT WITH OXYCODONE OR OXYCONTIN
2. NAUSEA/GAS: simethicone, compazine, famotidine
3. BOWELS: colace, senna, miralax BID, bisacodyl (every other
day)
4. Spiritual care is important at this time
5. Code status: DNR/DNI, no transfer to hospital (except for
comfort)
# C. Diff Infection: Will need to continue PO vanc for 10 days
after her course of ciprofloxacin is completed (last day: ___
Transitional Issues:
[ ] Ciprofloxacin for 14 day course (last day: ___
[ ] PO Vanc until 10 days after cipro course ends (last day:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
2. Bisacodyl 10 mg PO EVERY OTHER DAY constipation
3. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
4. DICYCLOMine 10 mg PO BID:PRN Abdominal Pain
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID
8. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
9. Vancomycin Oral Liquid ___ mg PO Q6H
10. Famotidine 20 mg PO Q12H
11. melatonin 3 mg oral QHS
12. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Every 12 hours
Disp #*28 Tablet Refills:*0
3. Famotidine 20 mg PO Q12H
4. Lidocaine 5% Patch 2 PTCH TD QAM pain
RX *lidocaine [Lidoderm] 5 % apply every morning Disp #*30 Patch
Refills:*0
5. melatonin 3 mg oral QHS
6. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth Every 12
hours Disp #*30 Tablet Refills:*0
7. Simethicone 40-80 mg PO QID:PRN burping, gas
RX *simethicone 80 mg 1 tab by mouth Four times per day Disp
#*120 Tablet Refills:*0
8. Bisacodyl 10 mg PO EVERY OTHER DAY constipation
9. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
10. DICYCLOMine 10 mg PO BID:PRN Abdominal Pain
11. Docusate Sodium 100 mg PO BID
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID
16. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
17. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth Every 6
hours Disp #*96 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Enterobacter Blood Stream Infection
Sepsis from a biliary source
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ came to the hospital with increasing abdominal pain and
fevers. We did a scan of your abdomen which showed that your
gallbladder was causing the problem. Our interventional
radiology colleagues placed a drain into the gallbladder. We
were also concerned that your bile duct was obstructed, so we
had our gastroenterologists change the stents.
___ had discussions with your primary oncology team and
together, it was decided that the best thing for your quality of
life would be to spend time at home.
Please take your medications as directed.
It was a pleasure taking part in your care, and we wish ___ all
the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19661562-DS-9
| 19,661,562 | 25,997,534 |
DS
| 9 |
2142-06-25 00:00:00
|
2142-06-25 12:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bees / sensitive to pain meds and sedation / dairy
Attending: ___.
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Ms. ___ is a ___ year-old lady with a history of
metastatic pancreatic cancer s/p 6 cycles of FOLFIRI currently
off treatment who was recently admitted ___ for CBD/PD
stent for biliary obstruction + EUS/FNS pancreatic mass who
presents with worsening abdominal pain and fever.
Of note, patient was having significant abdominal pain prior to
discharge. She declined ciprofloxacin post-procedural
prophylaxis
recommended by interventional endoscopy service in favor of
amoxicillin-clavulanate on discharge. She has continued having
significant abdominal pain until she developed a fever to 101.0F
prompting her to come to ED.
ED initial vitals were 99.8 99 111/69 17 98% RA
Prior to transfer vitals were 85 96/60 14 95% RA
ED work-up significant for:
-CBC: 10.6> 11.7 < 115
-Chemistry: 133/3.7 | ___ | ___
-Lactate: 2.1 -> 1.2
-LFTs: 515/691 | 3.1/445
-UA: unremarkable
-Blood Cx: GNRs
-RUQ-US: mild-moderate biliary dilation c/f stent occlusion, 2
hypoechoic hepatic lesions ~25mm
ED management significant for:
-Medications: 4L NS, LR 250cc/h, amp-sulbactam 3g x1, pip-tazo
4.5g x1, vancomycin 1g x1, hydromorphone 0.5mg iv x4, fentanyl
50mcg iv x1, ondansetron 4mg iv x1, metoclopramide 10mg iv x1
-Consult: ERCP, ? to scope in AM
On arrival to the floor, patient reports ___ abdominal pain
which she localizes to RUQ but also to RLQ. She has not eaten
for
the past 2 days and is concern about continuing to loose weight.
She is worried that she may miss her chemotherapy again this
week.
Patient denies night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
- Pancreatic Cancer
- ___ presented with 6 weeks of abdominal bloating,
heaviness, postprandial upper and lower abdominal discomfort
starting in ___. Ultrasound showed a 4 x 3 x 2 cm pancreatic
body mass as well as a 1.3 cm mass in the left lobe of the
liver.
-___ MRI at ___ revealed a 3.5x2.4x3.8cm pancreatic body
mass with encasement of the splenic vein and celiac axis with a
suspicious liver lesion in segment II. ___ was 2509
- ___ EUS demonstrated a mass in the body of the pancreas
with invasion of the splenic vein and a 2 cm mass in the liver.
FNA of the pancreatic and liver masses revealed moderately
differentiated and poorly differentiated adenocarcinoma
consistent with a pancreatic cancer origin.
- ___ consented to HALO3 trial but screen failed with HA low
status.
- ___: C1D1 gemcitabine/nab-paclitaxel.
- ___: C1D8 held for neutropenia, move to D1/d15 schedule
- ___: C2D1 gem/nab (D1/D15)
- ___ CT showed progression of disease , C3D1 held
- ___: port placement
- ___: C1D1 FOLFIRINOX
- ___: C2D1 FOLFIRINOX
- ___: CT showed decreased size of pancreatic mass to
5.1x2.5cm from 6.6x3.3cm in ___
- ___: C3D1 FOLFIRINOX. C3D15 HELD for thrombocytopenia.
- ___: C4D1 FOLFIRINOX (full dose)
- ___: C5D1 FOLFIRINOX
- ___: CT showed stability of pancreatic mass compared to
___
- CancerNext genetic testing returned negative
- ___: C5D15 FOLFIRI (oxali held for neuropathy), no
neulasta.
- ___: Screen failed for Bioline DFCI ___ because CT
showed response to FOLFIRINOX: hepatic mets difficult to see,
pancreatic mass decreased in size to 3.6x1.6cm compared to 5cm
on
prior ___
- ___: C6D1 FOLFIRI
- ___ C6D22 FOLFIRI (q3 week treatment plan). CA ___ up to
668 from 513 on ___.
- ___ CT Torso concerning for new hepatic metastasis
PAST MEDICAL HISTORY (Per OMR, reviewed):
-GERD
-IBS
-restless leg syndrome
-s/p hysterectomy, BSO
-s/p appendectomy
Social History:
___
Family History:
Mother: UC and polyps
Cancers in the family: relative with breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.3 PO 97 / 64 94 18 95 ra
GENERAL: Pale and anxious lady in significant pain lying on her
back, unable to sit due to abdominal pain
HEENT: Mildly jaundices, PERLL, Mucous membranes dry, OP clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, no collateral circulation, normal bowel
sounds, diffusely tender but exquisitely tender in RUQ and RLQ
with some voluntary guarding in RLQ.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE EXAM:
VS: Temp 99.1 BP 108/67 HR 86 RR 18 O2 93%RA
GENERAL: Anxious woman, sitting up on edge of bed.
HEENT: Anicteric sclerae, PERLL, MMM, OP clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended with subtle prominence over right mid
abdomen,
normal bowel sounds. Relatively point tender over right mid
abdomen with voluntary guarding but no rebound.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN III-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:35PM BLOOD WBC-10.6*# RBC-3.61* Hgb-11.7 Hct-34.5
MCV-96 MCH-32.4* MCHC-33.9 RDW-12.8 RDWSD-44.8 Plt ___
___ 12:35PM BLOOD Plt Smr-LOW* Plt ___
___ 12:35PM BLOOD Glucose-157* UreaN-12 Creat-0.6 Na-133*
K-3.7 Cl-93* HCO3-23 AnGap-17
___ 12:35PM BLOOD ALT-691* AST-515* AlkPhos-445*
TotBili-3.1*
___ 06:45AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.0*
Mg-2.0
___ 12:39PM BLOOD Lactate-2.1*
DISCHARGE LABS:
===============
___ 06:16AM BLOOD WBC-6.6 RBC-2.85* Hgb-9.3* Hct-26.7*
MCV-94 MCH-32.6* MCHC-34.8 RDW-13.8 RDWSD-47.8* Plt ___
___ 06:16AM BLOOD Glucose-113* UreaN-8 Creat-0.3* Na-137
K-3.9 Cl-102 HCO3-25 AnGap-10
___ 06:16AM BLOOD ALT-144* AST-51* LD(LDH)-117 AlkPhos-511*
TotBili-1.7*
___ 06:16AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
___ 07:08AM BLOOD Lactate-1.2
MICRO:
======
___ 12:35 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
CITROBACTER FREUNDII COMPLEX. FINAL SENSITIVITIES.
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.
ACINETOBACTER BAUMANNII COMPLEX. FINAL SENSITIVITIES.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S 8 S
CEFTAZIDIME----------- <=1 S 16 I
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S 2 S
PIPERACILLIN/TAZO----- <=4 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0219 ON
___ - ___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Urine Culture ___ - No growth
Blood Culture ___: NGTD
Blood Culture ___: NGTD
IMAGING:
========
IMAGING:
RUQ Ultrasound ___
1. Mild to moderate biliary dilatation, concerning for stent
occlusion. Recommend correlation with laboratory values.
2. Two hypoechoic hepatic lesions measuring up to 2.5 cm,
suspicious for metastases.
3. Prominence of the right renal collecting system is likely due
to an extrarenal pelvis, given a similar appearance on multiple
prior imaging studies.
CT Abdomen/Pelvis w/ Contrast ___
1. Increase of ill-defined hypoenhancing lesion in the
pancreatic head/mass, difficult to directly compare to prior
given differences in technique, though there is extensive
vascular involvement with increased narrowing of the main portal
vein and SMV, and encasement of the celiac axis with attenuation
of the common hepatic, left gastric, and proximal splenic
arteries.
2. Multiple hypodensities throughout the liver are new from
prior, concerning for metastatic disease. There is loss of fat
plane between the lesser sac of the stomach and a large hepatic
lesion in the left lobe.
3. Distended gallbladder, without wall thickening, as seen on
prior ultrasound. Of note, the gallbladder fundus extends down
nearly to the level of the iliac crest, which may localize pain
to the right lower quadrant.
4. Moderate volume ascites and omental nodularity is concerning
for carcinomatosis.
5. Large fecal load.
ERCP ___
Impression: The scout film showed metal and plastic stent in the
RUQ. The bile duct was successfully cannulated using a balloon
catheter. Contrast was injected and there was brisk flow through
the ducts. Contrast extended to the entire biliary tree. The
metal stent was widely patent. High pressure cholangiogram was
not performed due to risk of cholangitis. The biliary tree was
swept with a 9-12mm balloon starting at the bifurcation. Small
amount of sludge was successfully removed. The final occlusion
cholangiogram showed no evidence of filling defects in the CBD,
CHD and right and left main hepatic ducts. Excellent bile and
contrast drainage was seen endoscopically and fluoroscopically.
RUQ Ultrasound ___
1. Distended gallbladder with layering sludge within it and wall
thickening with pericholecystic ascites. These features are
unchanged compared to the recent CT abdomen dated ___. The patient had probe tenderness throughout the right
upper quadrant at the time of the exam and not particularly
localized to the gallbladder. These findings are equivocal for
acute cholecystitis.
2. Multiple hepatic metastases from the known pancreatic cancer
are unchanged compared to the recent CT abdomen.
Pelvis X-Ray ___
Impression: No definite lytic or blastic osseous lesion is
identified. There is likely pseudoarticulation of the right
transverse process of L5 and the sacrum. Mild degenerative
changes of the lower lumbar spine. Mild degenerative change of
the bilateral SI joints. Mild degenerative change of the
bilateral hips. Mild degenerative change of the pubic symphysis.
No fracture.
KUB ___
1. Nondilated bowel gas pattern with air-fluid levels is
nonspecific but may suggest enteritis.
2. Likely ascites.
3. No pneumoperitoneum.
4. Moderate right pleural effusion appears larger than the
previous CT.
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with a history of
metastatic pancreatic cancer s/p 6 cycles of FOLFIRI currently
off treatment who was recently admitted ___ for CBD/PD
stent for biliary obstruction + EUS/FNS pancreatic mass who was
admitted with with worsening abdominal pain and fever.
She was found to have polymicrobial GNR bacteremia. Source was
presumed from her biliary tree, and she underwent ERCP on ___
with removal of sludge from her stent. ID was consulted and she
was narrowed to Ciprofloxacin with planned 14 days of treatment.
Of note, she does have distended gallbladder on imaging with RUQ
US equivocal for cholecystitis. Surgery was consulted who
recommended against surgical intervention, and suggested if pain
persisted uncontrolled to consider HIDA scan and possible
percutaneous cholecystostomy. Her pain was better controlled
without recurrent fever or leukocytosis, and she had improving
LFT's. After discussion with patient, we elected to
conservatively manage and discharge home with outpatient
followup.
# Citrobacter Freundii bacteremia
# Acenitobacter baumannii bacteremia
# Severe sepsis: Met sepsis criteria with fever, tachycardia,
and elevated lactate. Sepsis physiology has resolved. Suspect
biliary source of her infection, and is s/p repeat ERCP on
___. She initially received IV zosyn and vancomycin, and was
previously on augmentin from prior ERCP. ID was consulted and
she was narrowed to ciprofloxacin with plan to complete 14 days
of treatment on ___. Of note, after acenitobacter resulted,
discussed with ID and no plan to change abx course or treatment.
# Elevated LFTs:
# Distended gallbladder: Initial RUQ US showed mild to moderate
biliary dilatation. ERCP on ___ did not show significant stent
occlusion but small amount of sludge was removed. Bilirubin and
LFT's continued to downtrend during her admission. Given
persistent abdominal pain, there was some concern for
inadequately treated cholecystitis. Surgery was consulted, who
deferred against surgical management, although recommended HIDA
with consideration of PTC if pain persisted. Given her improving
LFT's, lack of leukocytosis or fever, and improving pain, we
elected conservative management with close follow up.
# Acute on Chronic Abdominal Pain:
# Cancer-Related Pain:
# Constipation: She has been having abdominal pain since prior
to
her recent admission. Likely multifactorial, including acute
infection, new peritoneal
carcinomatosis, progression of pancreatic mass, distended
gallbladder, and constipation. Pain noted to improved during her
admission and was adequately controlled with oral dilaudid. Also
with successful BM following iniation of bowel regimen.
Palliative care was consulted for symptom management, and is
arranging outpatient followup on discharge.
# Metastatic Pancreatic Cancer: Metastatic to liver and
peritoneum. Hoping to intiated additional treatment with Dr.
___ on followup.
# Anemia/Thrombocytopenia: Likely in setting of malignancy and
acute infection. No evidence of active bleeding.
# Billing: >30 minutes spent coordinating and executing this
discharge plan
TRANSITIONAL ISSUES:
- Con't ciprofloxacin to complete 14 day course through ___
- If worsening abomominal pain and/or fever - consider HIDA scan
and possible percutaneous cholecystostomy.
- Please follow up LFT's and CBC on follow up
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DICYCLOMine 10 mg PO BID:PRN Abdominal Pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
4. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
Discharge Medications:
1. Bisacodyl 10 mg PO EVERY OTHER DAY constipation
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
every other day Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*17 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg 1 tablet(s) by mouth q4 hours Disp #*180
Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*24 Packet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
8. DICYCLOMine 10 mg PO BID:PRN Abdominal Pain
9. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Sepsis
# GNR bacteremia
# Abdominal pain
# Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___. You were admitted with worsening abdominal pain,
nausea, and fever. We found you had a bacterial infection in
your blood, likely from your biliary tract. You underwent ERCP
on ___ and were started on antibiotics. Your infection
improved but your pain persisted, so we started you on a pain
medication called dilaudid with our palliative care doctors. If
you develop a new fever, or if you have worsening abdominal
pain, this may be a sign that the infection has moved into your
gallbladder, and may need further testing or drainage of the
gallbladder.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19661672-DS-10
| 19,661,672 | 26,091,303 |
DS
| 10 |
2149-06-06 00:00:00
|
2149-06-06 21:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
House Dust
Attending: ___.
Chief Complaint:
Neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with recent hospital admission (___) with
diverticulitis, recent chemo on ___, found to have rigors and
be neutropenic in PCP office this am. She was diagnosed in ___
with breast cancer, s/p lumpectomy and reexcision, w/ negative
nodes. Started chemo 6 fdays ago:started cycle 1 of chemotherapy
with Taxotere/Cytoxan ___, received Neulasta ___. On ___, she
presented to ___ with head trauma after syncopal episode, in
the setting of diarrhea, found to have diverticulitis and new
AFib with RVR. She spontaneously cardioverted following Iv
hydration. She was treated in the MICU with fluids and
cipro/flagyl, and discharged on ___. Echo revealed normal EF
with moderate ___ and mild LAE, no LV motion abnormality. CT
head at the time showed no acute intracranial pathology, but she
has had a waxing/waning headache in the ___
region since, which persists today. She denies any visual
changes, nausea, visual changes. Does not wake up from sleep
with headache. She does have intermittent waxing/waning
abdominal pain, chronic for years, located in bilateral lower
quadrants. worse since ___. The pain is crampy and
debilitating but resolves with bowel movement. She is continuing
on oral cipro/flagyl since hosptial discharge. Lat BM was in
hospital, no nausea/vomiting/hematochezia/ melena since
discharge.
Today she went to her PCP's office for followup, and was found
to have rigors/chills whilst there. No fevers. CBC was notable
for pancytopenia (today is day 5 post-chemotherapy). Denies any
fevers, chest pain, dyspnea, dysuria, hematuria, neck stiffness,
photophocia.
In the ED, initial vital signs were 98.2 78 107/63 16 97% RA.
She was given 500 cc NS bolus, Zofran 4mg IV, Morphine 5mg IV
total as well as Toradol 30mg IV for headache. Given soft blood
pressure and neutropenia, the decision was made to admit her to
medicine for observation, wth concern for bacteremia
Past Medical History:
- Stage I invasive lobular breast cancer s/p left lumpectomy
___ with re-excision ___ started cycle 1 of
chemotherapy with Taxotere/Cytoxan ___, received Neulasta ___
- Asthma
- Meralgia paresthetica
- Depression
- Hypercholesterolemia
- H/o alcohol dependence
- Umbilical hernia
- Colonic adenoma
- Bilateral bunions
- ?Restless legs syndrome
Social History:
___
Family History:
Mother with CHF. Father with early-onset Alzheimer's disease.
Denies any family history of breast or ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.8, 118/68, 76, 20, 94% RA
GEN Alert, oriented, no acute distress
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 distended, soft NT normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge PE
VS 98.3 108/68 68 20 93% RA
GEN Alert, oriented, no acute distress
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 WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs
___ 06:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 04:32PM LACTATE-1.4
___ 04:10PM GLUCOSE-91 UREA N-6 CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
___ 04:10PM ALT(SGPT)-23 AST(SGOT)-34 ALK PHOS-68 TOT
BILI-0.8
___ 04:10PM LIPASE-13
___ 04:10PM ALBUMIN-3.9
___ 04:10PM WBC-2.7* RBC-3.72* HGB-12.3 HCT-35.4* MCV-95
MCH-33.0* MCHC-34.7 RDW-12.0
___ 04:10PM NEUTS-9* BANDS-0 LYMPHS-72* MONOS-10 EOS-3
BASOS-1 ATYPS-1* METAS-3* MYELOS-1*
___ 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 04:10PM PLT SMR-LOW PLT COUNT-128*
___ 06:25AM GLUCOSE-81 UREA N-7 CREAT-0.5 SODIUM-139
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-11
___ 06:25AM CALCIUM-7.7* PHOSPHATE-2.4* MAGNESIUM-1.9
___ 06:25AM TSH-3.4
___ 06:25AM WBC-2.3*# RBC-3.39* HGB-11.1* HCT-32.2*
MCV-95 MCH-32.8* MCHC-34.6 RDW-12.9
___ 06:25AM PLT SMR-LOW PLT COUNT-99*
Discharge Labs
___ 10:35AM BLOOD WBC-7.8 RBC-3.72* Hgb-12.1 Hct-35.6*
MCV-96 MCH-32.4* MCHC-33.9 RDW-12.3 Plt ___
___ 10:35AM BLOOD Neuts-36* Bands-16* ___ Monos-17*
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-3* Promyel-1*
Micro
___ STOOL
C. difficile DNA amplification assay-PENDING;
FECAL CULTURE-PENDING;
CAMPYLOBACTER CULTURE-PENDING;
OVA + PARASITES-PENDING
URINE URINE CULTURE-PENDING I
Blood Culture, Routine-PENDING EMERGENCY WARD
___
BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD
CXR ___
FINDINGS:
The heart size is top normal and unchanged. The mediastinal and
hilar
contours are stable and within normal limits. The pulmonary
vascularity is
not engorged. A trace left pleural effusion is likely present.
There is
minimal bibasilar atelectasis. No pneumothorax is present, and
no acute
osseous abnormalities seen.
IMPRESSION:
Small left pleural effusion and mild bibasilar atelectasis.
Brief Hospital Course:
This is a ___ C1D6 following Taxotere/Cyclophosphamide, reent
MICU admission for diverticulitis, on cipro/flagyl, now presents
with rigors in PCP office, soft blood pressures and neutropenia.
# Neutropenia/Abdominal pain/Hypotension: The patient was
recently discharged from the MIcu after hospital stay for
diverticulitis and continued on ciprofloxacin/metronidazole. She
presented to her PCP pancytopenic following chemotherapy (ANC
243). Given she was previously diagnosed with diverticulitis
during the past admission, the initial concern for bacteremia
vs. colitis with comlicatons such as abscess vs. other
infection. Abdominal exam was benign, patent's GI symptoms have
not worsened. CXR benign, no history of dysuria.
She was resuscitated with 2L IVF and responded adequately with
pressures going from ___ systolic to 110s systolic. A
repeat CBC shows uptrending WBC at 5.8 with 36% neutrophils, no
longer neutropenic. Her vitals were closely monitored and
serial abdominal exams were performed. She was afebrile and
never met SIRS criteria and her belly was soft and nontender
during the entire admission.
I spoke extensively with Dr. ___ atrius attending
covering heme/onc today, and he agreed with my assessment that
the patient likely is not acutely infected and is not at
increased risk for infection as her WBC recovered. Dr. ___,
___ PCP was contacted and her case was discussed. She agreed to
see the patient in her clinic the following day for close
monitoring.
# Headache: Her headache symptoms were minimal during this
hospital admission. The etiology is likely post-traumatic as
she denied photophobia/visual changes/neck stiffness/ altere
mental status to suggest meningitis/encephalitis, and past CT
scan of head showed no acute abnormalities. We continued her
percocet which adequately managed her pain
Chronic Issues: These issues were not active during this
hospital admission
- Stage I invasive lobular breast cancer s/p left lumpectomy
___ with re-excision ___ started cycle 1 of
chemotherapy with Taxotere/Cytoxan ___, received Neulasta ___
- Asthma- she was contined on her albuterol inhaler
- Meralgia paresthetica
- Depression- was continued on lorazepam
- Hypercholesterolemia
- H/o alcohol dependence
- Umbilical hernia
- Colonic adenoma
- Bilateral bunions
- ?Restless legs syndrome
TRANSITIONAL ISSUES
-Patient needs follow up on the following labs: Stool culture,
campylobacter culture, stool ova and parasites, C.Diff, Urine
culture, Blood culture
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen ___ mg PO Q8H:PRN pain or fever
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Hold for oversedation or RR < 12
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
7. Lorazepam 1 mg PO Q8H:PRN mild nausea, anxiety
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain or fever
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Lorazepam 1 mg PO Q8H:PRN mild nausea, anxiety
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Hold for oversedation or RR < 12
7. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenia (recovered)
Diverticulitis
Headache
Secondary
-Breast Cancer s/p lumpectomy, node excision, and cycle 1 day 6
chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to ___ for low white blood cell counts,
abdominal pain, and headache. Since ___ were here, we gave ___
several liters of IV fluids as your blood pressures were a bit
low. Additionally, we redrew your blood counts which showed ___
to have recovered your white blood cell numbers. We continued
the cipro and flagyl for the diverticulitis ___ were diagnosed
with earlier in the week. Fortunately, it did not look like ___
have a separate acute infection. We concluded that your
headache was due to your fall a few days back and we continued
your Percocet and Tylenol for pain.
CHANGES TO MEDICATIONS
NONE
It was a pleasure taking care of ___ while ___ were here.
Followup Instructions:
___
|
19661729-DS-7
| 19,661,729 | 25,335,513 |
DS
| 7 |
2162-02-18 00:00:00
|
2162-02-18 15:03:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Enbrel / Latex / Hayfever / Sulfa (Sulfonamide Antibiotics) /
Ace Inhibitors / Bactrim
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ F with S2 Tarlov cyst s/p bilateral S1-S2
laminectomy in ___, RA, MCTD,, recurrent osteomyelitis and
scleroderma who presents with worsening RLE pain and numbness
and tingling. Patient states she injured her left ankle 6 days
ago while she was running up th stairs; she presented to the
___ ED and was assessed as having an Achilles tendon injury
(no full tear, rupture or fracture)and has been using crutches
and boot since. One day later, she developed worsened right
sided parathesias, pain originating in the rt buttock, described
as 'burning/shooting/fiery' which radiates down her leg and is
worsened by any activity other than lying flat. The pain is
followed by numbness that is more widespread than her baseline,
involving her entire right leg. Previously, the patient had pain
in her sacral and genital area which was relieved for a few
weeks after her surgery last ___. However, her pain has
recurred since and she is on a heft pain regime currently
(morphine 30 q4, oxycontin 90 BID, gabapentin 1200 TID,
amitryptiline 10 OD). She has baseline numbness of her right
side and pain that was previously well controlled. She described
parathesias that ran down the side of her right leg and felt
like burning or fire and electric flames. These episodes last
for ~30 min before the pain begins to improve. Her pain
originates in the right lower back. She is now using wheelchair
because pain is more severe.
She has had intermittent nausea and vomiting with taking her
doxycycline, last episode 1.5 weeks ago. She had urinary
incontinence with vomiting. She has baseline urinary retention
and does report incomplete emptying. She also endorses
constipation that has been long standing, having one large bowel
movement every 3 days despite taking high doses of docusate,
senna, miralax. She has saddle anesthesia, areflexia in lower
extremeties at baseline. Denies fevers/chills, N/V, diarrhea.
In the ED, initial VS: T 95.2 BP 124/84 16. MRI showed no spinal
cord compression. She was seen by neurosurgery who felt there
was no indication for neurosurgical intervention. She was given
morphine 4 mg iv x 3 and dilaudid 1 mg iv x1. VS prior to
transfer were 98.6, P: 97, RR: 18, BP: 136/90, O2Sat: 98,
O2Flow: (Room Air).
Overnight, the patient underwent an MRI which ruled out acute
cord compression. She described to be in pain (10+/10) and
described pain even with stretching her arms as she lay in bed.
Past Medical History:
-Mixed connective tissue disease (elements of rheumatoid
arthritis, scleroderma and SLE)
-Recurrent osteomyelitis status post amputation of right hand
fingers in ___ now on doxycyline; possibly ___
immunosuppression d.t biologics, DMARDS, and steroids.
___ parasilopsis ___ s/p fluconazole x3 months
>--Enterococcus species ___ debrided ___ and treated with
vancomycin x6 weeks
>--MSSA isolated ___ treated empirically with vancomycin -
had tongue/lip numbness with test dose of nafcillin so resumed
vancomycin, s/p debridement ___ with hardware removal from ___
digit. Returned with fevers ___ and underwent debridement ___
of right thumb abscess
___ parasilopsis again isolated ___, treated with
fluconazole
-Raynaud's disease
-Hypertension
-Lupus anticoagulant
-Tarlov's cyst s/p Bilateral laminectomies S2, S1 and inferior
L5 for decompression with coagulation and reduction of Tarlov
cysts on ___
Social History:
___
Family History:
Father with coronary disease
Mother with uncontrolled diabetes
Also in her family are people with malignancy of stomach,
prostate, colon
Physical Exam:
PHYSICAL EXAM (remained unchanged during admission):
General: Awake, cooperative,oriented to place and date.
Excellent historian.
HEENT: NC/AT
Abdomen: soft, nontender, nondistended, no masses.
Extremities: no edema, right hand s/p finger amputation,+
bandaged fingers on right (x1) and left (x2) from recent
debridment. There are multiple rheumatoid nodules appreciated
overlying the patients arms, legs, and feet
Back: no appreciable skin changes. no tenderness overlying the
lumbar spine.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. Speech was not dysarthric. Able
to
follow both midline and appendicular commands. Pt. was able to
register and recall 3 objects. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
On flexion of the hamstrings with resistance the patient had a
suddent onset of her pain causing her to jumpm and begin crying.
-Sensory: diminished sensation to pinprick and temperature over
the posterior buttock extending down the right leg to to the 5cm
below the politeal fossa. The patient notes that the area of
numbness does not include the fossa itself. Sensation on the
left is intact. Positional sense is intact bilaterally. There is
decreased vibratory sensation overlying the right foot and ankle
(50%), normal on the left.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor.
-Gait: Patient has difficulty arising from bed due to fear of
spasms.
Her and her husband have devised a system which they used on
exam whereby she is able to get up without bending her legs/
using her quadriceps. When she walks she has small stride length
and trys not to bend her right leg. She also turns slowly as a
result of this. she is unsteady and needs assitance while
walking.
Romberg is +
Pertinent Results:
LABS ON ADMISSION:
___ 08:45PM BLOOD WBC-4.7 RBC-4.05* Hgb-13.3 Hct-38.1
MCV-94 MCH-32.8* MCHC-34.8 RDW-13.2 Plt ___
___ 08:45PM BLOOD Neuts-75.6* Lymphs-15.2* Monos-7.1
Eos-1.0 Baso-1.1
___ 09:05PM BLOOD ___ PTT-64.0* ___
___ 07:20PM BLOOD Glucose-99 UreaN-19 Creat-1.0 Na-139
K-4.4 Cl-104 HCO3-24 AnGap-15
___ 07:20PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.7
LABS ON DISCHARGE:
___ 07:57AM BLOOD WBC-3.0* RBC-3.98* Hgb-13.0 Hct-37.9
MCV-95 MCH-32.6* MCHC-34.2 RDW-13.2 Plt ___
___ 07:57AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-139
K-4.0 Cl-103 HCO3-29 AnGap-11
IMAGING:
ANKLE (AP, MORTISE, LAT) LEFT:
1. No acute fracture or dislocation.
2. No significant change in appearance of probable bursae along
the lateral aspect of the foot, as described above.
3. Freiberg's infraction of the second metatarsal head, not
significantly
changed in appearance.
FOOT XRAY:
1. No acute fracture or dislocation.
2. No significant change in appearance of probable bursae along
the lateral aspect of the foot, as described above.
3. Freiberg's infraction of the second metatarsal head, not
significantly
changed in appearance.
MR L-SPINE:
1. Post-surgical changes at S1 and S2 levels. Enhancing soft
tissue is noted at the surgical bed with extension of the scar
tissue in posterior sacral spinal canal. Mildly enhancing scar
tissue is noted in close proximity to and encasing the right S2
nerve root without significant deformity.
2. The right S2 perineural cyst is not visualized in the present
study which likely represents its resolution.
3. Bilateral pars defects at L3, better seen on prior CT L spine
study with minimal edema.
4. T2 hyperintense lesion in the right side of pelvis which is
unchanged
since the prior study and likely represents an ovarian cyst.
Multiple
hypointense lesions in the uterus which likely represent
fibroids.
Correlation with pelvic ultrasound is advised if not already
performed.
Brief Hospital Course:
HOSPITAL COURSE: Patient is a ___ F with Tavlov cyst s/p
laminectomy on spine, RA, mixed CT disease, scleroderma who
presented with worsening RLE pain and numbness and tingling
likely related to increased weight bearing of RLE after L ankle
injury. Had an MR which showed previously known Tralov cyst scar
on s2. Was discharged on home analgesic regimen.
ACTIVE ISSUES:
#RLE pain/numbness/pain: The patient's pain and neurological
symptoms correlate to ___ cyst in the S2 distribution now s/p
laminectomy as pain is similar to prior though now exacerbated
by overuse injury of the right side after the achilles injury on
the left. No sign of cord compression. Neurosurgery and
Orthopedics were consulted who said that there was no surgical
option for pain relief. Neurology was consulted and recommended
starting the patient on lyrica. Otherwise the pt was on her home
regime of pain meds with dilaudid 8mg q3hprn PO. She was
discharged home on her home regimen. Neurology felt strongly
that her symptoms were most likely due to her residual cyst, and
recommended having additional neurosurgical opinion. We have
arranged for a referral/follow-up with Neurosurgery at ___
___.
INACTIVE ISSUES:
# Mixed connective tissue disease/rheumatoid arthritis:
- we continued leflunomide, prednisone
.
# Recurrent osteomyelitis: s/p full course iv vancomyin, on
doxycycline for suppression. tobacco use likely worsening
circulation
- we continued doxycycline, gabapentin and nicotine patch
# Hypertension: well controlled on amlodipine, metoprolol
.
# Asthma: Exercise-induced, stable
- we continued albuterol nebs prn
.
# Tobacco use: likely contributing to worsened osteomyelitis
- we cotinued nicotine patch and encouraged patient to quit
.
# GERD: Continued home dose pantoprazole
.
# Allergies: chronic but stable currently
- we continued fluticasone, singulair; azelastine non-formulary
.
# FEN: replete lytes prn / regular diet
# PPX: heparin SQ, bowel regimen
# ACCESS: PIV
# CODE: full
# CONTACT: husband ___, Cell:
___
# DISPO: pending above
.
.
___, PGY-1
___
.
TRANSITIONAL ISSUES: Patient was set up with orthopedics,
rheumatology and her PCP for continued follow up. Neurology
recommended patient to approach Dr ___ for possible
surgical intervention.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs Inhalation Q6H (every 6 hours) as
needed for wheezing, SOB.
2. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
7. Mobic 15 mg Tablet Sig: One (1) Tablet PO daily ().
8. leflunomide 10 mg Tablet Sig: Three (3) Tablet PO daily ().
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxycodone 30 mg Tablet Extended Release 12 hr Oral
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
15. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
16. senna 8.6 mg Tablet Sig: ___ Tablets PO HS (at bedtime).
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
18. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: ___ puffs Inhalation Q6H (every 6 hours) as
needed for wheezing, SOB.
2. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
7. Mobic 15 mg Tablet Sig: One (1) Tablet PO daily ().
8. leflunomide 10 mg Tablet Sig: Three (3) Tablet PO daily ().
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxycodone 30 mg Tablet Extended Release 12 hr Oral
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
15. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
16. senna 8.6 mg Tablet Sig: ___ Tablets PO HS (at bedtime).
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
18. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*15 Capsule(s)* Refills:*1*
19. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
- Chronic Lumbar pain
- s/p bilateral laminectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you at the ___. You presented
with worsening pain in your right leg pain and numbness. You
were evaluated by surgeons, neurologist and medicine doctors who
agreed that your pain was a result of scar tissue at the site of
your prior surgery. The surgical team did not recommend
surgical intervention. You were started on a new medication
called lyrica and instructed on stretches to help with your
pain.
MEDICATION CHANGES
- STARTED lyrica
Followup Instructions:
___
|
19661729-DS-8
| 19,661,729 | 24,953,604 |
DS
| 8 |
2162-09-17 00:00:00
|
2162-09-17 14:13:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Enbrel / Latex / Hayfever / Sulfa (Sulfonamide Antibiotics) /
Ace Inhibitors / Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with S2 Tarlov cyst s/p bilateral S1-S2 laminectomy in
___, RA, MCTD, recurrent osteomyelitis and mixed connective
tissue disease on prednisone who presents with epigastric
abdominal pain x 1 day. Patient states that she began having
abdominal discomfort and cramping starting ___, has
associated nausea, nb/nb vomiting, watery nb diarrhea. Notably
patient was treated for presumed sinus infection with amox/clav
on ___ and has had mild diarrhea since starting.
In the ED, patient was noted to have Lipase 266, lactate of 3.9
which rose to 4.0 despite 2L of IV fluid. Had RUQ ultrasound
negative for cholecystitis, no intra or extra hepatic duct
dilation. CT abdomen/pelvis w/ contrast was negative for
intrabdominal pathology, no comment on pancreatitis. Patient was
given 2L NS and started on piperacillin/tazobactam.
Notably, patient has had elevated ALT/AST since ___ (nl in
___.
On arrival to the MICU, patient is complaining of abdominal
pain, but is otherwise hemodynamically stable. Repeat K was 3.2,
Lactate downtrended to 1.6. Ionized Ca was low at 0.84.
.
Review of systems:
(+) Per HPI, reports chills, night sweats, intentional mild
weight loss, positive of n/v/d
(-) Denies fever, recent weight gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies constipation. Denies dysuria,
frequency, or urgency.
Past Medical History:
-Mixed connective tissue disease (elements of rheumatoid
arthritis, scleroderma and SLE)
-Recurrent osteomyelitis status post amputation of right hand
fingers in ___
-Raynaud's disease
-Hypertension
-GERD
-Lupus anticoagulant
-Tarlov's cyst s/p Bilateral laminectomies S2, S1 and inferior
L5 for decompression with coagulation and reduction of Tarlov
cysts on ___
Social History:
___
Family History:
Father with coronary disease
Mother with uncontrolled diabetes
Also in her family are people with malignancy of stomach,
prostate, colon
Physical Exam:
ADMISSION EXAM
Vitals: T:98.1 BP:171/141 P:130 R:24 O2: 95 RA
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL,
___ appearance
Neck: supple, JVP difficult to appreciate, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, tender to palpation in epigastrium, no rebound,
no guarding, no organomegaly appreciated
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AxO x 3, moves all 4 extremities spontaneously.
DISCHARGE:
VS - 64.6 142-154/98-109 ___ 18 98 RA
GEN Alert, oriented, no acute distress
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 tenderness in epigastrium ND normoactive bowel sounds,
no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e, abscess site
healing well
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION:
___ 06:50PM BLOOD WBC-6.1# RBC-4.31 Hgb-14.1 Hct-41.0
MCV-95 MCH-32.8* MCHC-34.4 RDW-14.4 Plt ___
___ 06:50PM BLOOD Neuts-57 Bands-11* Lymphs-17* Monos-4
Eos-0 Baso-0 Atyps-2* ___ Myelos-9*
___ 06:50PM BLOOD ___ PTT-45.6* ___
___ 06:50PM BLOOD Glucose-105* UreaN-13 Creat-1.1 Na-135
K-8.3* Cl-102 HCO3-21* AnGap-20
___ 06:50PM BLOOD ALT-60* AST-110* AlkPhos-65 TotBili-0.4
___ 06:50PM BLOOD Lipase-266*
___ 06:50PM BLOOD Albumin-4.4 Phos-3.0 Mg-1.8
___ 02:35AM BLOOD Triglyc-159*
___ 02:45AM BLOOD ___ Temp-36.1 pO2-127* pCO2-33*
pH-7.33* calTCO2-18* Base XS--7 Intubat-NOT INTUBA
___ 06:58PM BLOOD Lactate-3.9* K-6.0*
___ 01:56AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:56AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:56AM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE
Epi-16
Micro:
Urine culture ___- YEAST ___
Blood culture ___- NGTD ___- PENDING
___ 7:18 pm SWAB Source: thumb.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Imaging:
CT abd ___: Findings suggestive of colitis although
underdistension is a confounding factorlimiting assessment;
noting lack of haustration along the distal colon, a more
subacute or chronic form of colitis such as ulcerative colitis
could be considered; acute inflammation is not excluded however.
No clear evidence of pancreatic inflammation or biliary
dilatation.
RUQ U/S ___: No evidence of cholelithiasis. Normal
gallbladder. No intra- or extra-hepatic biliary dilation.
FINGER(S) XR,2+VIEWS RIGHT ___: Pending
___ 06:00AM BLOOD WBC-2.9* RBC-3.34* Hgb-11.0* Hct-32.0*
MCV-96 MCH-33.1* MCHC-34.5 RDW-14.4 Plt ___
___ 06:00AM BLOOD Glucose-96 UreaN-2* Creat-0.7 Na-140
K-4.2 Cl-108 HCO3-22 AnGap-14
___ 06:00AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.7
Brief Hospital Course:
This is a ___ year old female with a past medical history of S-2
Tarlov cyst who is status post bilateral S1-S2 laminectomy in
___, rheumatoid arthritis, MCTD, recurrent osteomyelitis
and mixed connective tissue disease on prednisone who presents
with epigastric abdominal pain. On arrival to the MICU, the
patient was complaining of abdominal pain, but was
hemodynamically stable.
# Acute Pancreatitis: The patient presented with had epigastric
pain was found to have an elevated lipase an abdominal CT
notable only for chronic colitis. Given her clinical
presentation, she was treated for acute pancreatitis. She was
kept NPO and fluids were ressucitated aggressively with normal
saline. She continued to experience nausea, which was treated
with zofran prn. Her pain was controlled with her home dose of
oxycodone with dilaudid IV for breakthrough pain. Electrolytes
were monitored and repleted as neccessary. The etiology of her
pancreatiis is uncertian- she does report drinking 2
drinks/night, so there may be alcohol component. Additionally,
Rheumatology was consulted and expressed concern that her
symptoms may actually be due to vascutilits in the GI tract,
given the findings on CT and history of prior vasculitic event
___ led to amputation of the distal phalnyx on 3 fingers on
her right hand. ___ for this etiology, however, was
low. The reccomended consulting GI to biopsy her colon if she
failrs to improve. They also felt that is possible that recent
changes in her dose of topomax may have contriubuted to the
deveopment of disease, so this medication was discontinued.
Other etiologies, including infection, cholycystitis, and peptic
ulcer disease were considered. She was initially treated
empirically for infection with zosyn and flagyl, which was
discontinued after 3 days because the patient remained afebrile
during this admission and did not have a leukocytosis. She had a
RUQ ultrasound to evaluate for cholyistitis, which was
unremarkable. Pt was tolerating regular diet at time of dc. Was
dc-ed on increased doses of oxycontin and more frequent MSIR
#Connective Tissue Disease: When she was able to take POs, she
was continued on her home dose of prednisone and leflunomide.
She was found to have a wound on her right thumb. X-ray of the
thumb found no evidence of osteomylitis. Plastic surgery was
consulted and debrided the wound on ___. She was started on
vancomycin and metronidazole, which she will need to continue
for 7 days (until ___. Wound culture gre out MSSA so she
was started on keflex PO and improved. Was dc-ed home with wound
care instructions, script for keflex, and asked to set up f-up
with hand clinic.
#Hypertension: Her home anti-hypertension regimen was intitially
held due to concern for hypovolemia secondary to acute
pancreatitis. She was restarted on her home medications once she
regained the ability to tolerate POs. However, SBPs were high so
may need to be uptitrated as an outpt.
#Hx of chronic back pain secondary to tarlov cyst: She is on
large doses of narcotics at baseline. We continued her home
oxycodone and intiated treatment with dilaudid IV for
breakthrough pain. Was dc-ed on increased doses of oxycontin and
more frequent MSIR
# Possible EtOH abuse: The patient reports that she drinks 2
drinks per night. On admission, she had an AST/ALT ratio of
nearly 2:1. She was started on a CIWA protocol, but this was
discontinued after 2 days due to lack of withdrawal symptoms.
She was counseled about decreasing hr alcohol intake.
# GERD: She was continued on her home dose of pantoprazole.
#Hx of lupus anti-coagulant: Stable during this admission. She
was continued on her home medications.
# Asthma: No issues during this admission. She was continued on
albuterol nebs prn.
# Allergic rhinitis: Chronic, but stable currently. She was
continued on fluticasone and singulair. Her home dose of
azelastine was not on formulary and was held.
TRANSITIONAL ISSUES:
1. AUTOIMMUNE PANCREATITIS MAY BE EVALUATED WITH IGG4
2. MAY NEED UPTITRATION OF ANTI HTN MEDS
3. NEEDS ORTHO HAND F-UP
4. NEEDS DISCUSSION OF PAIN ___ as was uptitrated while in
___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Albuterol Sulfate (Extended Release) 90 mcg PO TID:PRN SOB
2. Amitriptyline 50 mg PO HS
3. Duloxetine 30 mg PO BID
4. Fexofenadine Dose is Unknown PO Frequency is Unknown
5. Furosemide 40 mg PO DAILY
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. NIFEdipine CR 90 mg PO DAILY
hold for sbp<100
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY
11. PredniSONE 10 mg PO EVERY OTHER DAY
12. Sildenafil 20 mg PO TID
13. Tizanidine 2 mg PO Q8H:PRN back pain
14. Topiramate (Topamax) 50 mg PO BID
15. DiphenhydrAMINE 25 mg PO BID
16. Docusate Sodium (Liquid) Dose is Unknown PO Frequency is
Unknown
17. Morphine Sulfate ___ ___ mg PO Q6H:PRN pain
18. Oxycodone SR (OxyconTIN) 60 mg PO Q12H
19. leflunomide *NF* 20 mg Oral qd
Discharge Medications:
1. Amitriptyline 50 mg PO HS
2. Docusate Sodium (Liquid) 100 mg PO DAILY
3. Duloxetine 30 mg PO BID
4. leflunomide *NF* 20 mg Oral qd
5. Montelukast Sodium 10 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
hold for sbp<100
7. Pantoprazole 40 mg PO Q24H
8. Sildenafil 20 mg PO TID
9. Tizanidine 2 mg PO Q8H:PRN back pain
10. PredniSONE 10 mg PO EVERY OTHER DAY
11. Albuterol Sulfate (Extended Release) 90 mcg PO TID:PRN SOB
12. Polyethylene Glycol 17 g PO DAILY
13. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth q6 Disp #*16 Tablet
Refills:*0
14. DiphenhydrAMINE 25 mg PO BID
15. Furosemide 40 mg PO DAILY
16. Metoprolol Succinate XL 150 mg PO DAILY
17. Topiramate (Topamax) 50 mg PO BID
18. Oxycodone SR (OxyconTIN) 80 mg PO Q12H
hold for sedation and rr<12
RX *OxyContin 80 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
19. Morphine Sulfate ___ 30 mg PO Q3H:PRN pain
hold for sedation, RR < 10
RX *morphine 80 mg 1 capsule(s) by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE PANCREATITIS
FALON ABSCESS
HYPERTENSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ for abdominal pain that is likely
secondary to acute pancreatitis. You improved with pain
medications, bowel rest and IV fluids. You were also noted to
have an infection of the thumb and improved with antibiotics.
You are being discharged home on antibiotics. Your pain
medications were also increased. You will need to followup with
your PCP for further ___ of your pain.
For your thumb, please follow the instructions given to ___ by
plastic surgery. Please dip your thumb in warm water or warm
water or betadine for 30 minutes thrice a Day after wick
removed. Please be sure to make it to your follow up appt.
Followup Instructions:
___
|
19661729-DS-9
| 19,661,729 | 21,040,967 |
DS
| 9 |
2163-05-06 00:00:00
|
2163-05-16 20:14:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Enbrel / Latex / Hayfever / Sulfa (Sulfonamide Antibiotics) /
Ace Inhibitors / Bactrim
Attending: ___.
Chief Complaint:
Abd Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o woman with PMHx S2 Tarlov Cyst s/p bilateral
S1-S2 laminectomy (___), RA, mixed connective tissues
disorder (on Prednisone) and recurrent osteomyelitis of R
fingers s/p amputation (___) presenting with with epigastric
abdominal pain x 1 day. She was admitted with a similar
presentation in ___, which was felt to be related to acute
pancreatitis. At that time her lipase was in the 200s; she was
made NPO and supported with IVF and her pain improved. Given her
h/o connective tissue disease, Rheumatology was consulted on
that admission and was concerned for vasculitis of the GI tract.
Biopsies of the antrum, duodenum and colon were performed and
were WNL.
.
She is well known to the GI service at ___ and has been
followed by Dr. ___ Dr. ___ her multiple GI
complaints. She last saw Dr. ___ in ___, at which time her
pancreatitis was felt to be EtOH realted. She has had normal
upper and lower endoscopies (___), normal MRCP (___) and a
normal barium swallow (___). She was seen by Dr ___ in GI
clinic ___ for her abnormal LFTs, at which time her hepatic
steatosis was also felt to be related to EtOH use. Viral
Hepatitis serologies were notable for HAV Ab positivity, but
were otherwise unremarkable. tTG-IgA was WNL, but ___ was
positive (1:160) with a negative anti SM Ab.
.
She states that she last ate the morning before admission. She
subsequently noted abd pain across the epigastrium that is
sharp, non-radiating and constant. There was associated nausea
and NBNB vomiting as well as a single episode of non bloody, non
melanotic diarrhea. She states that this feels exactly like her
previous pancreatitis flares. Denies recent travel, obstipation,
or abdominal surgery. She also denies recent antibiotic use. She
drank "a few" glasses of wine the evening prior to admission,
but does not think her EtOH use has been more than usual
recently. She states she has been trying to cut down on her EtOH
use at the advice of her various Gi doctors, but she does not
think this has helped at all. She has never had gall stones
before. Denies recent NSAID use. Denies fever, chills, chest
pain, shortness of breath, dysirua, urgency or frequency. All
other ROS negative.
.
In the ED, initial vitals were:
T 97.1 HR 59 BP 162/86 RR 28 O2 Sat 98% RA
Labs were notable for lactate 3.5, which normalized with IVF,
AST 74, ALT 54, HCO3 17, Lipase 31 and a normal CBC and UA. She
was given Morphine, Dilaudid and Zofran for symptom control. CT
Abd/Pelvis was unremarkable and was admitted to medicine.
.
On arrival to the floor, initial VS were:
T 98 BP 160/106 HR 90 RR 18 O2 Sat 99%RA
She was in obvious distress, writhing in bed, asking for Ativan
and Dilaudid.
Past Medical History:
-Mixed connective tissue disease (elements of rheumatoid
arthritis, scleroderma and SLE)
-Recurrent osteomyelitis status post amputation of right hand
fingers in ___
-Raynaud's disease
-Hypertension
-GERD
-Lupus anticoagulant
-Tarlov's cyst s/p Bilateral laminectomies S2, S1 and inferior
L5 for decompression with coagulation and reduction of Tarlov
cysts on ___
Social History:
___
Family History:
Father with coronary disease
Mother with uncontrolled diabetes
Also in her family are people with malignancy of stomach,
prostate, colon
Physical Exam:
Admission Exam:
T 98 BP 160/106 HR 90 RR 18 O2 Sat 99%RA
GENERAL - in obvious distress, though redirectable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, JVP not assesed
HEART - distant heart sounds, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - hypoactive bowel sounds, very slight TTP in the
epigastrium, 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, non focal
.
Discharge Exam:
T 98 BP 100-150/80-90 HR 90-100s RR 20 O2 Sat 98% RA
GENERAL - NAD, resting comfortably
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, JVP not assesed
HEART - distant heart sounds, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, very slight TTP in the epigastrium, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, non focal
Pertinent Results:
Admission Labs:
___ 03:53AM BLOOD WBC-5.3 RBC-4.37 Hgb-13.0 Hct-40.6 MCV-93
MCH-29.8 MCHC-32.1 RDW-14.8 Plt ___
___ 01:10PM BLOOD ___ PTT-76.4* ___
___:53AM BLOOD Glucose-86 UreaN-9 Creat-0.8 Na-142 K-3.8
Cl-108 HCO3-17* AnGap-21*
___ 03:53AM BLOOD ALT-54* AST-74* AlkPhos-80 TotBili-0.3
___ 03:53AM BLOOD Albumin-4.5 Calcium-9.0 Phos-3.9# Mg-1.7
___ 04:02AM BLOOD Lactate-3.5*
___ 01:10PM BLOOD IGG SUBCLASSES 1,2,3,4-Test
.
Discharge Labs:
___ 07:50AM BLOOD WBC-3.5* RBC-3.74* Hgb-11.6* Hct-35.1*
MCV-94 MCH-31.0 MCHC-33.0 RDW-14.4 Plt ___
___ 07:50AM BLOOD Glucose-90 UreaN-8 Creat-0.8 Na-137 K-4.1
Cl-108 HCO3-19* AnGap-14
___ 07:50AM BLOOD ALT-46* AST-59* CK(CPK)-384* AlkPhos-70
TotBili-0.6
___ 07:50AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.5* Mg-2.2
___ 07:01AM BLOOD Lactate-1.3
.
CT Abd/Pelvis (___):
LUNG BASES: The bases of the lungs are clear without nodules,
consolidations, or pleural effusions. The base of the heart is
normal. There is no pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There are
no focal
hepatic lesions. There is no intra- or extra-hepatic biliary
duct dilation. The gallbladder is not distended, and normal in
appearance. The spleen is normal. There are no focal splenic
lesions. The pancreas is normal with homogeneous enhancement
and no surrounding inflammatory changes. The bilateral adrenal
glands and bilateral kidneys are normal. There is no evidence
of pyelonephritis, hydronephrosis, or focal renal lesions.
The stomach and small bowel are unremarkable. There is no
evidence of
obstruction. There are no focal inflammatory changes. There is
no free air or free fluid. There is no mesenteric, abdominal,
or retroperitoneal
lymphadenopathy.
PELVIS: The colon is normal in course and caliber without
surrounding
inflammatory changes or obstruction. The appendix is not
definitely
visualized, although there are no secondary signs of
inflammation in the right lower quadrant.
An IUD is present within the uterus. The uterus is otherwise
unremarkable. The ovaries are normal in appearance. There is
no free fluid in the pelvis. There is no pelvic or inguinal
lymphadenopathy.
The soft tissues are unremarkable. There is no evidence of a
hernia.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
osseous
lesions. No fracture is identified. There are no significant
degenerative
changes.
IMPRESSION: No abdominal or pelvic abnormality to explain the
patient's pain.
.
RUQ Ultrasound (___):
1. No gallstones and no biliary dilatation.
2. Mild echogenicity of the liver consistent with mild fatty
infiltration.
Other forms of liver disease and more advanced liver disease
including
significant hepatic fibrosis/cirrhosis can't be excluded on this
study.
Brief Hospital Course:
Primary Reason for Admission: ___ y/o woman with PMHx S2 Tarlov
Cyst s/p bilateral S1-S2 laminectomy (___), RA, mixed
connective tissues disorder (on Prednisone) and recurrent
osteomyelitis of the digits s/p amputation (___) presenting
with ___ pancreatitis for the second time since ___
.
Active Problems:
.
# Abd Pain/Pancreatitis: CT abdomen and lipase WNL on admission,
RUQ ultrasound also unremarkable (see reports). Her current
presentation seems most consistent with her last admission for
pancreatitis, which resolved with supportive care and IVF,
though would note that during her admission in ___ her lipase
was elevated. Of her medications, Protonix, Lasix and
Montelucast are associated with pancreatitis. These were held;
would recommend discussion with PCP ___: benefits/risks of
continuing these. On discussion with radiology, no splenic or
other venous thrombus. Many other causes for her pain have been
ruled out with an extensive outpatient workup - appendicitis,
acute cholecystitis, bowel obstruction, colitis, PUD, IBD and
vasculitis are all extremely unlikely given her CT scan, normal
WBC count and previous workup. Nephrolithiasis is also possible,
but also less likely given UA without blood and her overall
clinical presentation. UCG negative in the ED. Would also note
that while NPO and receiving IV pain medications the patient was
surreptitiously taking POs; once this was discovered her IV pain
medications were d/c'ed and the patient asked to leave soon
thereafter.
.
# Hepatocellular Transaminitis: Likely related to EtOH use given
AST>ALT and otherwise unrevealing workup. Pt endorsed drinking
"a few" drinks daily in the days preceding admission. ___ was
positive (1:160) though anti SM Ab was negative. HBV negative
and HCV Ab negative. CT Abd/Pelvis and RUQ ultrasound were
largely unremarkable (see reports). Her outpatient Hepatologist
also felt her liver disease was likeyl EtOH related. The patient
was counseled on the importance of reducing her EtOH intake.
.
Chronic Problems:
.
# Lupus Anticoagulant: Confirmed via repeat testing; last seen
in ___ clinic in ___. She has never had arterial or venous
thromboembolic disease and is therefore only on ASA, which was
continued.
.
# Mixed Connective Tissues Disease: We continued her home
Prednisone and Leuflonamide
.
# HTN: We continued her home Nifedipine and Metoprolol
.
# Pain: We continued her home Cymbalta, Amitriptyline and
Fenyanyl patch
.
# GERD: We continued her home Protonix
.
# Perihperal Edema: We held her home Lasix while NPO
.
Transitional Issues:
# f/u with Liver, GI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID;PRN wheezing
2. Amitriptyline 50 mg PO HS
3. Baclofen 10 mg PO TID
4. Duloxetine 30 mg PO BID
5. Fentanyl Patch 75 mcg/h TP Q72H
6. Furosemide 40 mg PO DAILY
7. leflunomide *NF* 20 mg Oral daily
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
please hold for sedation, RR <12
11. NIFEdipine CR 90 mg PO DAILY
hold for SBP <100
12. ondansetron *NF* 4 mg Oral Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q24H
14. PredniSONE 10 mg PO DAILY
15. sildenafil *NF* 20 mg Oral TID
16. Polyethylene Glycol 17 g PO DAILY
17. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH TID;PRN wheezing
2. Amitriptyline 50 mg PO HS
3. Baclofen 10 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 30 mg PO BID
6. Fentanyl Patch 75 mcg/h TP Q72H
7. leflunomide *NF* 20 mg Oral daily
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
10. NIFEdipine CR 90 mg PO DAILY
11. ondansetron *NF* 4 mg Oral Q8H:PRN nausea
12. PredniSONE 5 mg PO DAILY
13. sildenafil *NF* 20 mg Oral TID
14. Furosemide 40 mg PO DAILY
15. Montelukast Sodium 10 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Idiopathic Chronic Pancreatitis
Secondary Diagnosis:
Mixed Connective Tissue Disorder
RA
Lupus Anticoagulant
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 the ___
___. You were admitted with abd pain, which is likely
related to your pancreatitis. For this, we gave you medications
and fluids to allow your pancreas to heal. You are now safe to
leave the hospital. We would recommend you discuss some of the
medications that you take with your PCP, as they can cause
pancreatitis. Thank you for allowing us to participate in your
care.
Followup Instructions:
___
|
19661870-DS-12
| 19,661,870 | 22,386,235 |
DS
| 12 |
2187-03-19 00:00:00
|
2187-03-19 17:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Cardizem / Morphine / Vancomycin /
Penicillins / Propofol Analogues / glucose gel / gabapentin /
Nortriptyline / nystatin
Attending: ___.
Chief Complaint:
Cervical Cord Compression
Major Surgical or Invasive Procedure:
___: anterior cervical spine decompression
History of Present Illness:
___ year old Male presents with progressive weakness and back
pain after sustaining a fall 2 weeks and then 2 days prior to
admission. The patient notes that his weakness and pain have
progressed over the last several weeks although his family tells
me symptoms started in ___, and that he fell due to the
weakness 2 days prior to admission. He denies cauda-equina
symptoms. In the fall 2 days prior to admission he did have a
frontal head strike, where he struck the night stand. He did not
have LOC or post-concussive symptoms. He reports severe pain in
both shoulders/clavicles and is unable to raise his arms past 90
degrees. He has had chronic weakness of the right foot with foot
drop, which is worse.
In the ED they were concerned for cervical cord compression as
they elicited myelopathy signs on exam, so an urgent C/T Spine
MRI was performed and orthospine was consulted. The MRI was
positive for cord compression, and so will require decompression
and fusion of the C-Spine. The patient will require medical
optimization prior to going to surgery.
In the ED initial vitals were: 97.8, 149/57, 71, 97%.
Past Medical History:
CAD
--s/p MI ___ with PCI to LAD ___
--s/p CABGx4 ___ (Lima-LAD, SVG-D1, SVG-OM, SVG-PDA), after
pre-op cath before arthroplasty revealed 3VD
Type 2 DM on insulin
Hypertension
Hyperlipidemia
Obesity
trivial MR ___ on ___ ___ that was otherwise normal with
EF>55%)
chronic peripheral edema
proteinuria and CKD (baseline Cr 1.4)
depression
glaucoma
tobacco use
peripheral neuropathy
low back pain
s/p lumbar spinal fusion ___
s/p lumbar laminectomy ___
s/p lipoma excision from right forearm ___
s/p removal of bone spurs from knees bilaterally
s/p right hip arthroplasty ___
Social History:
___
Family History:
Father-CAD
Mother-Type 2 DM
Physical Exam:
ADMISSION:
Vitals - T: 97.6 BP: 118/68 HR: 64 02 sat: 100%RA
GENERAL: Mildly uncomfortable but well appearing man sitting up
in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, NECK: JVP to ear
CARDIAC: RRR, soft heart sounds, no murmurs, gallops, or rubs
LUNG: End expiratory rhonchi with no wheeze or crackles, reduced
breath sounds throughout
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: ___ with bilateral purplish hue, warm to touch, 2+
edema bilaterally to knees
PULSES: Reduced pedal pulses bilaterally, 2+ popliteal pulse
bilaterally
BACK: Minimal tenderness to palpation over lumbar spine
NEURO: CN II-XII intact, moving extremities equally against
gravity
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
PHYSICAL EXAM:
Vitals - 97.3, 70, 115/79, 98% on RA
GENERAL: alert and awake
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, NECK: surgical dressings c/d/i
CARDIAC: RRR, soft heart sounds, no murmurs, gallops, or rubs
LUNG: decreased breath sounds at L>R baseline
ABDOMEN: obese, NT, no rebound or guarding
SKIN: warm and well perfused, no excoriations or lesions,
erythema bilaterally of feet
Ext: trace pitting edema bilaterally to ankles, TEDS in place
Pertinent Results:
ADMISSION LABS:
___ 10:42PM BLOOD WBC-11.1* RBC-3.82* Hgb-11.1* Hct-32.0*
MCV-84 MCH-29.0 MCHC-34.6 RDW-15.3 Plt Ct-UNABLE TO
___ 10:42PM BLOOD Neuts-68 Bands-0 Lymphs-17* Monos-9 Eos-3
Baso-1 Atyps-2* ___ Myelos-0
___ 10:42PM BLOOD ___ PTT-31.8 ___
___ 10:42PM BLOOD Glucose-245* UreaN-111* Creat-2.5* Na-137
K-4.1 Cl-93* HCO3-28 AnGap-20
___ 10:42PM BLOOD CK(CPK)-1144*
___ 10:42PM BLOOD Calcium-9.8 Phos-5.3* Mg-2.4
___ 10:42PM BLOOD CRP-7.2*
DISCHARGE LABS:
___ 10:19AM BLOOD WBC-17.7* RBC-3.66* Hgb-10.3* Hct-31.8*
MCV-87 MCH-28.3 MCHC-32.5 RDW-15.2 Plt Ct-UNABLE TO
___ 06:10AM BLOOD Glucose-173* UreaN-90* Creat-1.9* Na-142
K-4.6 Cl-100 HCO3-26 AnGap-21*
___ 06:10AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.5
IMAGING:
MR ___ CONTRAST Study Date of ___ 2:32 AM
Wet Read by ___ on SAT ___ 4:17 AM
Severe multilevel cervical spondylosis with multilevel disc
bulges resulting in flattening of the spinal cord from C3
through C7. Increased T2 signal in the left aspect of the spinal
cord at the level of C2-3 either represents myelomalacia or cord
edema however the lack of spinal cord enlargement at this level
favors myelomalacia. No prevertebral soft tissue edema. Moderate
anterolisthesis of C7 on T1.
Scout views of the lumbar spine are included, however the
patient aborted the examination prior to diagnostic quality
images being obtained. There is evidence of prior lumbar spine
surgery.
Brief Hospital Course:
___ y M with complicated medical hx including CAD s/o CABG, DM,
COPD, CKD, CHF, ?autoimmune sz who presented with progressive
back pain, generalized weakness and associated recent fall,
found to have cord compression and admitted to medicine for
optimization prior to surgery.
ACTIVE MEDICAL ISSUES:
#Cord compression with cervical myelopathy:
Pt presented with pain, increased weakness, and imaging findings
with cervical spinal stenosis/cord compression. No bowel/bladder
changes and mild tenderness to palpation. Pt went to OR on ___nterior approach. His pain was managed with
oxycodone and APAP. Pt was evaluated by ___ who recommended home
with ___. Per ortho spine, plan for posterior approach surgery
which will be done as an outpatient. Pt offered MRI L spine
prior to discharge in preparation for surgery however he
preferred to have as outpatient. Pt will also need outpatient
follow up with cardiologist, vascular and PCP for surgical risk
stratification
#Acute on chronic diastolic CHF: Patient with evidence of volume
overload and mild respiratory symptoms on admission. He was
diuresed prior to surgery. No ___ available since ___, when
LVEF >55%. Pt's respiratory status improved prior to OR although
received 1.8L intra-op. He was able to be weaned back to room
air and restarted on home diuretics prior to discharge. He was
continued on home ACE-in and beta blocker.
CHRONIC MEDICAL ISSUES:
#CAD: Pt continued on home BB, ___, statin
# Type 2 Diabetes Uncontrolled with Complications: Pt continued
on home glargine and HISS
#CKD Stage 3: Baseline Cr appears to be in low 2s. BUN/Cr on
admission slightly worse than prior but likely minimal change in
GFR with Cr increased from 2.3->2.5. His Cr downtrended to 1.9
on discharge.
#?Autoimmune dz: Unclear dx, chronically elevated CK and CRP
with no significant change from ___.
#Glacuoma: Pt continued on home Latanoprost
TRANSITIONAL ISSUES:
[] MRI L spine with and without contrast as outpatient prior to
second stage of surgery
[] PCP risk stratification as well as follow up with vascular
surgery for further risk stratification
[] Pt needs to wear c collar when ambulating or driving in car
[] Leukocytosis noted on discharge, likely in setting of recent
surgery. Will need follow up cbc in ___ weeks as outpatient to
ensure resolution
[] Pt's home 80 mg lasix restarted at discharge. He will also
restart metolozone 5mg 2x per week.
[] Weight on discharge: 237 lb
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
3. Zolpidem Tartrate ___ mg PO QHS insomnia
4. Metoprolol Succinate XL 400 mg PO DAILY
5. Pravastatin 80 mg PO QPM
6. Furosemide 80 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4-6H:PRN pain
8. alpha lipoic acid ___ mg oral daily
9. Nystatin-Triamcinolone Cream 1 Appl TP BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Aspirin 325 mg PO DAILY
12. Citalopram 20 mg PO DAILY
13. Metolazone 5 mg PO 2X/WEEK (___) edema, wt gain
14. Calcitriol 0.25 mcg PO 3X/WEEK (___)
15. Glargine 84 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Home dose
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcitriol 0.25 mcg PO 3X/WEEK (___)
3. Citalopram 20 mg PO DAILY
4. Furosemide 80 mg PO DAILY
5. Glargine 84 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Home dose
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Lisinopril 40 mg PO DAILY
8. Nystatin-Triamcinolone Cream 1 Appl TP BID
9. Pravastatin 80 mg PO QPM
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
11. alpha lipoic acid ___ mg oral daily
12. Metolazone 5 mg PO 2X/WEEK (___) edema, wt gain
13. Metoprolol Succinate XL 400 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4-6H:PRN
pain
15. Zolpidem Tartrate ___ mg PO QHS insomnia
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Cervical spine cord compression
Acute on chronic systolic heart failure exacerbation
SECONDARY:
CAD
CKD
DM
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 taking care of you during your stay at ___
___. You were admitted to the hospital with neck and back
pain. You were found to have a compression of your spinal cord.
You had surgery to help fix this. You will need the second part
of the surgery in ___ weeks with the spine surgeons. Before you
have this surgery, it is very important that you come back to
___ for an outpatient Lumbar MRI as we have discussed. Please
call Dr. ___ office to schedule this as well as schedule
your surgery. It is also very important that you wear your
cervical collar when walking or driving in the car. This is very
important. You will have a visiting nurse to help with wound
care.
You were also found to be in heart failure when you came into
the hospital. You received IV lasix (waterpill) to help get
fluid off. Your breathing improved and you were put back on your
oral lasix dose. Please be sure to weigh yourself daily and call
you cardiologist if you weight changes by >3 lb. It is very
important that you follow up with your cardiologist as an
outpatient.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19662586-DS-4
| 19,662,586 | 23,040,121 |
DS
| 4 |
2163-09-18 00:00:00
|
2163-09-18 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Left foot pain and swelling
Major Surgical or Invasive Procedure:
Joint arthrocentesis
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ is a ___ year old male with a history of chronic C4
glomerulonephritis and proteinuria presenting after a recent
trip to ___ with swelling and pain in his left foot.
Patient states that he returned from ___ on ___ at
which point some swelling on the distal portion of his left
plantar foot. He states that he then developed swelling and pain
in his left ankle. Over the weekend, the pain increased to the
point where he was unable to tolerate much activity at all. He
took a dose of ibuprofen for pain relief. He states that he was
unable to ambulate on the ankle. Pt reports developing similar
swelling in his ankles roughly a year ago that prevented him
from getting off the couch for a few days. He states that over
roughly 10 days, his symptoms improved spontaneously. For this
episode, he was able to go to a PCP visit today where labs
demonstrated a WBC of 16 and D-dimer of 1646 prompting concern
for an infectious process vs. VTE. MRI of his left foot and
ultrasound of his LLE were also obtained and pt received CTX 1g
IV x 1. Of note, pt's MRI foot did not show evidence of OM, but
did show possible tibiotalar joint effusion and MTP joint
effusion with findings possible consistent with gout. In
addition, the LLE U/S was negative for DVT. Pt was referred to
the ED for further evaluation.
In the ED, initial vital signs were: 98.3 94 137/75 17 100% RA
- Exam was notable for: Intact distal pulses and sensation is
intact, the left foot and calf are both swollen and tender to
palpation
- Labs were notable for: WBC 15.3, H/H 9.7/29.1, plts 240, Na
138, BUN/Cr ___ from baseline , CRP 139.1.
- UA pH 6.0, SG 1.017, 300 protein, 40 WBC, 46 RBC, lg blood,
sm leuks, neg nitrites
- Imaging: Left foot and ankle X-ray without fracture, but
evidence of DJD; LLE ultrasound without DVT.
- The patient was given: Percocet x 2
- Consults: Orthopedics was consulted in the ED and believed
that there was low likelihood for osteomyelitis or septic joint,
but did believe the presentation was consistent with gout flare.
Pt was also seen by vascular surgery who believed the problem
was not vascular, but likely represents gout vs. other
arthritis.
Vitals prior to transfer were: 99.0 73 129/71 15 100% RA
Upon arrival to the floor, pt reports that the Percocet was
ineffective and his ankle is very painful to minimal touch. In
addition, he states that the first MTP on his right foot is
beginning to feel painful.
REVIEW OF SYSTEMS: Negative except as above.
Past Medical History:
Chronic C3 glomerulopathy
Proteinuria
Social History:
___
Family History:
FAMILY HISTORY:
No family history of GN
Father with history of gout
Physical Exam:
ADMISSION EXAM
==============
VITALS: 100.4 142/75 77 18 100% on RA, Wt 87.8 kg
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
NECK: Supple.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Left ankle warm with palpable effusion and TTP,
left ___ MTP mildly tender with some warmth, right ___ MTP
mildly tender.
SKIN: Without rash.
NEUROLOGIC: A&Ox3.
DISCHARGE EXAM
==============
Vitals: T:98.1 BP:132/76 P:66 R:18 O2:100RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
NECK: Supple.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Left ankle warm with palpable effusion and TTP
diffusely, left ___ MTP mildly tender with some warmth, no
overlying skin erythema, right ___ MTP tender to light palpation
without swelling or erythema. full ROM at right ankle joint.
limited active and passive ROM at left ankle joint due to severe
pain and swelling. remainder of joint exam was wnl.
SKIN: Without rash.
NEUROLOGIC: A&Ox3.
Pertinent Results:
ADMISSION LABS
==============
___ 08:45PM URINE MUCOUS-RARE
___ 08:45PM URINE GRANULAR-3* HYALINE-22*
___ 08:45PM URINE RBC-46* WBC-40* BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 08:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:45PM URINE GR HOLD-HOLD
___ 09:26PM ___ PTT-30.7 ___
___ 09:26PM PLT COUNT-240
___ 09:26PM NEUTS-80.9* LYMPHS-11.3* MONOS-7.1 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-12.38* AbsLymp-1.73 AbsMono-1.08*
AbsEos-0.01* AbsBaso-0.02
___ 09:26PM WBC-15.3* RBC-3.25* HGB-9.7* HCT-29.1* MCV-90
MCH-29.8 MCHC-33.3 RDW-12.3 RDWSD-39.8
___ 09:26PM CRP-139.1*
___ 09:26PM estGFR-Using this
___ 09:26PM GLUCOSE-125* UREA N-28* CREAT-1.5* SODIUM-138
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-15.0* RBC-3.01* Hgb-8.9* Hct-26.9*
MCV-89 MCH-29.6 MCHC-33.1 RDW-12.1 RDWSD-39.0 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-132* UreaN-30* Creat-1.3* Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
___ 07:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
STUDIES
=======
Left lower extremity ultrasound
No evidence of deep venous thrombosis in the left lower
extremity veins.
Left Foot Xray
No fracture or dislocation. Degenerative changes, as noted
above with areas of spurring and small fragments at the
tibiotalar joint, possibly related to prior injury.
MICRO
=====
URINE CULTURE (Final ___: NO GROWTH.
Joint Fluid:
GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION (Pending):
___ 04:45PM JOINT FLUID ___ Polys-98*
___ ___ 04:45PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-I/E Birefri-NEG Comment-c/w monoso
Brief Hospital Course:
___ year old with chronic C4 glomerulopathy and proteinuria
presenting with a polyarticular inflammatory arthritis, also
found to have ___.
ACTIVE ISSUES
=============
# Acute Gouty Polyrthritis: Left foot swelling with isolated
tenderness to left MTP and also right MTP joints was most
consistent with gout. He was evaluated by orthopedics and
vascular surgery in the ED, given elevated D dimer on outpatient
labs. Left lower extremity dopplers were negative for DVT. There
was low suspicion for septic joint. Rheumatology was consulted.
Arthrocenteis was performed with negative ___, <50,000 WBC, and
needle Monosodium Urate Crystals with negative birefrig
consistent with gout flare. He was given 60mg PO Prednisone with
improvement in his swelling and pain. He was discharged on a PO
prednisone taper, with initiation of colchicine and allopurinol
daily for gout prophylaxis. He will have follow up with a
rheumatologist at ___ as an outpatient. CCP was negative (<16),
RF was 20 and Urine GC/Chlamydia was negative. Joint fluid
culture results were pending at the time of discharge but were
preliminarily no growth.
# ___ on CKD, C3 GN: Pt presented with Cr 1.6 from baseline 1.3
in the setting of recent NSAID use and inflammatory arthritis.
Cr returned to baseline s/p IVF and holding NSAIDS. Home
lisinopril was restarted and he was set up to see a nephrologist
in the outpatient setting on ___. Protein/Cr ratio was elevated
at 12.3 on admission, to be follow up on the day after discharge
in Nephrology as an outpatient.
CHRONIC ISSUES
==============
# Hypertension: Continued home lisinopril
# Nasal congestion: Continued home Flonase
TRANSITIONAL ISSUES
===================
# Gout/Rheumatology
- Final joint fluid culture pending at discharge
- Patient will need Rheumatology follow up upon discharge, to be
arranged by PCP through ___.
- Started on daily colchicine 0.6mg and allopurinol ___ for
prophylaxis. To be continued daily unless otherwise directed in
Rheumatology follow up.
- Recommend eating red meat and drinking alcohol in moderation
to avoid precipitating gout attacks.
- Prednisone taper
___: 50mg
___: 40mg
___: 30mg
___: 20mg
___: 10mg
___: 5mg
___: Stop
# C3 glomerulopathy and proteinuria
- Patient with scheduled Nephrology follow up on ___
- Holing NSAIDs on discharge
# CONTACT: ___ (partner) ___
# CODE STATUS: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
3. Vitamin D ___ UNIT PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Vitamin D ___ UNIT PO 1X/WEEK (MO)
4. PredniSONE 10 mg PO DAILY Duration: 18 Days
Take 5 pills x1day, Then 4 pills x3day; 3 pills x3day,2 pill
x3day,1 pill ___ pill x3 days.
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily starting ___
Disp #*37 Tablet Refills:*0
5. Lisinopril 10 mg PO DAILY
6. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gout
Secondary Diagnosis
C3 glomerulopathy and proteinuria
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were admitted with swelling in
your left foot and pain in your right foot. You were given
steroids and your symptoms improved. The Rheumatologists sampled
the fluid in your ankle and this showed signs consistent with
gout. Please continue taking the Prednisone according to the
following taper:
___: 50mg (5 pills)
___: 40mg (4 pills)
___: 30mg (3 pills)
___: 20mg (2 pills)
___: 10mg (1 pill)
___: 5mg ___ pill)
___: Stop
You will also start taking the medications Colchicine and
Allopurinol daily, which will help to prevent gout attacks in
the future.
Please follow up with your nephrologist on ___ and
discuss whether or not it is safe to resume taking your NSAIDs.
If you are in pain, it is safe to take Tylenol.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
19662699-DS-17
| 19,662,699 | 21,559,268 |
DS
| 17 |
2139-08-21 00:00:00
|
2139-08-21 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cipro
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of bipolar disorder who is ___ s/p recent
laparoscopic cholecystectomy ___ with Dr. ___ who presented to the ER today with complaint of
nausea, emesis, and abdominal pain x 1 day. The patient reports
eating this morning and experiencing sudden-onset severe
post-prandial RUQ/epigastric abdominal pain with associated
nausea. The pain was non-radiating. She subsequently had
multiple
bouts of non-bloody, reportedly bilious emesis and has been
unable to tolerate oral intake since. Last BM was ___ prior
to
surgery but she reports she is passing flatus. Does not feeling
distended. Has been taking 5mg oxycodone q8hours at home
post-operatively. Denies fevers, chills, chest pain, SOB.
Past Medical History:
PMH:
Bipolar d/o
Graves disease
DJD
HTN
HL
PSH:
lap cholecystectomy ___
left total knee replacement
Social History:
___
Family History:
FH: noncontributory
Physical Exam:
VS: 98.4 152/77 73 16 94RA
GEN: Pleasant female in NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CARDIAC: RRR, no murmurs
CHEST: No increased work of breathing, (-) cyanosis.
ABDOMEN: soft, non-tender, non-distended, port incision sites
are c/d/i
EXTREMITIES: Warm, well perfused, no edema
NEURO: AA&O x 3
Pertinent Results:
___ 01:33PM BLOOD WBC-15.8*# RBC-4.90 Hgb-14.1 Hct-45.6*#
MCV-93 MCH-28.8 MCHC-30.9* RDW-12.0 RDWSD-41.7 Plt ___
___ 09:41AM BLOOD WBC-15.0* RBC-4.31 Hgb-12.5 Hct-39.2
MCV-91 MCH-29.0 MCHC-31.9* RDW-11.9 RDWSD-39.8 Plt ___
___ 05:10AM BLOOD WBC-11.8* RBC-3.99 Hgb-11.6 Hct-35.8
MCV-90 MCH-29.1 MCHC-32.4 RDW-12.1 RDWSD-40.2 Plt ___
___ 01:33PM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-138
K-5.6* Cl-99 HCO3-25 AnGap-20
___ 12:14AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-101 HCO3-23 AnGap-17
___ 05:20AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-140 K-3.9
Cl-101 HCO3-27 AnGap-16
___ 05:10AM BLOOD Glucose-93 UreaN-7 Creat-0.5 Na-135 K-3.5
Cl-100 HCO3-24 AnGap-15
___ 03:08PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 01:33PM BLOOD ALT-38 AST-60* AlkPhos-90 TotBili-0.4
___ 05:20AM BLOOD ALT-28 AST-23 AlkPhos-93 TotBili-0.5
Brief Hospital Course:
The patient is a ___ with history of bipolar disorder who
presented to the ER on ___ s/p laparoscopic cholecystectomy
___ with Dr. ___ with complaint of nausea,
emesis, and abdominal pain x 1 day. Her labwork was notable for
a WBC of 15.8 but LFTs were normal. CT abdominal imaging
demonstrated no drainable fluid collections and no evidence of
bowel perforation or obstruction. Cardiac work-up (EKG,
troponins) were negative. Given the patient's po intolerance and
leukocytosis without clear source, she was admitted for
observation, IV fluid hydration, and IV anti-nausea medication.
Her nausea and pain gradually improved with Zofran and a
scopolamine patch. Her diet was advanced from clears to regular,
which she tolerated by time of discharge. She will go home with
a prescription for standing Zofran for 4 days and then prn
Zofran subsequently. Her WBC improved from 15.8 to 15 to 11.8 by
time of discharge. She remained afebrile and hemodynamically
stable.
During her stay, she was also noted to be hypertensive with SBP
between 150-170. She was therefore started on amlodipine 5mg
with good results. She was advised to follow up with her primary
care physician ___ 1 weeks regarding blood pressure management.
She will follow up in general surgery clinic in ___ weeks as
previously scheduled.
Medications on Admission:
Trazodone 100 qHS
Gabapentin 300''
Trileptal 300'
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID
Hold for loose stools.
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
5. Gabapentin 300 mg PO BID
6. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
post-operative nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the general surgery service two days after
having your gallbladder removed with abdominal pain, nausea, and
vomiting. You were rehydrated with IV fluids and given
anti-nausea medication with good effect. Your pain improved.
You tolerated a regular diet and your labwork normalized prior
to discharge home. You should continue taking zofran every 8
hours at home for the next 4 days then only as needed. You
should continu a bowel regimen at home (senna, colace, and
miralax if needed). You should follow up in general surgery
clinic in ___ weeks as previously scheduled.
Please follow the discharge instructions 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 should continue to walk several
times a day.
- 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.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
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 surgery.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you should take a stool softener
(such as Colace, one capsule) or gentle laxative (such as senna
and/or miralax). You can get 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:
- You were previously discharged after surgery with a
prescription for oxycodone for pain control. You may take
Tylenol as directed, not to exceed 3500mg in 24 hours. Take
regularly for a few days after surgery but you may skip a dose
or increase time between doses if you are not having pain until
you no longer need it. You may take the oxycodone for moderate
and severe pain not controlled by the Tylenol. You may take a
stool softener while on narcotics to help prevent the
constipation that they may cause. Slowly wean off these
medications as tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
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.
WOUND CARE:
- dressing removal: Your outer dressing is already removed.
-You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off.
Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon is you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team
Followup Instructions:
___
|
19662788-DS-3
| 19,662,788 | 23,858,922 |
DS
| 3 |
2116-10-05 00:00:00
|
2116-10-09 15:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Penicillins / lisinopril / Augmentin
Attending: ___.
Chief Complaint:
L hip fracture
Major Surgical or Invasive Procedure:
___ Left TFN (Trochanteric Fixation Nail)
History of Present Illness:
Mrs. ___ is a ___ with cerebral vascular dementia, prior
stroke, prior left hip surgery (closed reduction percutaneous
pinning), and is wheelchair bound at baseline who presented ___
with left hip pain. Mrs. ___ lives in a nursing home and is
AOx1 and minimally verbal at baseline, but coherent. Per Niece,
___ ___, HCP), patient does not ambulate at
all at her nursing home and is unsure how she sustained a fall.
Past Medical History:
Cerebral vascular dementia
Anemia
Stroke
HTN
DM
Left Hip CRPP (closed reduction, percutaneous pinning) ___
at ___
Social History:
___
Family History:
Diabetes in father, niece
Physical ___:
Vitals: stable
General: Baseline oriented x1.
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: Tachycardia, Nl S1, S2, No MRG
Abdomen: soft, NT/ND, no rebound tenderness or guarding, no
organomegaly
Neuro: CN difficult to assess due to participation, No facial
droop or dysarthric speech. able to move all extremities ___
strength.
Extremities:
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- Mild deformity to left proximal thigh.
- Painful to attempted ROM of left hip and knee.
- Palpable distal pedal pulses.
DISCHARGE EXAM:
Vitals: 97.1 149 / 68 91 20 98
General: Baseline oriented x1.
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, NT/ND, no rebound tenderness or guarding, no
organomegaly
GU: No foley.
Ext: warm, well perfused. L hip with clean, intact, dry dressing
without surrounding erythema. Bruising along L knee.
Neuro: CN difficult to assess due to participation, No facial
droop or dysarthric speech. able to move all extremities.
Pertinent Results:
ADMISSION LABS:
___ 02:20AM BLOOD WBC-21.1* RBC-2.37* Hgb-8.1* Hct-25.9*
MCV-109* MCH-34.2* MCHC-31.3* RDW-17.1* RDWSD-65.7* Plt ___
___ 02:20AM BLOOD Neuts-86* Bands-1 Lymphs-7* Monos-6 Eos-0
Baso-0 ___ Myelos-0 NRBC-1.4* AbsNeut-18.36*
AbsLymp-1.48 AbsMono-1.27* AbsEos-0.00* AbsBaso-0.00*
___ 02:20AM BLOOD Hypochr-NORMAL Anisocy-3+
Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-1+
Ovalocy-OCCASIONAL
___ 02:20AM BLOOD ___ PTT-21.1* ___
___ 02:20AM BLOOD Glucose-345* UreaN-45* Creat-0.9 Na-143
K-4.3 Cl-104 HCO3-29 AnGap-14
___ 02:20AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.3
INTERVAL LABS:
___ 12:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 12:15PM URINE RBC-1 WBC-41* Bacteri-FEW Yeast-NONE
Epi-1
___ 12:15PM URINE CastGr-1* CastHy-4*
___ 06:06AM BLOOD WBC-11.9* RBC-2.02* Hgb-6.7* Hct-21.4*
MCV-106* MCH-33.2* MCHC-31.3* RDW-20.7* RDWSD-78.9* Plt ___
DISCHARGE LABS:
___ 10:40AM BLOOD WBC-12.6* RBC-2.89* Hgb-9.4* Hct-29.9*
MCV-104* MCH-32.5* MCHC-31.4* RDW-20.9* RDWSD-74.9* Plt ___
___ 10:40AM BLOOD Glucose-228* UreaN-18 Creat-0.8 Na-139
K-4.5 Cl-105 HCO3-21* AnGap-18
___ 05:56AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
MICROBIO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ DX PELVIS AND FEMUR
1. Comminuted proximal left intertrochanteric femur fracture.
2. Suspected left proximal tibial fracture.
___ FEMUR (AP AND LAT) LEFT IN OR
Steps related to intramedullary rod and dynamic screw fixation
of proximal
left femoral periprosthetic fracture are noted. Hardware appears
intact,
without evidence of complication.
Total fluoroscopy time: 126.1 seconds.
___ Chest XR
Lungs clear. Heart size normal. Thoracic aorta tortuous but
not dilated. No pleural abnormality.
___ KNEE (AP, LAT AND OBLIQUE) LEFT
Degenerative changes. No acute bony injury seen.
Brief Hospital Course:
Mrs. ___ is a ___ with cerebral vascular dementia, prior
stroke, prior left hip surgery (closed reduction percutaneous
pinning), and is wheelchair bound at baseline who presented with
a periprostethic left interotrochanteric fracture. She was taken
to the OR on ___ for screw removal and TFN (Trochanteric
Fixation Nail) by the orthopedic surgery service and was
subsequently transferred to medicine for treatment of delirium
and sepsis.
#Sepsis: After the operation, the patient developed elevated WBC
to 25.4 (up from 19.9 prior to surgery), was tachycardic to 118,
had a RR of 18, had a low grade fever of 100.6, and was
reportedly delirious. UA was positive; urine culture had mixed
flora. Chest XR negative. Treated with IVF and 7d of Cipro
250mg BID (last day ___ for presumed urosepsis. The patient
was at her baseline mental status by time of discharge.
# S/P Left trochanteric repair: Patient found to have a
periprostethic left interotrochanteric fracture with extension
into her screws. She went to the OR with orthopedic surgery on
___ for removal of the deep implant and intramedullary nailing.
On ___, the patient had a hemoglobin of 6.7 which required a
transfusion of 1 unit of blood. Thereafter, CBC and VS were
stable. The patient was WBAT LLE for transfer to wheelchair in
the LLE extremity, and was discharged on Lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___ on
___.
# Ecchymosis on labia majora: The patient also was found to have
ecchymosis on her left labia majora after the operation. Per
ortho, this is commonly seen post surgery secondary to
positioning during the operation.
CHRONIC:
#Dementia/functional quadriplegia: Patient has baseline cerebral
vascular dementia and requires help with all ADLs.
#Depression: Patient was continued on home mirtazapine
#Insomnia: Patient was continued on home trazadone
#Type 2 DM: Home metformin held on admission. Covered with SSI
while in the hospital
TRANSITIONAL:
#Antibiotics: Started on 7d of cipro 250 BID for sepsis. Last
day ___
#Anticoagulation: Lovenox 40mg SC was started and should
continue daily for 4 weeks. Last day ___
#Diabetes: Patient on metformin at nursing facility for
diabetes. Given that her estimated GFR is ___, please consider
discontinuing and covering with a long acting insulin instead,
due to risk of lactic acidosis.
#Nutrition: Best diet with least aspiration risk assessed to be
pureed diet with nectar thick liquids. Nutrition recommended
nutritional supplement: nectar thickened Glucerna Shake TID.
Daily multivitamin.
#Safety: Patient non-ambulatory at baseline, unclear how patient
fell and broke leg. Nursing facility/DPH to conduct
investigation.
#F/u: Follow up with Dr. ___ on ___
# CODE STATUS: DNR/DNI based on MOLST
# CONTACT: HCP: Niece, ___ ___
Medications on Admission:
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Mirtazapine 22.5 mg PO QPM
3. TraZODone 37.5 mg PO QPM:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 250 mg PO Q12H
3. Enoxaparin Sodium 40 mg SC DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Mirtazapine 22.5 mg PO QPM
6. TraZODone 37.5 mg PO QPM:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L periprosthetic IT fx
Urosepsis
Dementia
Discharge Condition:
Mental Status: AOx1. Minimally verbal.
Level of Consciousness: Alert and interactive.
Activity Status: Wheelchair bound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for a left hip fracture. You were
taken to the operating room, and had a nail fixation for the
fracture. You should follow up with the orthopedic team on
___. Please see your visit instructions below.
After the operation, you had an infection in your bladder. You
were treated with antibiotics, which you should continue to take
until ___.
Sincerely,
Your ___ Team
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks. Last day ___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
19662810-DS-11
| 19,662,810 | 23,874,248 |
DS
| 11 |
2149-12-02 00:00:00
|
2149-12-06 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Transesophageal Echo (___)
History of Present Illness:
___ with history of severe aortic stenosis, CAD s/p DES x2 to
LAD
in ___, MGUS with newly worsening anemia of unclear etiology,
presenting with 2 weeks of progressive shortness of breath, with
ED visit complicated by a syncopal episode.
Briefly, pt reports increasing dyspnea with minimal exertion
over
the last few weeks. He does not have orthopnea or chest
pain/pressure (notably did have chest pain prior to undergoing
stent placement in ___, though does endorse occasional
palpitations. He notes somewhat stable vs slightly worse
bilateral lower extremity edema which he attributes to
amlodipine, though has not had any weight gain despite the
edema.
With regard to his syncopal episode, pt states he was in the ED
and got up to go to the bathroom. He walked over to the sink and
became light headed. He thinks he may have been short of breath
as well, but was not having chest pain or nausea. He then fell
to
the ground, which has never happened before. He was found by the
nurse after hearing a loud thump and was noted to have lost
consciousness; he was also diaphoretic and tachycardic. He awoke
after 30 seconds and improved with IVF. Notably, he had new ST
changes on his ECG following the event, but these changes
resolved.
He was planning to go on a trip to ___ today, but due to
worsening symptoms, he called his doctor who advised him to come
to the ED.
ROS:
+ poor appetite/weight loss over the last 2 months
+ dry cough x2 months that has recurred over the last 2 days
and bilateral lower extremity swelling that is slightly worse
than usual
- denies nausea, vomiting, diarrhea, constipation, bloody or
black BMs, hematuria/dysuria, abdominal pain, fevers (none at
home), chills, night sweats
In the ED:
VS: T 99.9-100.9, HR ___ BP 97-117/45-59 RR ___ O2 93-99% RA
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD - LAD s/p DES x2 (___)
- LVEF 60-65%
- Severe aortic stenosis
3. OTHER PAST MEDICAL HISTORY
- MGUS with new anemia
- Myopic Degeneration
- Bilateral pseudophakia
- Colonic Adenoma
Social History:
___
Family History:
Father died at age ___ of cardiac disease (specifics are unknown)
No known history of cancers
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
VS: 24 HR Data (last updated ___ @ 219)
Temp: 98.5 (Tm 98.5), BP: 102/64, HR: 80, RR: 18, O2 sat:
97%, O2 delivery: Ra
GENERAL: Well developed, well nourished male in NAD, lying flat
in bed. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink.
NECK: No JVD
CARDIAC: RRR, loud systolic ejection systolic murmur
LUNGS: Bibasilar crackles otherwise clear
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. Bilateral 1+ pitting edema to
the shins
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
========================
24 HR Data (last updated ___ @ 751)
Temp: 98.5 (Tm 98.7), BP: 128/74 (118-146/67-77), HR: 77
(69-88), RR: 16 (___), O2 sat: 96% (95-97), O2 delivery: Ra
Exam:
General: Not in acute distress, resting comfortably supine in
bed.
Cardiac: Loud systolic ejection murmur consistent with history
of aortic stenosis, regular rate, regular rhythm
Pulm: Clear to auscultation bilaterally
Extremities: No lower extremity edema. Good distal pulses.
Pertinent Results:
========================
ADMISSION LABS
========================
___ 09:52PM CK(CPK)-40*
___ 09:52PM cTropnT-0.01
___ 09:52PM CK-MB-<1
___ 03:19PM GLUCOSE-110* UREA N-27* CREAT-1.3*
SODIUM-131* POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION
GAP-11
___ 03:19PM estGFR-Using this
___ 03:19PM CK(CPK)-47
___ 03:19PM cTropnT-0.02*
___ 03:19PM CK-MB-1
___ 03:19PM WBC-15.5* RBC-3.06* HGB-8.7* HCT-27.1* MCV-89
MCH-28.4 MCHC-32.1 RDW-14.6 RDWSD-47.4*
___ 03:19PM NEUTS-90.3* LYMPHS-4.1* MONOS-4.7* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.98* AbsLymp-0.63* AbsMono-0.72
AbsEos-0.00* AbsBaso-0.02
___ 03:19PM PLT COUNT-230
___ 03:19PM ___ PTT-27.1 ___
___ 01:49PM URINE HOURS-RANDOM
___ 01:49PM URINE UHOLD-HOLD
___ 01:49PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 01:49PM URINE RBC-1 WBC-4 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 01:49PM URINE HYALINE-72*
___ 01:49PM URINE MUCOUS-RARE*
========================
DISCHARGE LABS
========================
___ 05:20AM BLOOD WBC-11.2* RBC-2.66* Hgb-7.5* Hct-23.9*
MCV-90 MCH-28.2 MCHC-31.4* RDW-14.6 RDWSD-47.4* Plt ___
___ 05:20AM BLOOD Plt ___
=======================
REPORTS
=======================
TEE ___:
IMPRESSION: No discrete vegetation or abscess seen.
MR ___/ and ___ contrast:
There are findings suggestive of discitis and osteomyelitis at
L5-S1. These include high signal intensity of the vertebral
endplates and the
intervertebral disc at this level on the STIR images,
hypointensity on the T1 weighted images, enhancement after
contrast administration, and a fluid
collection anterior to the sacrum, best seen on image 13 of
series 3. This area demonstrates peripheral enhancement with a
central fluid signal as well as broad prevertebral soft tissue
swelling.
Alignment is normal. There are ___ type 2 signal intensity
changes of the endplates at L3-4 and L4-5 with less prominent
involvement at L1-2 and L2-3. There is loss of signal of the
intervertebral discs on the T2 weighted images due to
degenerative disease. Axial imaging from T12-L3 demonstrates
facet osteophytes and intervertebral osteophytes but no more
than mild narrowing of the spinal canal. The neural foramina
appear normal.
At L3-4 there is bulging of the disc, a tiny midline protrusion,
ligamentum flavum thickening and facet osteophytes. These
combine to produce moderate-severe spinal canal narrowing.
There is narrowing of the left neural foramina. At L4-5 bulging
of the disc, facet osteophytes and ligamentum flavum thickening
encroach on the traversing L5 nerve roots bilaterally. The
neural foramina appear normal.
The spinal cord appears normal in caliber and configuration and
ends at L1-2.
IMPRESSION:
1. Findings suggesting discitis and osteomyelitis at L5-S1 with
an anterior abscess.
2. There is no spinal canal encroachment at this level and no
evidence of an epidural abscess.
Brief Hospital Course:
=====================
SUMMARY STATEMENT
=====================
___ with history of severe aortic stenosis, CAD s/p stent
placement, MGUS with progressive anemia of unclear etiology,
presenting with 2 weeks of progressive shortness of breath and
months of weight loss and sporadic fever found to have strep
viridans bacteremia now on ceftriaxone for endocarditis also
found to have L5-S1 osteomyelitis and prevertebral abscess on
MRI spine.
CORONARIES: LAD s/p DES x2 (___)
PUMP: LVEF 60-65%, grade II diastolic dysfunction
RHYTHM: nSR
===============
ACTIVE ISSUES:
===============
# Strep viridans bacteremia
# osteomyelitis
# possible infectious endocarditis.
Mr. ___ presented with intermittent fevers, weight loss,
night sweats, anemia, and dyspnea, which initiated our
infectious work-up. He was initially treated with vancomycin.
BCx from the ED grew streptococcus viridans in ___ tubes on
___. UCx was negative. He is at risk for subacute infectious
endocarditis due to his severe AS valvular disease, which can
serve as nidus for infection, especially given his poor
dentition. TEE was negative for vegetation, but infectious
disease advised to treat empirically for endocarditis, so IV
ceftriaxone was started. MRI of the spine obtained due to back
pain, showed L5-S1 osteomyelitis and discitis, with paraspinal
abscess (15 mm). Given lack of neurologic symptoms and known
source with concurrent bacteremia, would held did not pursue
aspiration. Orthospine was also consulted and advised on
antibiotic treatment without aspiration. Patient to complete a
6-week course of antibiotics with ceftriaxone 2gm IV Q24 hours.
He will need outpatient follow-up with infectious disease which
will be set up.
He should also follow up with cardiology in the outpatient
setting and consider a repeat TTE in 2 weeks. He should also
have weekly CBC with differential, BUN, Cr, AST, ALT, Total
Bili, ALK
PHOS, CRP in order to track the infection. Please also consider
reimaging of the spine to ensure resolution of the abscess prior
to completion of therapy. Encourage outpatient follow-up with
dentist soon after discharge.
# History of MGUS
# Normocytic anemia:
Hb 8.7 with no evidence of active bleeding on admission. His Hb
has beendowntrending since ___. Given his known histoy of
MGUS, he is
undergoing work up for his new anemia with his outpatient
oncologist. Notably, labs from ___ show a haptoglobin of 329,
ferritin 488.4 and vitamin B12 of 358. And SPEP and free K:L
pending (per atrius records). Will leave the remainder of the
work up to his outpatient oncologist. Can also consider checking
a
methylmalonic acid level since his B12 was less than 400.
# Severe aortic stenosis, presyncope with exercise.
He has progressive aortic stenosis, now severe, with symptoms of
dyspnea on exertion along with a syncopal episode in the ED.
CT-A without PE though with mild pulmonary edema and proBNP was
elevated, so he may have a component of volume overload as well.
These symptoms are likely a result of his severe aortic stenosis
and bacteremia. Syncopal episode in the ED was due to
micturition, decreasing his blood pressure, which his heart
could not compensate for, due to his severe AS. However,
previous episodes of presyncope that he has experienced during
physical activity are concerning for progression of his valvular
disease. Surgical management of his valvular disease must be
deferred until his bacteremia is appropriately treated.
CT-surgery and structural heart team were consulted initially,
but correction of severe AS was deferred to after resolution of
the infectious endocarditis. ID recommended that given the lack
of vegetation or abscess on TEE, would likely be able to do TAVR
to correct AS (would not require valve excision). On this
admission, did not require diuretics and his metoprolol was
continued. Once the antibiotic course is completed, he should
call ___ in order to make appointment with Dr. ___
(___) in the outpatient setting. He can also follow up with
structural heart team regarding management of AS in outpatient
setting.
# Relative hypotension, resolved
Patient's pressures initially 100s/60s, off from baseline of
130s-140s/70s. Likely combination of severe AS, bacteremia, and
poor PO intake. Lactate was normal at 0.8 and he was warm on
exam. BPs improved throughout hospital course. No concern for
sepsis. Due to lower pressures, home medications losartan and
amlodipine were held. Fractionated metoprolol was given. Please
consider restarting in the outpatient setting if
# Transaminitis:
Uptrending. Likely due to inflammatory state due to systemic
infection. Did not have any abdominal pain so did not do any
abdominal ultrasound. Please consider repeat transaminitis to
ensure resolution as an outpatient.
# Acute kidney injury:
Baseline Cr 1.0, admission Cr 1.3. Likely secondary to poor PO
intake and poor forward flow secondary to bacteremia. Held
losartan. Cr on discharge was 0.9.
# Coagulopathy:
INR 1.5, ___ 16.4. This was likely secondary to poor PO intake.
================
CHRONIC ISSUES:
================
# CAD s/p DES x2 to LAD
No active chest pain and troponin minimally elevated to 0.02 and
downtrended to 0.01. He did have ST changes on his ECG following
his syncopal episode, but these resolved. In the hospital,
continued aspirin (home dose aspirin 162 mg decreased to aspirin
81 mg). Continued metoprolol and statin. Will likely require an
ischemic work up prior to risk stratification for TAVR vs AVR as
an outpatient.
# Hyperlipidemia: Continued home Atorvastatin 40 mg PO QHS
# Myopic Degeneration: Home PreserVision AREDS-2 non-formulary
====================
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 178.57 lb
DISCHARGE Cr/BUN: ___
DISCHARGE DIURETIC: none
MEDICATION CHANGES:
- NEW:
CefTRIAXone 2 gm IV Q 24H
- STOPPED:
None
- CHANGED:
Aspirin is now 81mg from 162mg
FOR CARDIOLOGY:
[] consider repeat TTE in 2 weeks as outpt
FOR PCP:
[] follow up with dentist. do any procedures while still on
antibiotics
[] ___: He can call to schedule cardiac surg f/u apt
[] For anemia, would recommend checking a methylmalonic acid
level since B12 was less than 400
[] Follow up with structural heart team regarding management of
AS in outpatient setting.
FOR INFECTIOUS DISEASE:
[] repeat T spine MRI to ensure resolution of abscess prior to
finishing abx
[] WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK PHOS, CRP. All labs should be sent to ATTN: ___
CLINIC - FAX: ___
[] The ___ will schedule follow up and contact the patient
or discharge facility. 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.
[] Antibiotics: Ceftriaxone 2gm IV Q24 hours
Start Date: ___
Projected End Date: ___
[] PICC line in place for antibiotics on ___ and going home
with ___ services
# CODE STATUS: Full (presumed)
# CONTACT: ___, wife - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Vitamin D ___ UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
8. Aspirin 162 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H Osteomyelitis, discitis Duration:
6 Weeks
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams
intravenous once per 24 hours Disp #*2 Intravenous Bag
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
7. Vitamin D ___ UNIT PO DAILY
8. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your doctors ___ to
9. HELD- Losartan Potassium 100 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your doctors ___
___ to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Bacteremia
Osteomyelitis of L5-S1, discitis, prevertebral abscess
Possible infectious endocarditis
Secondary diagnosis
Aortic stenosis (severe)
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 ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had increasing
shortness of breath as well as weight loss and intermittent
fever. Your blood cultures grew bacteria (streptococcus
viridans).
Initially, we did not know what was causing bacteria to grow in
your blood. We talked with infectious disease doctors about the
___, and for concern for infection of the aortic valve due
to your aortic stenosis, we put a camera down your esophagus
(transesophageal echocardiogram,TEE) in order to visualize the
aortic valve better and see if any bacteria was growing on it.
There was no evidence of a collection of bacteria on the valve,
but due to risk factors such as lack of dental care for several
years, severe aortic stenosis, as well as recent weight loss and
increased inflammatory markers in your blood, the infectious
disease doctors wanted to ___ you for infection of your heart
valve (endocarditis). We inserted a peripherally inserted
central catheter (PICC) line in order to administer IV
antibiotics (ceftriaxone) to treat endocarditis due to suspected
infection. You also described having recent back pain, so we
took an MRI of your spine. This showed infection of your L5 and
S1 vertebrae, as well as a small abscess in front of your
vertebrae. The orthopedic surgeons said that the abscess was too
small to drain. Complete 6 weeks of IV ceftriaxone in order to
treat the bacterial infection in your spine (osteomyelitis). A
nurse ___ come to your house to administer this medication
through your PICC line.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- The ___ will schedule follow up and contact the patient
or discharge facility. 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.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Seek medical attention if the ___ line site becomes
infected, such as if there is drainage, redness, increased pain,
or if you have new fever.
- Your discharge weight: 178.57 lb. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19662810-DS-13
| 19,662,810 | 29,953,063 |
DS
| 13 |
2150-05-08 00:00:00
|
2150-05-08 14:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Syncope, ? seizure
Major Surgical or Invasive Procedure:
___: Coronary artery bypass grafting x1 (SVG-OM1); patch
repair of healed aortic root abscess with bovine pericardium;
Aortic valve replacement with 21mm Magna Ease tissue valve.
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
aortic stenosis, coronary artery disease, and MGUS with newly
worsening anemia of unclear etiology. He was hospitalized at
___ in ___ with septic bacteremia. He initially presented on
___ with dyspnea on exertion, significant unintentional
weight loss, and worsening lumbar pain. He was hypotensive and
had an episode of syncope in the bathroom in the ER. Blood
cultures on admission were positive for strep viridans. Cardiac
surgery was consulted and on ___ took him to the OR for
coronary artery bypass grafting x1 (SVG-OM1); patch repair of
healed aortic root abscess with bovine pericardium; Aortic valve
replacement with 21mm Magna Ease tissue valve. His postoperative
course was significant for postoperative delirium but this
resolved before discharge. He was seen by speech and swallow and
had a video swallow with diverticulum increasing risk of
aspiration and SLP discussed with the patient strategies to
lower risk of aspiration and patient agreeing to thins/soft. He
was discharged home on POD 8 in stable condition. Today, Mr.
___ wife was on the phone with cardiac surgery office when
she heard her husband make strange noise. When she got to him,
he was unresponsive with dilated pupil for ___ seconds. He
regained consciousness and was neuro intact. Wife called ___ and
SBP 70's upon ___ arrival. He had systolic BP of 82 when he
arrived to ED. In ED he became pale and diaphoretic, altered and
not responding to staff. Seizure like activity was noted in
upper extremities. Seizure lasted ~2 minutes and 2 mg Ativan was
given. When examined, he was awake and alert, appeared weak and
lethargic, but neurology intact. He will be admitted to the
___ for further workup.
Past Medical History:
Aortic Stenosis
Colon Adenoma
Coronary Artery Disease s/p stents ___
Hyperlipidemia
Hypertension
MGUS with Anemia
Myopic Degeneration
Osteomyelitis of L5-S1, discitis, prevertebral abscess
Pseudophakia, bilateral
Pulmonary Nodule
Strep Viridans Bacteremia
Past Surgical History:
Cataract surgery, ___
___ eye surgery
Tonsillectomy
Social History:
___
Family History:
Father died at age ___ of cardiac disease (specifics are
unknown).
Physical Exam:
HR: 90 BP: 104/71 RR: 19 O2 sat: 99% 2 liters
Height: 68"
Skin: Dry [x] intact [x] Sternal incision clean/dry/intact,
sternum stable. Some serous drainage from saph site incision
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x] Diminished at left base
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 1+ ___ edema,
trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:+ Left:+
___ Right:+ Left:+
Radial Right:+ Left:+
Carotid Bruit: none
Discharge Physical Exam:
General: NAD [x]
Neurological: non focal exam, A/O x3 [x] Moves all extremities
[x] Follows commands [x]
HEENT: PERRL [x]
Cardiovascular: RRR [x] SR
Respiratory: CTA [x] No resp distress [x]
GU/Renal: Urine clear [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema +1
Left Lower extremity Warm [x] Edema +1
Pulses:
DP Right: + Left:+
___ Right: Left:
Radial Right: + Left:+
Ulnar Right: Left:
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Lower extremity: Right [] Left [x] CDI [x]
Upper extremity: Right [] Left [] CDI []
Other:left lower leg ___ site old staple site CDI
Pertinent Results:
Head CT ___
No acute intracranial process.
CTA Chest ___
1. No evidence of pulmonary embolism or acute thoracic aortic
abnormality.
2. New moderate size left hemothorax. Minimally complex small
right pleural effusion.
3. Status post CABG and aortic valve replacement with interval
development of a mildly complex small pericardial effusion.
4. Right lower lobe pneumonia.
5. Interval acute left first rib fracture. No pneumothorax.
Transthoracic Echocardiogram ___
The interatrial septum is aneurysmal. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. Overall left ventricular
systolic function is normal. The visually estimated left
ventricular ejection fraction is >=65%. Normal right ventricular
cavity size with normal free wall motion. An aortic valve
bioprosthesis is present. The prosthesis is well seated with
normal leaflet motion and gradient. The tricuspid valve leaflets
appear
structurally normal. There is no tricuspid regurgitation. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and global biventricular systolic function.
Well seated, normal functioning bioprosthetic AVR with normal
gradient No pericardial effusion. No structural cardiac cause of
syncope identified. Compared with the prior TTE (images
reviewed) of ___, the aortic valve has been replaced with
a normal functioning bioprosthetic AVR with normal gradient.
___ 06:34AM BLOOD WBC-7.7 RBC-2.68* Hgb-8.1* Hct-24.9*
MCV-93 MCH-30.2 MCHC-32.5 RDW-15.6* RDWSD-51.9* Plt ___
___ 10:30AM BLOOD Hct-27.0*
___ 01:48AM BLOOD ___ PTT-26.5 ___
___ 06:34AM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-100 HCO3-27 AnGap-11
___ 06:34AM BLOOD Mg-2.0
___ PCXR
Mild interval improvement in the size of the medial basal
components of the
left pneumothorax. There is a tiny left apical pneumothorax.
Left pleural
effusion is not significantly changed. Otherwise, no
significant change in
radiograph performed 3 hours earlier.
IMPRESSION:
No significant change in findings compared to chest film
performed 3 hours
earlier.
Brief Hospital Course:
Patient was admitted to the ___ on ___ for further work
up and management after syncopal episode at home. CTA negative
for PE, but + for moderate hemothorax. He had left chest tube
placed for drainage of large left bloody effusion. Acute new
Fractured left upper rib. He underwent a head CT which was
negative and was seen by the Neurology service. His neurologic
baseline and his neurologic exam was nonfocal. Per neurology his
history was not classic for seizure (no tongue biting,
bowel/bladder incontinence, post-tictal state, etc.). These
episodes seemed more likely related to hypotension, as he was
noted to be ___ systolic on ambulance arrival and ___ systolic
in the ED during his symptoms. He also had multiple etiologies
for hypotension, including sepsis (RLL pneumonia), hemothorax
(requiring blood transfusions), and home meds
(metoprolol/lasix). Neurology recommended holding off on AEDs
and any further imaging while inpatient as his episodes seem
more likely to be related to hypotension. Will undergo
outpatient EEG for further evaluation upon discharge and will
f/u with neurology.
He had TTE that was stable. Patient remains hemodynamically
stable. He was restarted on low dose Lasix and Lopressor. ON HD
3 his Hct drifted to 23 with mildly orthostatic and he received
2 packed red blood cells. He continued to progress well and
transferred to the floor,where he continued to do well. He
continued on ceftriaxone for RLL pneumonia, transitioned to
levoquin. His left CT was removed on HD 3 with small left
pneumothorax that has improved on follow-up CXRs.
Patient has known oropharyngeal dysphagia, ?esophageal
diverticulum per Video Swallow Study (___). His swallow
appears to be improving in the setting of improved overall
strength. He was seen by the speech and swallow department this
admission, there was no overt s/sx c/f aspiration. Patient
states he has been
ingesting soft solids without issue. Given that patient has been
ingesting soft solids since ___ without significant
issue, speech and swallow recommended this diet level to
maximize safety from a possible post-prandial aspiration risk
standpoint. SLP provided general guidelines of foods that can be
modified to soft and bite sized consistency within home setting
w/ patient acknowledging understanding. They continue to
recommend GI consult to assess post-prandial
aspiration risk and to advance beyond soft solids. Patient is
looking forward to GI consult to discuss options/further
assessment of post-prandial aspiration risk & further
evaluation. Appointment made with Dr. ___.
In light of patients progress and lack of symptoms, patient
was ready for discharge to home on HD4. He will f/u with next
week for CXR and repeat HCT. All follow-up appointments
arranged. Patient aware of all f/u appointments and advised to
call our service with any further questions or concerns that he
or his family may have.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Furosemide 40 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO TID
4. Potassium Chloride 40 mEq PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Aspirin EC 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cyanocobalamin 1000 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
11. Vitamin D ___ UNIT PO EVERY OTHER DAY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. LevoFLOXacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
3. Ramelteon 8 mg PO QPM:PRN sleep
4. Metoprolol Tartrate 12.5 mg PO TID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
three times a day Disp #*60 Tablet Refills:*1
5. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tab by mouth once a day Disp
#*10 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cyanocobalamin 1000 mcg PO DAILY
9. Famotidine 20 mg PO BID
10. Furosemide 40 mg PO DAILY
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
11. Multivitamins 1 TAB PO DAILY
12. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D ___ UNIT PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
syncope multifactorial
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Left Lower extremity SVH old staple site CDI, distal SVH site
draining occasional serosang drainage
Edema: +1 lower ext left > right. Ecchymotic left upper thigh.
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19663196-DS-10
| 19,663,196 | 21,518,278 |
DS
| 10 |
2159-05-12 00:00:00
|
2159-05-13 22:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old man with recent diagnosis of cholangiocarcinoma
(staging/treatment information not available overnight) followed
at ___ who is trasferred from ___ with altered
mental status and concern new lesion on ___.
Patient recently diagnosed with choloangiocarcinoma at ___ in
___ after developing weeks of jaundice, dark urine, RUQ
pain, and weight loss. He established care with his outpatient
oncologist, Dr. ___ began chemotherapy as an outpatient
on ___. He felt relatively well on ___. However, on ___ he
began acting strangely upon waking up. His wife describes
difficulty getting his shoes on and inability to use a
telephone. He was insistent that he had to go to work, and was
uncooperative and difficult with her. He also was pacing around
the house, and repeatedly opened and closed the refrigerator
door, and would insist that he was fully clothed even though he
was only wearing his underwear. His wife called his PCP, who
directed him to the ___. In the ___, non-contrast
CT scan of head was concerning for new hypodense lesion in the
right parietal lobe, and MRI was recommended. Because MRI was
not available at ___ or ___ over the weekend, patient was
transferred to ___.
In the ___, initial VS were pain 0, T 98.3, HR 95, BP 171/94 RR
18 O2 96%RA. On exam patient had no focal deficit. He was
oriented x2-3. Labs notable for Na 131, K 6.1 (repeat 4.6), HCO3
24, Cr 0.7, ALT 219, AST 433, ALP 500, Tbili 7.3, Alb 2.2, WBC
28.4 (96%N) HCT 35.7, PLT 344. UA unremarkable. Neurology was
consulted who felt encephalopathy likely due to metabolic
derangements +/- HE rather than vascular etiology. They
recommended MRI/MRA of head. VS prior to transfer were pain 0, T
98.1, HR 94, BP 173/83, RR 18, O2 99%RA.
On arrival to the floor, patient is without acute complaint,
other than being 'tired'. As part of his chemotherapy, he takes
dexamethasone bid for two days after chemotherapy. He was also
started on MS ___ and oxycodone. He denies recent fevers or
chills. No headache. No diplopia. No dysphagia. He endorses mild
SOB and non-productive cough. No CP. He has mild RUQ pain that
is improving since his diagnosis. Mild nausea after chemo, but
no vomiting. His appetitie is good. No diarrhea, no BM in 2
days. He notes new bilateral leg edema since his diagnosis.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- Cholangiocarcinoma
- ASTHMA
- ECZEMA
- HCV S/P INTERFERON TREATMENT ___
- ETOH ABUSE
- HTN
Social History:
___
Family History:
Mother: ___
Sister: ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.3 BP 174/98 HR 92 RR 22 O2 95%RA
GENERAL: Somewhat uninhibited, jaundiced sitting up in bed
comfortably
HEENT: Icteric sclerae, MMM, OP clear, No LAD
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Moderately protuberant with dullness to percussion
dependently. No caput or spider angiomas. NABS Tender
hepatomegaly ~3cm below costal margin. No splenomegaly. No TTP
elsewhere without rebound or guarding.
EXT: Warm, well perfused, 2+ pitting edema to mid shin
bilaterally
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: Alert, oriented to person, year, and hospital, CN III-XII
intact, strength equal throughout all four extremities.
Intention tremor on FTN R>L. HTS intact.
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.0PO 146 / 95 94 16 100 RA
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: soft, BS present, mildly distended
NEURO: Alert, Oriented to ___ and to date; no asterixis; ___
strength throughout
PSYCH: calm, appropriate
Pertinent Results:
Admission Labs:
___ 10:00PM BLOOD WBC-28.4* RBC-3.69* Hgb-11.7* Hct-35.7*
MCV-97 MCH-31.7 MCHC-32.8 RDW-21.5* RDWSD-75.3* Plt ___
___ 10:00PM BLOOD Neuts-96.1* Lymphs-2.2* Monos-0.4*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-27.25* AbsLymp-0.63*
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.05
___ 10:00PM BLOOD ___ PTT-26.3 ___
___ 10:00PM BLOOD Glucose-131* UreaN-26* Creat-0.7 Na-131*
K-6.1* Cl-95* HCO3-24 AnGap-18
___ 10:00PM BLOOD ALT-219* AST-433* AlkPhos-500*
TotBili-7.3*
___ 10:00PM BLOOD Lipase-66*
___ 10:00PM BLOOD Albumin-2.2*
Discharge Labs:
___ 05:40AM BLOOD WBC-4.1 RBC-3.26* Hgb-10.2* Hct-30.3*
MCV-93 MCH-31.3 MCHC-33.7 RDW-19.9* RDWSD-66.9* Plt ___
___ 05:40AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-133
K-3.3 Cl-99 HCO3-24 AnGap-13
___ 05:40AM BLOOD ALT-276* AST-427* AlkPhos-461*
TotBili-7.4*
___ 05:40AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9
Cholest-287*
___ 10:00PM BLOOD ALT-219* AST-433* AlkPhos-500*
TotBili-7.3*
___ 06:15AM BLOOD ALT-206* AST-351* LD(LDH)-355*
AlkPhos-483* TotBili-7.0*
___ 09:45AM BLOOD ALT-225* AST-331* AlkPhos-529*
TotBili-9.0*
___ 05:38AM BLOOD ALT-209* AST-297* AlkPhos-456*
TotBili-8.0*
___ 05:40AM BLOOD ALT-276* AST-427* AlkPhos-461*
TotBili-7.4*
___ 05:40AM BLOOD %HbA1c-4.6 eAG-85
___ 05:40AM BLOOD Triglyc-156* HDL-8 CHOL/HD-35.9
LDLcalc-248*
___ 06:15AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 11:01PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:01PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-4* pH-5.5 Leuks-NEG
___ 11:01PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
HCV VIRAL LOAD (Final ___: HCV-RNA NOT DETECTED.
BLOOD CX PENDING x 2
RUQ U/S - IMPRESSION: Innumerable hepatic masses consistent with
metastases given history of cholangiocarcinoma. Consider
staging CT or MRI as clinically indicated. Moderate ascites.
MRI/MRA Head - IMPRESSION:
1. Portions of the brain MRI and the brain MRA are motion
limited.
2. Area of encephalomalacia and gliosis in the right superior
parietal lobe, without evidence for superimposed acute
infarction or contrast enhancement.
3. Overall, there is no evidence for intracranial metastatic
disease, though motion artifact limits evaluation for small
lesions.
4. No acute infarction.
5. Unremarkable neck MRA. Unremarkable motion-limited brain
MRA.
TTE - The left atrial volume index is normal. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 65%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta 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
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
___ y/o M with PMHx of asthma, eczema, HTN, prior EtOH abuse, HCV
s/p interferon treatment, as well as recent
diagnosis of cholangiocarcinoma with initiation of chemotherapy,
who presented with confusion. Non-contrast CT scan of head at
OSH was concerning for new hypodense lesion in the right
parietal lobe. He was transferred here for MRI. Neurology was
consulted who felt encephalopathy likely due to metabolic
derangements +/- HE rather than vascular etiology. Mental status
much improved after getting lactulose. MRI performed, which
showed evidence of prior stroke but nothing acute.
# Altered Mental Status
# Lesion on Head CT
As above, MRI showed evidence of prior CVA but nothing acute.
This makes leading diagnosis for AMS to be hepatic
encephalopathy, given improvement with lactulose. Infectious
process seems less likely given absence of fever or new
abdominal symptoms, as well as clinical stability off of abx (he
was initially placed on biliary coverage on admission given WBC
in the ___; however, this was stopped after a few days).
Drastic improvement in WBC over course of admission is peculiar
and could have been ___ abx, but initial leukocytosis could have
also been related to steroids given around time of recent
chemotherapy. The patient was discharged on a regimen of
lactulose to titrate to ___ BM's per day. Continued on oxycodone
for pain control; however, MS contin ___ in case it was
contributing to AMS. Pt was maintained on this regimen in house
with good pain control.
# Prior CVA: Seen on MRI. Neuro was involved throughout
admission. TTE unremarkable for source of embolic stroke. A1C
was WNL. Lipid panel did reveal elevated LDL (240's). Could
consider treatment of this if within goals of care. Pt was
started on an aspirin prior to discharge.
# Hyperbilirubinemia / Tranaminitis: Likely related to known
biliary cancer. There was concern initially for possible
infectious process; however, as above, this seems less likely.
Hepatitis serologies sent and were negative. HCV viral load
undetectable.
# Biliary cancer: Started chemotherapy on ___. There has been
concern that lesion on head CT could represent new
brain mets vs CVA, MRI pending. Discussed hospital course and
lab findings with outpatient oncologist on the day of discharge.
Given presentation with hepatic encephalopathy in the setting of
known cholangiocarcinoma, prognosis is poor. He is planning to
discuss hospice with patient this week.
# Hyponatremia: Mild. Resolved prior to discharge.
TRANSITIONAL ISSUES:
- Pt needs close oncology f/u for goals of care discussion.
- Consider tx of hyperlipidemia if within goals of care.
- 2 blood cultures pending at the time of discharge, will need
to be followed up
- Platelets noted to be slightly low on the day of discharge. ?
___ chemotherapy. This should be trended.
- LFT's remained significantly elevated at discharge: ALT 276
AST 427 ALK PHOS 461 T BILI 7.4. Likely ___ cholangiocarcinoma
with mets to liver. This should be followed up at outpt oncology
appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 4 mg PO Q12H
2. Morphine SR (MS ___ 30 mg PO Q8H
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
4. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lactulose 30 mL PO Q8H
RX *lactulose 20 gram/30 mL 30 mL by mouth every 8 hours as
needed Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Metabolic Encephalopathy
Cholangiocarcinoma
TIA or Stroke (Ischemic or Hemorrhagic)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with confusion and an abnormal CAT
scan of your head. Ultimately, it seems that your confusion was
likely related to liver dysfunction in the setting of your
cancer. You were treated with lactulose with improvement in your
mental status. It is important that you continue to take your
lactulose so that you have ___ bowel movements per day.
You were found to have evidence of a prior stroke on your MRI.
You were seen by the neurology team and were started on a baby
aspirin. You were also noted to have somewhat elevated
cholesterol levels on your lab work. You should further discuss
this with your doctor at your follow up appointment.
It is very important that you keep your follow up appointment
with Dr. ___.
Followup Instructions:
___
|
19663491-DS-5
| 19,663,491 | 21,765,130 |
DS
| 5 |
2182-09-15 00:00:00
|
2182-09-15 20:23:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
abacavir
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Chest tube placement
PICC
History of Present Illness:
Mr. ___ is ___ with history of HIV on HAART, last CD4 count
875 viral count 2422, presenting with shortness of breath. He
initially presented to his PCP's office today with complaint of
hematuria and was found to be hypoxic (80%) on room air. The
patient reports that for the past couple of days he has been
short of breath. He also reports associated fever, chills and
cough productive of greenish sputum and pleuritic chest pain on
the R. Denies any abdominal pain, n/v, diarrhea, consipation,
dysuria, frequency, palpitations, headache. He denies any
recent travel. He lives alone in an apartment and is on
disability.
In the ED, initial vitals were98.1, 110, 127/81, 24, 91% on 4 L
NC. ABG 7.33/___. Patient was put on biPAP did not
tolerate it well but did have some improvement in oxygen
saturation. He was then placed on a NRB 95%. Repeat ABG
___. Labs otherwise notable for WBC 29.4, PMN
87%,HCO3 38. A CXR showed large widespread opacification of the
right mid-to-lower hemithorax with mass effect, suspected to
represent a pleural effusion at least in part, including a
possible large loculated component; widespread atelectasis or
pneumonic consolidation. The patient was given ASA 81mg,
ceftriaxone 1 g, methylprednisone 125 mg, TMP-SMX 600 mg,
azithromycin 500mg.
CT chest showing large R effusion, likely empyema.
On arrival to the MICU, vitals were 97.6, 120, 157/82, 16, 95%
on NRB.
Past Medical History:
HIV
HTN
Obesity
Hepatitis C chronic
Tobacco dependence
Anxiety
COPD?
History of Opioid use on methadone
Social History:
___
Family History:
Father Cancer - ___
Mother- Lung condition
Physical Exam:
Admission exam:
General: Alert, oriented, no acute distress
HEENT: buffalo hump, Sclera anicteric, MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Absent breath sounds and dullness to percussion R lower
___, crackles LLL
Abdomen: soft, distended, bowel sounds present, no organomegaly,
no tenderness to palpation, no rebound or guarding
Ext: clubbing, Warm, well perfused, 2+ pulses, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge exam:
Vitals: T 98.3, BP 132/98, HR 96, RR 20, SvO2 95% 1L NC
General: alert, oriented
CV: RR, nl rate, no rubs, callops or murmurs
Lungs: diffuse crackles on left lung sparing apex, crackles
lower half of right lung, has some pain on left side with deep
inspiration
Abdomen: soft, nontender, nondistended, +BS
Ext: clubbing, WWP, no pitting edema
Pertinent Results:
___ 10:31AM BLOOD WBC-29.4* RBC-5.06 Hgb-14.9 Hct-47.3
MCV-93 MCH-29.5 MCHC-31.5 RDW-12.8 Plt ___
___ 05:15AM BLOOD WBC-8.7 RBC-4.01* Hgb-12.0* Hct-37.1*
MCV-92 MCH-30.0 MCHC-32.5 RDW-13.0 Plt ___
___ 03:15AM BLOOD Glucose-119* UreaN-18 Creat-0.5 Na-137
K-4.5 Cl-96 HCO3-38* AnGap-8
___ 06:35AM BLOOD UreaN-14 Creat-1.0 Na-132* K-3.5 Cl-93*
HCO3-37* AnGap-6*
___ 05:15AM BLOOD UreaN-12 Creat-1.0 Na-132* K-4.5 Cl-91*
HCO3-35* AnGap-11
___ 05:20AM BLOOD ALT-35 AST-65* AlkPhos-73 TotBili-1.8*
___ 05:20AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9
___ 02:45PM BLOOD Osmolal-270*
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 06:48AM URINE Hours-RANDOM UreaN-328 Na-65 K-27 Cl-88
___ 06:48AM URINE Osmolal-342
___ 2:14 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT (___).
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
.
PREVIOUSLY REPORTED AS.
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA
(___).
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
WORK-UP PER ___ ___ (___).
BETA STREPTOCOCCUS GROUP C. MODERATE GROWTH.
ENTEROBACTER AEROGENES. SPARSE GROWTH.
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.
ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S 4 S
CEFTAZIDIME----------- <=1 S 8 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 8:41 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___ 08:30AM.
STREPTOCOCCUS ANGINOSUS (___) GROUP. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
CXR: IMPRESSION: Widespread opacification of the right
mid-to-lower hemithorax with mass effect, suspected to represent
a pleural effusion at least in part, including a possible large
loculated component; a mass could also be considered, in
addition to widespread atelectasis or pneumonic consolidation.
CTAP:IMPRESSION: ___. Large loculated right pleural
effusion; saccular bronchiectasis of the bilateral lower lobes
and consolidation of the right middle and right lower lobes with
heterogeneous hypoenhancement and rounded hypodensities that may
represent either the underlying saccular bronchiectasis versus
multifocal necrotizing pneumonia. 2. Cholelithiasis without
cholecystitis. 3. Hilar lymphadenopathy may be reactive; follow
up imaging after treatment is recommended to ensure resolution.
CXR: ___ Right lower lobe opacity a combination of
consolidation and pleural effusion has increased. Left lower
lobe retrocardiac consolidation has worsened consistent with
worsening atelectasis and/or pneumonic consolidation. There is
no evident pneumothorax. Cardiac size cannot be evaluated, is
obscured by the pleuroparenchymal abnormalities.
Brief Hospital Course:
___ with HIV on HARRT (CD4 count of 800), HCV (failed
treatment), history of IVDU on methadone, who presented with
dyspnea and was found to have pneumonia and empyema. He was
treated with antibiotics and had a chest tube placed. The
cultures from the sputum and pleural fluid returned and he was
switched to IV cefepime and PO flagyl for a 4 week course. ID
will follow as an outpatient.
# Pneumonia with empyema: He had hypoxemia, pneumonia and a
large empyema on chest CT. He was initially started on
vancomycin, cefepime, and levofloxacin. Interventional
pulmonology placed a chest tube on ___. The effusion was
loculated and required tPA and ___ injections. The results of
the pleural effusion cultures were strep milleri species. Sputum
cultures grew Beta streptococcus group C, enterobacter
aerogenes, acinetobacter baumannii complex, haemophilus
influenza and beta lactamase negative (see results secontion).
He improved with treatment and drainage and his chest tube was
pulled on ___. He was seen by infectious disease specialists
who recommended a 4 week course of cefepime and flagyl. He will
need to continue this until ___ (and will need to be seen
by ID prior to discontinuation). A picc line was placed. He
should not be discharged from rehab with the ___ as he is at
risk of IVDU. After completion of his antibiotics this should be
removed. At the time of discharge he was on 1L NC.
# Opioid dependence: He takes 91mg of methadone per day (Habit
OPAC on ___.). He was continued on methadone 90mg per day.
He is at risk of abuse of the PICC. This should be removed prior
to discharge. He is also getting oxycodone as needed for pain.
# Chronic CO2 retention: Likely secondary to COPD or obesity
hypoventilation syndrome. He has been relatively stable with NC
and has not required positive pressure ventilation. This should
be evaluated further after discharge. He was treated with PRN
nebulizers.
# Hyponatremia: He had hyponatremia. Initially he was treated
with IVF with some improvement in his sodium. However, the urine
lytes were suggestive of SIADH. Thus, he was put on a fluid
restriction. However, the patient was unhappy with this and
refused to comply. His Na was stable at 132 without treatment.
Sodium should be checked a couple of times per week to make sure
it is stable at rehab.
# HIV: His most recent CD4 count is 875 with a viral load of
2422. He should be continued on truvada and kaletra.
# Hypertension: He was continue on amlodipine BID. Blood
pressures largely controlled.
# Anxiety: He was continued on his clonazepam.
# Constipation: he was writted for a bowel regimen
# Asthma: stable, continued on inhalers.
Transitional issues:
- ID follow up and outpatient lab work
Outpatient Lab Work
Diagnosis: empyema CBC with differential (weekly) (x) Chem 7
(weekly) (x) BUN/Cr (weekly) (x) AST/ALT (weekly) (x) Alk Phos
(weekly) (x) Total bili (weekly) (x) ESR/CRP (weekly) (x) All
laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
- removal of picc after completion of antibiotics
- pain control
- PCP follow up once discharged from rehab
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Atrius.
1. Amlodipine 5 mg PO DAILY
hold for SBP<100,
2. Clonazepam 1 mg PO BID:PRN anxiety
3. Vitamin D 1000 UNIT PO DAILY
4. Kaletra 2 TAB PO BID
5. Loratadine *NF* 10 mg Oral daily
6. Beclomethasone Dipro. AQ (Nasal) *NF* 42 mcg Other TID
7. Truvada 1 TAB PO DAILY
8. Ketoconazole 2% 1 Appl TP BID
9. Methadone
Discharge Medications:
1. Amlodipine 5 mg PO BID
hold for SBP < 105
2. Clonazepam ___ mg PO BID:PRN anxiety
hold pls if sedated or RR < 10
RX *clonazepam 1 mg ___ tablet(s) by mouth twice per day Disp
#*5 Tablet Refills:*0
3. Kaletra 2 TAB PO BID
4. Truvada 1 TAB PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipat
8. CefePIME 1 g IV Q12H
continue through ___
9. Docusate Sodium 100 mg PO BID
10. Heparin 7500 UNIT SC TID
11. 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.
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Methadone 90 mg PO DAILY
hold for sedation, RR<10
RX *methadone 10 mg 9 tabs by mouth daily Disp #*18 Tablet
Refills:*0
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
continue through ___
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
HOLD for sedation, RR<12, confusion
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 1 TAB PO BID:PRN constipation
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. Beclomethasone Dipro. AQ (Nasal) *NF* 42 mcg Other TID
20. Loratadine *NF* 10 mg Oral daily
21. Vitamin D 1000 UNIT PO DAILY
22. Outpatient Lab Work
Diagnosis: empyema
CBC with differential (weekly) (x)
Chem 7 (weekly) (x)
BUN/Cr (weekly) (x)
AST/ALT (weekly) (x)
Alk Phos (weekly) (x)
Total bili (weekly) (x)
ESR/CRP (weekly) (x)
All laboratory results should be faxed to the ___
R.N.s at ___. All questions regarding outpatient
parenteral antibiotics should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pneumonia and infected fluid in your
lung. You had this drained with a chest tube and you were
started on antibiotics. Based on the results of type of
bacteria, you will require 4 weeks of intravenous antibiotics.
You will need to follow up with infectious disease doctors to
make sure you continue to have improvement.
You were found to be slightly weak from your long
hospitalization. You were discharged to rehab so you could get
your antibiotics and improve your strength.
Followup Instructions:
___
|
19663491-DS-6
| 19,663,491 | 26,565,741 |
DS
| 6 |
2183-02-15 00:00:00
|
2183-02-21 11:32:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
abacavir
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ placement ___
History of Present Illness:
___ year old male with a history of HIV
(last CD4 >800), hepatitis C, pneumonia, hypertension,
anxiety, asthma, empyema, and osteoarthritis who presents
with worsening dyspnea on exertion. The patient was on ___
at ___ for dyspnea on exertion and found to have a
O2 sat of 76% on room air. He declined EMS and ED evaluation. He
returned to clinic today and found to have a O2 sat of 80% on
room air which increased to 86% with 2L-NC. Transported ___ via
EMS to ED. ___ route EMS noted O2sat of 90% with 5L-NC. The
patient endorces increasing dyspnea forr the past two weeks as
well and left leg swelling for the past week.
He was last hospitilized from ___ to ___ for
pneumonia and empyema. Interventional
pulmonology placed a chest tube on ___. The effusion was
loculated and required tPA and ___ injections. The results of
the pleural effusion cultures were strep milleri species. Sputum
cultures grew Beta streptococcus group C, enterobacter
aerogenes, acinetobacter baumannii complex, haemophilus
influenza and beta lactamase negative. He was discharged with a
PICC line and a 4 week course of cefepime and flagyl.
___ the ED, initial VS were 98.1 HR: 104 BP: 133/85 Resp: 20
O(2)Sat: 93 on 5L-NC. He recieved levofloxacin, supplemental O2
and a CXR showed a right lower lobe infiltrate without
significant effusion or signs empyema. He was transfered to the
floor. VS at the time of arrival were 97.0, 131/91, 78, 20, 94%
4L-NC.
Past Medical History:
HIV
HTN
Obesity
Hepatitis C chronic
Tobacco dependence
Anxiety
COPD?
History of Opioid use on methadone
Social History:
___
Family History:
Father Cancer - ___
Mother- Lung condition
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.0, 131/91, 78, 20, 94% 4L-NC
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - Bilateral crackles with scattered wheezes, no fremitus.
CV - RRR, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, erythema and edema with 5cm horizontal wound
extending from medial to lateral malleolus with purulence and
tenderness to palpation, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - Bilateral crackles with scattered wheezes much improved
from prior. no fremitus.
CV - RRR, S1/S2, no m/r/g
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or
rebound
EXT - WWP, improving erythema and edema with 5cm horizontal
wound extending from medial to lateral malleolus without
purulence or tenderness to palpation, 2+ pulses palpable
bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN: Multiple lesions ___ various stages of healing. On hand
extensor surface over MCJ there are circular 5mm
keratinic/scabbed leasions without purulence or discharge.
Similar excoriations on inner thighs bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 09:30AM BLOOD WBC-7.2 RBC-4.95 Hgb-13.8* Hct-43.1
MCV-87 MCH-27.9 MCHC-32.0 RDW-15.6* Plt ___
___ 09:30AM BLOOD Neuts-66.8 ___ Monos-7.9 Eos-0.5
Baso-0.5
___ 06:43AM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Target-1+
___ 09:30AM BLOOD Plt ___
___ 06:51AM BLOOD WBC-7.4 Lymph-46* Abs ___ CD3%-93
Abs CD3-3176* CD4%-18 Abs CD4-609 CD8%-75 Abs CD8-2556*
CD4/CD8-0.2*
___ 09:30AM BLOOD Glucose-82 UreaN-14 Creat-0.8 Na-128*
K-4.6 Cl-90* HCO3-32 AnGap-11
___ 09:30AM BLOOD ALT-24 AST-50* LD(LDH)-262* AlkPhos-87
TotBili-0.6
___ 09:30AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.0
___ 09:30AM BLOOD Lactate-1.0
IMAGING:
CT CHEST - ___
FINDINGS:
___ and peribronchovascular opacities are seen diffusely
throughout
the right lung and on the left predominantly ___ the left upper
lobe. Few
nodular opacities are seen bilaterally. Lower lobe predominant
bronchiectasis, left greater than right, has progressed compared
to prior,
with air-fluid levels ___ the left lower lobe dilated airways.
No pleural
effusion or pneumothorax is seen. Biapical paraseptal emphysema
and moderate
centrilobular emphysema is seen. Mild secretions are seen
layering ___ the
trachea.
The main pulmonary artery is dilated to 4 cm, suggesting
pulmonary
hypertension, which is likely secondary to the underlying
pulmonary
parenchymal process. There is bilateral hilar lymphadenopathy,
increased
compared to prior. Prominent mediastinal lymph nodes have
increased compared
to prior. A tiny focus of calcification ___ the left circumflex
coronary
artery is new compared to prior.
Prominent epigastric lymph nodes are again noted. No acute
upper abdominal
findings are seen on this study, which is not tailored for
evaluation of
subdiaphragmatic structures.
No concerning lytic or sclerotic osseous lesions are detected
IMPRESSION:
1. Right greater than left pulmonary infection with interval
progression of
lower lobe predominant bronchiectasis and evidence of secondary
pulmonary
hypertension. Strongest differential diagnostic considerations
include
infection and tuberculosis.
2. Increased mediastinal lymphadenopathy and bilateral hilar
lymphadenopathy,
with persistently prominent epigastric lymph nodes. ___ this
patient with HIV,
lymphoma should be considered.
Other considerations for this patient, which are thought to be
less likely,
include sarcoidosis, mycobacterium avium intracellulare, and
Kaposi's sarcoma,
which is not typically unilateral ___ the lungs.
Chest Xray - ___
FINDINGS:
The patient is rotated to the right. There are persistent
opacities ___ both
lung bases, somewhat more conspicuous ___ the right mid lung on
the frontal
radiograph although not confirmed on the lateral radiograph.
The small
anterior loculated collection seen ___ has resolved.
The small
pleural effusion has resolved. The cardiomediastinal silhouette
and hilar
contours are normal. There is no pneumothorax.
IMPRESSION:
1. Persistent bilateral lower lung opacities are somewhat more
conspicuous ___
the right mid lung and may represent atelectasis however,
infection is not
excluded.
2. The small anterior loculated fluid collection, and small
pleural effusion
have resolved.
Left foot Xray - ___
Three radiographs of the left foot demonstrate mild metatarsus
adductus and
hallux valgus deformities. There is slight joint space narrowing
with
subchondral sclerosis at the first metatarsophalangeal joint
with overlying
soft tissue prominence. There is a pes planus & sloight osseous
spurring along
the dorsal aspect of the talonavicular joint. No cortical
disruption or
periosteal reaction. There is no soft tissue ulceration
identified.
IMPRESSION: No radiographic evidence of osteomyelitis.
Left hand Xray - ___
FINDINGS:
Three views of the left hand demonstrate soft tissue swelling of
the ___
digit. There are no findings suggestive of osteomyelitis. There
is some faint
soft tissue lucency ___ the web space between the ___ and ___
digits, which may
represent air trapping ___ the skin ulcers. No fracture or
dislocation is
seen. No erosion or lytic or sclerotic lesion is identified.
No soft tissue
calcification or radiopaque foreign body is detected. There are
mild
degenerative changes of the ___ interphalangeal, MCP and CMC
joints. There is
IV tubing projecting over the wrist.
IMPRESSION:
1. No radiographic evidence of osteomyelitis. If there is
continued clinical
concern, recommend CT scan for further evaluation.
2. Mild DJD of the ___ interphalangeal, MCP and CMC joints.
3. Soft tissue swelling.
MICROBIOLOGY:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
DISCHARGE LABS:
___ 06:01AM BLOOD WBC-8.6 RBC-4.81 Hgb-13.4* Hct-43.6
MCV-91 MCH-27.8 MCHC-30.7* RDW-15.5 Plt ___
___ 06:01AM BLOOD Neuts-16* Bands-0 Lymphs-69* Monos-13*
Eos-2 Baso-0 ___ Myelos-0
___ 06:01AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:01AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:01AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-133
K-4.0 Cl-94* HCO3-33* AnGap-10
Brief Hospital Course:
This is a ___ year old male with HIV therapy with a CD4 count of
609, Hepatitis C, and a history of IV drug abuse on methadone,
who presented with dyspnea and was found to have MRSA pneumonia.
A PICC line was placed and he was sent home on four weeks
vancomycin IV 1250mg every 12 hours.
# MRSA pneumonia and hypoxemia: Hypoxemia ___ the setting of
pneumonia. Treated with IV vancomycin. Normal CD4 count
reassuring for no atypical infection. No large effusion or
empyema. With IV antibiotics clinical improved with resolution
of hypoxemia.
# Left foot and left hand wounds: Erythema and edema with 5cm
horizontal wound extending from medial to lateral malleolus
without obvious purulence. Podiatry was consulted and were not
concerned for osteomyelitis or cellulitis. Xrays of both were
negative for osteomyelitis. Dermatology was consulted as well
and recommend application of mupirocin 2% ointment to the base
ofthe ulcers followed by non-adherent dressing such as Xeroform
gauze, Vaseline impregnated gauze, or Adaptic then gauze and
Kerlix wrap around the entire foot. Dressing changes should be
performed daily to every other day following discharge.
# Skin lesions: Dermatology was consulted for resolving pruritic
eczematous eruption on the bilateral medial and lateral thighs
with post inflammatory hyperpigmentation and healing
excoriations from lotion use, likely contact dermatitis. Was
counciled to discontinue lotion product.
# Opioid dependence: He takes 90mg of methadone per day. Habit
OPco on ___. is the prescriber. He was continued on
methadone 90mg per day.
# Hyponatremia: Per his old records this is a chronic issue. He
was placed on water restriction last admission for concern of
syndrome of inappropriate anti-diuretic hormone but refused to
comply. We followed his sodium and his hyponatremia improved
somewhat with improvement of his pneumonia.
# Human Immunodeficiency Virus: CD4 count was order and found to
be 609. We continued his home doses of truvada and kaletra.
# Hypertension: Denies current amlodipine despite having been
discharged on this medication ___ ___. His blood pressures
were normal on admission and throughout his course without
medication.
# Anxiety: This is a chronic stable issue. We continued his home
clonazepam.
# Constipation: This is a chronic stable issue related to his
opiate use. We placed him on a bowel regimen.
# Asthma: This is a stable chronic issue. We continued his home
Albuterol inhaler.
TRANSITIONAL ISSUES:
- Discharged home with PICC line and four weeks of vancomycin.
- Nursing assistance with IV antibiotics and with dressing
changes of left foot and left middle finger.
- Will need to follow up with primary doctor and infectious
disease.
- Will need repeat CT chest ___ 2 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 90 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Lopinavir-Ritonavir 2 TAB PO BID
Discharge Medications:
1. Outpatient Lab Work
WEEKLY CBC with differential, Chem 7, LFT's, Vancomycin trough.
All laboratory results should be faxed to the ___
R.N.s at ___. Questions regarding outpatient
antibiotics should be directed to the ___ R.N.s
at ___.
2. Wound care
Mupirocin 2% ointment to the base of the ulcers followed by
non-adherent dressing such as Xeroform gauze, Vaseline
impregnated gauze, or Adaptic then gauze and
Kerlix wrap around the entire foot. Dressing changes should be
performed daily.
3. Vancomycin 1250 mg IV Q 12H
RX *vancomycin 750 mg 1 vial twice a day Disp #*56 Vial
Refills:*0
4. Vancomycin 500 mg IV Q 12H Duration: 28 Days
RX *vancomycin 500 mg 1 vial twice a day Disp #*56 Vial
Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Lopinavir-Ritonavir 2 TAB PO BID
8. Methadone 90 mg PO DAILY
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
RX *heparin lock flush (porcine) [Heparin Lock] 10 unit/mL 2mL
every twelve (12) hours Disp #*56 Vial Refills:*0
10. Mupirocin Cream 2% 1 Appl TP TID
RX *mupirocin calcium [Bactroban] 2 % 1 application twice a day
Disp #*56 Tube Refills:*0
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
RX *sodium chloride 0.9 % [BD PosiFlush Normal Saline] 0.9 % 3mL
every twelve (12) hours Disp #*56 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MRSA Pneumonia
HIV
Hepatitis C
Hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted for
pneumonia which is a lung infection. We treated you with
intravenous antibiotics and you improved. Beacuse of the
severity of your infection we discharged you with a IV and you
will need IV antibiotics through this IV twice a day for four
weeks to make sure this infection has been completely treated.
Please follow up with your primary doctor and with infectious
disease. We also treated you for a foot and hand infection.
These have resolved. Please make sure to keep these areas dry
and clean. You may shower but place a clean dressing over the
injured area. If you are unsure how to do this please ask your
visiting nurse or call your doctor.
NEW MEDICATIONS:
Vancomycin is a IV antibiotic that a nurse ___ administer to
you once daily through your IV and you will administer once
daily at night through your IV.
Followup Instructions:
___
|
19663491-DS-7
| 19,663,491 | 23,099,981 |
DS
| 7 |
2184-11-27 00:00:00
|
2184-11-29 21:03:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
abacavir
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy (___)
___ embolization of right bronchial artery (___)
History of Present Illness:
___ history of HIV (last CD4 425, HIV DNA 240 copies in ___,
COPD, MRSA empyema, HepC, HTN, Anxiety, who presents with
worsening shortness of breath and hemoptysis over the past few
weeks. Over past week increasing volume of clotted hemoptysis.
No hemoptysis over past 2 days; however past 2 days has had
profound DOE w/o CP. Productive cough thick sputum over this ___s well. 25 pound weight loss over past year,
unintentional, and 110 pounds over past ___ years.
Patient normally on 3 L home O2 for his COPD. Endorses hot
flashes and night sweats - taking his HAART therapy. No prior hx
hemoptysis or GIB. Had EGD in ___ which showed no bleed but
indicated ___ esophagitis, s/p fluconazole Tx.
Denies hx imprisonment or travel. Lived in homeless shelter ___
years ago for 2 weeks. Multiple negative PPDs, most recently
this year. No TB history. Takes bactrim 1xDS daily for PCP ___.
In the ED, initial vitals: 99.2 90 91/56 20 87% 5L NC.
CXR was concerning for multifocal PNA vs TB.
He received 1LNS, CTX, DS Bactrim x2, Levaquin.
No transfusion or active hemoptysis in ED, HD stable, Guiac
negative.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
HIV
HTN
Obesity
Hepatitis C chronic
Tobacco dependence
Anxiety
COPD?
History of Opioid use on methadone
Social History:
___
Family History:
Father Cancer - ___
Mother- Lung condition
Physical Exam:
Admission Physical Exam:
BP: 120/80 P: 65 R: 18 O2: 100% 3L
GENERAL: AOx3, NAD, breathing comfortably
HEENT: OP clear w/o blood or secretion, no ulceration, poor
dentition
LUNGS: cta b/l, diffused expiratory wheezes and rhonchi
CV: rrr, no murmur
ABD: soft, nt, nd
EXT: Warm, well perfused, 2+ pulses
Skin: no rash
NEURO: no lateralizing motor defecits
Discharge Physical Exam:
98.3 97.6 133/84 86 18 96(3L)
General: AAOx3, NAD
HEENT: PERRL. EOMI. OP clear
Neck: Soft, supple, cachectic, no LAD
CV: RRR. S1 and S2. no m/r/g
Lungs: Breath sounds decreased on right but improved compared
to prior exam, air movement throughout lung fields. Diffuse
rhonchi, occasional wheezes as well.
Abdomen: Soft, nontender. Normoactive bowel sounds. Ventral
hernia.
Ext: Warm, well-perfused. 1+ pitting edema to shins.
Neuro: CN II-XII grossly intact. Moves all extremities.
Skin: Warm, dry, no rashes
Pertinent Results:
Admission Labs:
___ 06:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:00PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 06:00PM URINE MUCOUS-RARE
___ 01:02PM LACTATE-1.3
___ 01:00PM GLUCOSE-96 UREA N-11 CREAT-0.8 SODIUM-133
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-32 ANION GAP-9
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-28 AST(SGOT)-71* LD(LDH)-123 ALK
PHOS-85 TOT BILI-0.3
___ 01:00PM ALBUMIN-2.5* CALCIUM-8.7 PHOSPHATE-2.9
MAGNESIUM-2.0 IRON-13*
___ 01:00PM calTIBC-328 FERRITIN-84 TRF-252
___ 01:00PM WBC-9.2 RBC-2.75*# HGB-8.1*# HCT-26.0*#
MCV-95 MCH-29.5 MCHC-31.2 RDW-13.9
___ 01:00PM NEUTS-66.6 ___ MONOS-7.6 EOS-0.2
BASOS-0.3
___ 01:00PM PLT COUNT-278#
___ 01:00PM ___ PTT-28.5 ___
___ 01:00PM RET AUT-4.6*
Discharge Labs:
___ 06:00AM BLOOD WBC-5.0 RBC-3.27* Hgb-9.5* Hct-30.6*
MCV-93 MCH-29.1 MCHC-31.1 RDW-13.6 Plt ___
___ 06:00AM BLOOD ___ PTT-27.0 ___
___ 08:15AM BLOOD Ret Aut-2.1
___ 06:00AM BLOOD Glucose-93 UreaN-21* Creat-0.8 Na-131*
K-4.5 Cl-95* HCO3-33* AnGap-8
___ 03:55AM BLOOD ALT-29 AST-62* AlkPhos-84 TotBili-0.2
___ 06:00AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.8
___ 05:30PM BLOOD Cortsol-3.0
___ 06:00PM BLOOD Cortsol-12.9
___ 06:30PM BLOOD Cortsol-15.3
___ 03:34
LYMPHOCYTE SUBSET PANEL
Test Result Reference
Range/Units
% CD3 (MATURE T CELLS) 93 H ___ %
ABSOLUTE CD3+ CELLS ___
cells/uL
% CD4 (HELPER CELLS) 23 L ___ %
ABSOLUTE CD4+ CELLS 441 L ___
cells/uL
% CD8 (SUPPRESSOR T CELLS) 70 H ___ %
ABSOLUTE CD8+ CELLS 1310 H ___
cells/uL
HELPER/SUPPRESSOR RATIO 0.34 L 0.86-5.00
ABSOLUTE LYMPHOCYTES ___
cells/uL
Microbiology:
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STAPH AUREUS COAG +, STAPH AUREUS COAG +, STAPH
AUREUS COAG +, KLEBSIELLA PNEUMONIAE}; ACID FAST SMEAR-FINAL
NEG; ACID FAST CULTURE-PRELIMINARY {AFB GROWN IN CULTURE};
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL {POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII)};
MTB Direct Amplification-FINAL NEG
Studies:
CXR ___
Multi focal bronchovascular opacities suggesting an infectious
process
___ CT CHEST:
1. Extensive bilateral cylindrical and saccular bronchiectasis
with marked interval progression since ___,
including extensive peribronchial consolidation and bronchial
wall thickening. Mediastinal and hilar lymphadenopathy. Findings
likely reflect superimposed infection. However, a history of HIV
was provided on a prior imaging study, and it is noted that
neoplasm such as ymphoproliferative disorder or ___'s
sarcoma, could have a similar appearance.
2. Focal consolidation is most marked in the left upper lobe
with additional patchy areas of consolidation within the lower
lobes bilaterally. No areas of active extravasation identified
to localize a site of hemoptysis.
3. No evidence of pulmonary embolism, aortic aneurysm or
dissection.
4. Pulmonary artery enlargement consistent with pulmonary
hypertension, presumably related to underlying lung disease.
5. Splenomegaly.
___ ECHO:
The left atrial volume index is moderately increased. 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%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. 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. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Mildly dilated right ventricle.
___ CXR:
Heart size and mediastinum are unchanged. Right lower lobe
consolidation appears to be similar to the prior study. Left
basal consolidation has slightly improved. Left upper lobe
consolidation as well as nodules in the lower lobes appear to be
similar in appearance. Bronchiectasis are better assessed on the
prior chest CT. No interval increase in pleural effusion
demonstrated.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of HIV (CD4 441
(23%), VL 13,000 ___, COPD with chronic bronchiectasis (on
home ___ NC), HCV, recent ___ esophagitis (EGD ___,
s/p 2 weeks fluconazole) and hx of IV opiate dependence (on
methadone 55 mg daily) who was admitted with one month of
hemoptysis and was found to have sputum positive for
Pneumocystis jirovecii and MRSA.
#Hemoptysis:
Had hemoptysis on admission causing Hct drop from 43 to 26. This
was likely secondary to bronchial artery bleed due to erosion
from MRSA pneumonia in the setting of longstanding
bronchiectasis. On ___ he had ~400cc of hemoptysis and was
re-transferred to the ICU. On ___ he had bronchoscopy showing
RLL bleeding, and ___ embolization of the right bronchial artery
was performed. His bleeding subsequently improved. His
hemoptysis was attributed to MRSA pneumonia in the setting of
chronic bronchiectasis.
# MRSA and PCP ___:
History of profound dyspnea on exertion, hemoptysis, and HIV
positive (CD4 400s). PJP positive and MRSA from sputum culture
on ___. He also had sparse Klebsiella from sputum that was
resistant to bactrim, but likely contaminant so specific
treatment was deferred. CT chest from ___ with extensive
progressive bronchiectasis also raises concern for
superinfection. Covered initially with vanc/unasyn/bactrim,
switched to bactrim only ___ after sputum showed MRSA sensitive
to bactrim. He had 3 negative AFB's to rule out TB, and MTB
probe was also negative. His antibiotics were subsequently
switched to atovaquone/doxycycline given concern for worsening
hyperkalemia on Bactrim. At time of discharge he was on baseline
O2 requirement of 3L with no further hemoptysis. Plan was made
to treat PJP for total 21 days and MRSA for total 14 days
(details below).
# HIV:
HIV viral laod 240 in ___, however he has had ___
infection since that time (___). CD4 441, viral load 13,100
copies/ml during this admission. He did endorse missing some
doses at home of his HAART. We continued Lopinavir-Ritonavir and
Emtricitabine-Tenofovir during this admission. Infectious
disease was consulted, with suspicion that he may have another
source of immunosuppresion given PJP and ___ despite CD4
count >400.
# Hyponatremia:
History of SIADH and hypovolemia. He had urine electrolytes
checked with Na of 112 consistent with SIADH, likely
attributable to acute lung process. Review of his medication
with pharmacy revealed that Lopinavir-Ritonavir may contribute
to SIADH; however, this is not a new medication. He was
initially given salt tabs and fluid restriction, which were
discontinued prior to discharge with stabilization of serum Na.
# Suspicion for adrenal insufficiency:
Random cortisol was low at 3.0. He had ACTH stimulation test
3.0->12.9->15.3, however baseline and ACTH-stimulated total
cortisol concentrations are lower in ill patients with
hypoproteinemia. Given controversy regarding interpretation of
ACTH stimulation in acute illness, may need further assessment
as an outpatient.
# Hyperkalemia:
Treated with kayexelate x1. This was thought secondary to high
dose Bactrim, and improved after high dose Bactrim was
discontinued.
# Constipation:
Gave aggressive bowel regimen with
bisacodyl/senna/docusate/miralax/lactulose prn.
# Weight loss: Infection vs malignancy. Mediastinal/hilar
lymphadenopathy seen on CT may represent a lymphoproliferative
disorder or Kaposi's sarcoma or reaction to infection. Consider
biopsy of hilar/mediastinal LN biopsy in future as below
Chronic Issues:
# COPD: Continued albuterol neb PRN. Gave tiotropium, and
changed fluticasone to advair 250/50 per pulmonary
recommendations.
# History of IVDU: Continued methadone at 55 mg daily
# Anxiety: Continued home clonazepam Q12 PRN
TRANSITION ISSUES:
- He will need to continue a course of atovaquone after
discharge. Last day of atovaquone is ___. After finishing
atovaquone, he will resume single-strength bactrim once daily
for prophylaxis
- He will need follow-up with interventional pulmonary service
with repeat chest imaging and potential bronchoscopy with
EBUS/TBNA if he has persistent mediastinal/hilar
lymphadenopathy.
- He will need non-urgent EGD for evaluation of dysphagia
symptoms/GERD after his pulmonary issues are resolved
- He will need follow up with his HIV provider (Dr. ___
___ to reassess his response to his HAART as he had virologic
breakthrough upon admission to ___, in the setting of
endorsing missing some doses of his HAART.
- He had acid-fast bacilli on acid fast cultures in the setting
of negative MTB probe x2 and 3 negative AFB smears. He will need
followup of this finding in the outpatient setting.
- He will need a repeat TTE once his pneumonia has improved to
re-assess for RA dilatation and PA enlargement suggestive of
pulmonary hypertension.
- Consider starting tiotropium bromide for symptomatic relief of
COPD; he received this medication in-house.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lopinavir-Ritonavir 2 TAB PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H dyspnea
4. ClonazePAM 1 mg PO Q12H:PRN anxiety
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
8. Methadone 55 mg PO DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO Q12H:PRN anxiety
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Lopinavir-Ritonavir 2 TAB PO BID
4. Methadone 55 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY
6. Senna 8.6 mg PO BID
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H dyspnea
8. Polyethylene Glycol 17 g PO DAILY constipation
Hold for loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth Once a day Disp #*30 Packet Refills:*0
9. Atovaquone Suspension 750 mg PO BID
RX *atovaquone 750 mg/5 mL 5 mL by mouth Twice a day Disp #*210
Milliliter Milliliter Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*60 Capsule Refills:*0
11. Lactulose 30 mL PO DAILY constipation
RX *lactulose 20 gram/30 mL 30 mL by mouth Once a day Disp #*900
Milliliter Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Massive Hemoptysis
Pneumocystis jirovecii (carinii) and Methicillin-resistant Staph
Aureus Pneumonia
Bronchiectasis
SECONDARY DIAGNOSIS:
Human immunodeficiency virus
Chronic obstructive pulmonary disease
Hyponatremia secondary to the Syndrome of Inappropriate
Anti-diuretic hormone secretion
Chronic constipation
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 ___
___. You were admitted for shortness of
breath and an episode of coughing up blood. You were first in
the intensive care unit and then transferred to the regular
floor. Imaging of your chest showed signs of infection. Cultures
of your sputum showed multiple bacteria and you were placed on
appropriate antibiotics. Subsequently, you had more coughing of
blood and were transferred back to the intensive care unit,
where a bronchoscopy showed bleeding in the lung. This was
treated by embolizing the bleeding blood vessel. Your bleeding
subsequently improved.
After discharge, please follow up with your usual medical
providers. You will also have additional specialist appointments
(see below).
Followup Instructions:
___
|
19663531-DS-15
| 19,663,531 | 26,439,808 |
DS
| 15 |
2129-04-23 00:00:00
|
2129-04-23 13:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
sulfamethizole
Attending: ___
Chief Complaint:
s/p fall with headache, right wrist pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ female who presents to ___ s/p mechanical fall at
approximately 2:30am last night. Per patient, she was woken up
by her dog and was on the way to the bathroom and accidently
fell down 11 stairs. The patient endorses a head strike, but
denies any associated loss of consciousness. Patient denies
lightheadedness, chest pain, or other cardiac complaints prior
to fall. Denies use of Coumadin/Plavix/NOACS, but does take
Aspirin 81mg daily. CT head obtained at ___ revealed evidence
of right frontal IPH and patient was also noted to have a right
distal radius fracture. Patient endorses mild right frontal
headache but denies any nausea, vomiting, changes in vision. ACS
is consulted in the setting of the patient's polytrauma.
Past Medical History:
PMHX/PSHX: HTN, Afib, GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T 97.8, HR 80, BP 148/69, RR 14 100% RA
Gen: mild distress, nontoxic, c-collar in place
HEENT: abrasion noted over right frontal scalp; palpable
hematoma; EOMI, PERRLA, no step offs appreciated; premorbid
occlusion; no intraoral findings or lacerations
CV: Afib
P: nonlabored breathing with nasal cannula in place
GI: soft, nontender, nondistended
Ext: RUE splinted s/p closed reduction by orthopedic surgery;
Left hand with swelling of ___ digit; WWP, no CCE
Discharge Physical Exam:
AVSS
GEN: NAD, AOx3, hard of hearing
HEENT: abrasion over right frontal scalp stable, no active
bleeding; EOMI, PERRLA, MMM, sclera anicteric
CV: irregular rhythm, regular rate
PULM: CTAB, breathing comfortably on room air
GI: soft, non-tender, non-distended
EXT: RUE cast in place, L ___ digits stabilized with tape;
able to move digits on both extremities; moving ___, WWP no CCE
Pertinent Results:
Radiology:
___ Chest: No acute sequelae of trauma. Moderate intrahepatic
and extrahepatic biliary ductal dilatation with associated mild
ductal dilatation of the main pancreatic duct. Findings may
be related to sphincter of Oddi dysfunction or an occult stone
or
mass in the pancreatic head. MRCP could be considered for
further evaluation. 1 cm area of ground-glass opacity in the
left
upper lobe for which ___ month follow-up chest CT is recommended
to confirm persistence. Extensive diverticulosis.
___ wrist: Moderately comminuted fractures of the distal right
radius and ulna with moderate posterior and ulnar displacement
and angulation of the distal fracture fragments.
___ wrist: Fine bony detail is obscured due to a new overlying
cast with substantial improvement in alignment of previously
noted comminuted right wrist fracture with dorsal angulation.
Mild dorsal angulation persists on lateral views.
___ forearm: Moderately comminuted fractures of the distal
right
radius and ulna with moderate posterior and ulnar displacement
and angulation of the distal fracture fragments.
___ ___: Irregularity of the glenoid suggestive of an impaction
injury. No injury of the humeral head.
___ hand: Fourth middle phalanx is dislocated dorsally in
relation to the proximal phalanx. No acute fracture seen.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Trauma
Surgery service on ___ after a reportedly mechanical fall
from standing down 11 stairs without loss of consciousness. CT
head revealed evidence of small right frontal intraparynchamal
hemmhorage. Patient endorsed right wrist pain and xrays showed
right distal radius fracture. Further physical exam revealed
left ___ finger dislocation. Neurosurgery was consulted and
recommended Keppra for 7 days and no further intervention if
neurologic exam remains intact. Orthopedic surgery was consulted
and splinted the right wrist and left middle finger at bedside.
Hand surgery was consulted who recommended operative fixation of
the radial fracture, to be delayed one week. The patient was
admitted to the Acute Care surgery service for hemodynamic
monitoring, neurologic monitoring, and further management of her
injuries.
On HD1 she remained alert and oriented tolerating a regular
diet. Pain was controlled with oral medications. Aspirin was
held.
On HD2 she remained hemodynamically stable. She was seen and
evaluated by physical therapy who recommended discharge to an
___ rehabilitation ___. Pain was managed with oral
medications.
On HD3 she remained stable, tolerating a regular diet and was
evaluated by occupational therapy for concussion who agreed with
discharge to ___ rehab. She was
On HD4 she was deemed appropriate for discharge. She was
tolerating a diet and ambulating with assistance. Her pain is
appropriately managed with oral medications.
At time of discharge she was afebrile and hemodynamically stable
and neurologically intact. She is being discharged to rehab to
promote functional gains in ADLs and mobility. She is being
discharged on her home medications and will finish her seven-day
course of Keppra. She will follow-up with the hand surgeons
regarding operative management of the wrist fracture and finger
dislocation.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small right frontal IPH
Right distal radius fracture
Left ___ middle phalanx dorsal dislocation
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 Trauma Surgery service on
___ after sustaining a fall. You were found to have
multiple injuries including a small bleed in your head, a right
wrist fracture, and a left ___ finger dislocation. You had
frequent neurologic checks and CT head imaging that showed the
bleed was stable. There is no surgical intervention needed and
the blood with slowly reabsorb over time. You initially had the
wrist and finger injuries splinted at the bedside. The
orthopedic and hand surgery teams evaluated your injuries and
felt that operative management would be ideally scheduled for
approximately one week after surgery.
Dr. ___ has scheduled you for surgery on ___. Please
call his office with any questions or concerns at ___.
You were seen and evaluated by physical and occupational therapy
who recommended discharge to ___ rehabilitation to re-gain
your strength and mobility.
You are now doing better and ready to be discharged to rehab
with the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19663568-DS-22
| 19,663,568 | 27,591,225 |
DS
| 22 |
2148-03-27 00:00:00
|
2148-03-27 20:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Weakness, dyspnea, abnormal labs
Major Surgical or Invasive Procedure:
CT-guided lung biopsy
History of Present Illness:
___ y/o M with a h/o recent dx of
cirrhosis and metastatic HCC, h/o bladder cancer, HTN, HLD, CAD,
who recently was seen at the liver tumor clinic in ___, who
presents with leukocytosis, weakness, dyspnea.
He was recently diagnosed with cirrhosis and likely metastatic
HCC during an admission to ___. He then
established care at ___ Multi-disciplinary liver tumor clinic.
Plans were made for outpatient ___ paracentesis, as well
as
lung biopsy to confirm metastatic disease diagnosis. Labs were
done, showing leukocytosis and hypophosphatemia and
hypercalcemia.
He was called ___ by Dr. ___ elevated WBC. Plan was
established that should he develop any red flags or feel worse
for any reason he should come in to ___ ED. He has complained
of weakness, fatigue, lightheadedness upon standing, dyspnea on
exertion. Thus he came in ___. He has pain in his abdomen and
his back, and has abdominal distension. He has had a poor
appetite, nausea, and dry heaving. He denies vertigo, fever,
chills, cough.
Upon arrival to the floor, the patient endorses the history
above. Of note, he says that most of his symptoms date back to
about ___ and haven't changed much since then. He is most
bothered by a diffuse "ache" most notable in his shoulders,
back,
and hips. He also reports abdominal distention though notes this
has been present for weeks-months.
Past Medical History:
-CAD: cardiac cath ___ 50% LAD, other vessels nml and EF 75%;
treadmill stress test ___ no ischemia
-dyslipidemia
-HTN
-gout
-hiatal hernia
-prior hernia repair
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
=======================
VS: 98.4 160 / 84 65 20 93 RA
GENERAL: NAD. Mildly uncomfortable elderly M sitting upright in
bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: Supple, JVD elevated to mid-neck sitting upright
HEART: Heart sounds distant, RRR, no m/r/g
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended. Mild, diffuse TTP. BS+.
EXTREMITIES: WWP. Mild pitting edema to knee.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
=====================
24 HR Data (last updated ___ @ 849)
Temp: 98.5 (Tm 98.5), BP: 138/74 (121-138/65-82), HR: 67
(60-74), RR: 16 (___), O2 sat: 94% (94-97), Wt: 226.19
lb/102.6
kg
GENERAL: Alert and interactive, lying comfortably in bed, NAD
HEENT: NC/AT, EOMI, sclera anicteric, MMM
CV: RRR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi, unlabored
respirations
BACK: Right biopsy site dressing c/d/i
GI: Soft, distended, no TTP, no rebound or guarding, normoactive
bowel sounds, + fluid wave
SKIN: No rashes or spider angiomata
NEURO: A&Ox3, moving all four extremities with purpose
EXTREMITIES: Warm, well-perfused, 1+ pitting edema bilaterally
to
the mid-shin
Pertinent Results:
ADMISSION LABS
========================
___ 09:48AM BLOOD WBC-22.0* RBC-3.86* Hgb-11.8* Hct-35.0*
MCV-91 MCH-30.6 MCHC-33.7 RDW-17.0* RDWSD-55.9* Plt ___
___ 09:48AM BLOOD Neuts-85.9* Lymphs-4.3* Monos-7.9
Eos-0.5* Baso-0.4 Im ___ AbsNeut-18.93* AbsLymp-0.94*
AbsMono-1.74* AbsEos-0.10 AbsBaso-0.09*
___ 11:10AM BLOOD ___ PTT-34.4 ___
___ 09:48AM BLOOD Glucose-99 UreaN-20 Creat-1.1 Na-139
K-4.3 Cl-97 HCO3-26 AnGap-16
___ 09:48AM BLOOD ALT-25 AST-74* AlkPhos-236* TotBili-0.7
___ 09:48AM BLOOD Lipase-130*
___ 09:48AM BLOOD Albumin-3.3* Calcium-12.1* Phos-1.7*
Mg-1.7
RELEVANT STUDIES
=======================
___ RUQ U/S:
1. Patent portal vein.
2. Liver mass nearly replacing the central portion of the liver
is better seen on the outside MRI from ___.
___ CT-GUIDED LUNG BIOPSY:
1. CT-guided core needle biopsy of the largest right lower lobe
nodule, with specimens submitted to pathology.
2. Moderate postprocedural pulmonary hemorrhage and trace right
pneumothorax.
RECOMMENDATION(S):
1. Close clinical follow-up of patient's respiratory status and
vital signs.
2. Repeat chest x-ray at 2 hours and 4 hours to exclude
expanding
pneumothorax.
___ CXR PORTABLE AP:
1. No appreciable pneumothorax. The small right apical
pneumothorax on
CT-guided biopsy from earlier the same day is not seen on the
current study.
2. Focal density located at the lateral aspect of the right
lower lung base measures approximately 6.4 x 5.2 cm, and is
compatible with post procedural changes after the biopsy as seen
on prior CT from ___.
___ CXR PORTABLE AP:
1. Appropriate right-sided postprocedural changes status post
biopsy.
2. Known pneumothorax on the prior CT, is not definitively seen
on the current radiograph.
3. Multiple bilateral pulmonary nodules are re-demonstrated.
___ SECOND READ CT TORSO:
-Large number of pulmonary metastatic nodules.
-Small ascites is new since CT abdomen and pelvis ___.
___ SECOND READ MR TORSO:
1. Infiltrative mass involving the entire left lobe of the liver
with
innumerable small satellite nodules seen in the right lobe of
the liver in
primarily segment VIII and segment V, findings are highly
concerning for
cirrhotometic hepatocellular carcinoma.
2. Left hepatic vein is thrombosed. Right and middle hepatic
veins are
patent but attenuated. Left portal vein is also attenuated.
3. Focal edema surrounding/interdigitating between the
pancreatic head and
pancreaticoduodenal groove, concerning for acute pancreatitis,
recommend
correlation with lipase.
4. Bilateral complex renal cysts with the most suspicious 4.4 cm
hemorrhagic
cyst in the left mid pole with thickened septations, for which
short-term
six-month follow-up is recommended.
RECOMMENDATION(S):
1. Correlation with lipase.
2. Six-month follow-up evaluate complex renal cysts.
___ CXR PORTABLE AP:
The 3.5 x 5.4 cm nodular opacity in the right lower lobe is
unchanged.
Multiple scattered pulmonary nodules are again seen.
Cardiomediastinal
silhouette is stable. There is no pleural effusion. No
pneumothorax is seen. There is evidence of internal replacement
of the left humerus.
MICROBIOLOGY
=======================
Urine, blood, and ascetic fluid negative for bacterial growth.
DISCHARGE LABS
=======================
___ 06:37AM BLOOD WBC-19.4* RBC-3.70* Hgb-11.2* Hct-34.3*
MCV-93 MCH-30.3 MCHC-32.7 RDW-18.0* RDWSD-60.3* Plt ___
___ 06:37AM BLOOD ___ PTT-36.5 ___
___ 06:37AM BLOOD Glucose-85 UreaN-23* Creat-1.4* Na-139
K-4.0 Cl-100 HCO3-25 AnGap-14
___ 06:37AM BLOOD ALT-33 AST-98* AlkPhos-274* TotBili-1.1
___ 01:05PM BLOOD Phos-2.3* UricAcd-7.5*
___ 06:37AM BLOOD ___-77*
Brief Hospital Course:
Mr. ___ is a ___ male with hx of
recently-diagnosed cirrhosis and presumed metastatic HCC, hx
bladder cancer, HTN, HLD, CAD, who was recently seen at ___
tumor clinic in ___ and presented with weakness, dyspnea, and
leukocytosis.
ACUTE PROBLEMS
===============================
# Leukocytosis:
Patient was noted to have leukocytosis from ___ during recent
___ admission which was unexplained. Blood and urine
cultures were negative. Peritoneal fluid from ___ diagnostic
paracentesis grew one colony on one culture of yeast. Infectious
Disease evaluated patient and thought this positive culture was
likely contaminant because he had recent history of leukocytosis
with no other systemic signs or symptoms. Repeat paracentesis
was done on ___ which showed no evidence of infection at time of
discharge with final cultures pending. Beta-glucan and
galactomannan negative. Antibiotics were not initiated given
clinical stability. White count remained elevated at time of
discharge, but stable.
# Hepatocellular carcinoma:
Presumed diagnosis was made during recent admission at ___
___. He met with ___ liver tumor clinic and had labs
showing leukocytosis. In conjunction with his constitutional
symptoms, he was admitted for further work-up. CT-guided biopsy
of lung nodules was done on ___ with pathology prelim showing
poorly differentiated carcinoma.
# Cirrhosis:
Decompensated by ascites though low volume with only 500 cc able
to be removed during admission. He has no history of hepatic
encephalopathy and recent EGD did not show varices. Lasix 20 mg
daily and Spironolactone had been started three days before
admission and were held pending infectious work-up. Patient
remained stable and Lasix/spironolactone were restarted with
improvement in lower extremity edema. Continued thiamine,
folate, MVI w/ minerals.
# Hypercalcemia:
# Hypophosphatemia:
PTH and Vitamin D both low. Electrolyte abnormalities were
suspected to be secondary to metastatic disease. Bone scan was
deferred during this admission because patient does not know
where he will get oncologic care. ___ be a contributor to his
fatigue and abdominal discomfort though also has known HCC as
above. He was given one dose of pamidronate on ___ with
subsequent improvement of calcium. His phosphorous was repleted
but proved difficult to maintain. Endocrine was consulted for
guidance with work-up for his refractory hypophosphatemia,
checked repeat PTH, PTHrp, 1,25 via D, FGF-23, and 12hr uric
Na/Phos/Cr which were all pending at time of discharge. Patient
discharged with 500 mg PO phosphate TID.
# Right PTX:
Developed iatrogenic right pneumothorax due to CT-guided biopsy.
He had mild hemoptysis which resolved and no hypoxemia. He was
monitored with serial X-rays for 24 hours with resolution of
PTX.
# HTN: Held Moexipril, continued verapamil.
TRANSITIONAL ISSUES
================================
Discharge weight: 104.9 kgs
Code Status: DNR/DNI confirmed with patient
Health care proxy: ___ (wife), ___
[] Please refer to endocrinology in ___ for hypercalcemia
and hypophosphatemia. Patient did not want to follow with
endocrinology in ___ due to distance.
[] Please follow-up lung biopsy results in ___ clinic.
Patient has appointment in ___ and in ___ with liver
tumor clinic due to patient wanting to be treated in ___
close to home.
[] Please check CHEM-10 at follow-up visit on ___. Monitor for
hypocalcemia s/p pamidronate. Also required significant
phosphorous repletion and will be discharged on daily
phosphorous. Please discontinue PO phosphorus if phosphate level
>2.5 on ___.
[] if elevated BP, can consider restarting moexipril if Cr close
to baseline (1.1).
[] Follow up PTHrP and other tests for hypercalcemia which are
pending at discharge. Consider bone scan if warranted in further
oncologic evaluation given hypercalcemia most likely from
malignancy.
[] Consider repeat MRI Abdomen. MRI Abdomen from ___ showed
bilateral complex renal cysts with most suspicious 4.4 cm
hemorrhagic cyst in the left mid-pole with thickened septations.
Recommend short-term six-month follow-up.
[] As per patient desire, would consider medications that can be
discontinued if limited benefit as patient overwhelmed by number
of medications has to be taken.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. Ranitidine 150 mg PO BID
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Furosemide 20 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Verapamil SR 360 mg PO Q24H
7. Tamsulosin 0.4 mg PO QHS
8. Pravastatin 20 mg PO QPM
9. Finasteride 5 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Moexipril 30 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Diclofenac Sodium ___ 50 mg PO BID
16. Ondansetron 8 mg PO Q8H:PRN Nausea
17. Simethicone 120 mg PO QID:PRN Gas pain
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl [Alophen] 5 mg 1 tablet(s) by mouth once a day
Disp #*1 Tablet Refills:*0
2. Phosphorus 500 mg PO TID
RX *sod phos di, mono-K phos mono [Phospha 250 Neutral] 250 mg 2
tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s)
by mouth once a day Disp #*1 Bottle Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp
#*30 Tablet Refills:*0
5. Allopurinol ___ mg PO DAILY
This is for preventing gout
6. Aspirin 81 mg PO DAILY
7. Finasteride 5 mg PO DAILY
This is for your prostate
8. Fluticasone Propionate NASAL 2 SPRY NU BID
This is for nasal congestion
9. Furosemide 20 mg PO DAILY
This medication is to reduce the extra water in your body
10. Multivitamins 1 TAB PO DAILY
This is to help for nutrition
11. Omeprazole 20 mg PO BID
This is for acid reflux. If you do not have further acid reflux
you can consider stopping
12. Ondansetron 8 mg PO Q8H:PRN Nausea
This is for if you have nausea
13. Pravastatin 20 mg PO QPM
This is for your cholesterol. You can talk to your doctor if you
want to continue this medication
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
This medication is another one for nausea
15. Ranitidine 150 mg PO BID
This is for acid reflux. If you do not have further acid reflux
you can consider stopping
16. Simethicone 120 mg PO QID:PRN Gas pain
This is for gas pain if you have it
17. Spironolactone 50 mg PO DAILY
This medication is to reduce the extra water in your body
18. Tamsulosin 0.4 mg PO QHS
This is for your prostate
19. Verapamil SR 360 mg PO Q24H
This is for your blood pressure, you can talk to your doctor if
you want to continue this medication
20. HELD- Moexipril 30 mg PO DAILY This medication was held. Do
not restart Moexipril until seeing your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Decompensated Cirrhosis
Hepatocellular carcinoma
Acute Kidney Injury
Secondary diagnosis:
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 here?
- You were admitted to the hospital because you had weakness,
shortness of breath, and a high white blood cell count.
What was done for me while I was here?
- You had fluid removed from your belly which grew yeast. The
Infectious Disease doctors saw ___ and thought this yeast was
contamination. You had fluid removed from your belly again.
- You had a biopsy of the nodules in your lung. After the
biopsy, you had shortness of breath and some collapsed lung
(pneumothorax). Your breathing was monitored and the collapsed
lung improved.
- You were dehydrated and given albumin.
- You had low phosphorous which was repleted
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should attend all of your follow-up appointments including
in liver tumor clinic.
- You will hear from Dr. ___ your biopsy results.
If you do not hear in 1 week, please call her office at ___
Take care.
YOUR ___ Team
Followup Instructions:
___
|
19663837-DS-11
| 19,663,837 | 28,383,809 |
DS
| 11 |
2175-05-20 00:00:00
|
2175-05-20 11:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain and headache
Major Surgical or Invasive Procedure:
___ L craniotomy for evacuation of L ___
History of Present Illness:
___ h/o PE on coumadin, DM2, PMR, who presents with 2 weeks of
frontal and occipital/neck headache. Her headache occurred some
time after she rolled out of bed and may have struck her head.
She had EVAL after that fall and had negative head CT per
patient. Headache is constant, not associated with visual
changes, dizziness, nausea, and is not associated with
phono-photophobia. Tylenol helps to reduce head discomfort. No
fevers or new focal weakness or confusion.
She also presents with 5d of gradual onset and now worsening LLQ
pain associated with pain involving the R thigh. Pain is worse
when she sits upright. and when she extends at the R hip. She
has not had recent trauma to that area. She has no associated
urinary or GI symptoms including dysuria or
constipation/diarrhea.
She presented to OSH ED and then to ___. Here ED eval
including CT abdomen without acute or explanatory pathologic
changes. She is hungry and requests food and has ongoing
headache. Pain is improved with the dilaudid she received down
stairs.
13pt ROS otherwise negative
All clinical information confirmed wiht patient and with review
of OMR.
Past Medical History:
History of 2 pulmonary emboli, on lifelong warfarin, last PE
___
PMR on chronic prednisone
Hypertension
Hyperlipidemia
Type 2 Diabetes
Osteoporosis
Osteoarthritis
Aortic aneurysm -4.8cm ascending aortic aneurysm, currently
being followed with Q6 month scans as pt refused surgery
Insomnia
GERD
H. Pylori s/p triple therapy ___
Pituatary adenoma s/p resection
adhesive capsulitis
s/p appy
s/p cholecystectomy
s/p ovarian cyst removal
Social History:
___
Family History:
Mother died at age ___ of asthma, father died at age ___ of
pulmonary edema. Pt with one sister who died at ___ from an MI
and a brother who died in his ___ of a heart attack. Pt's
daughter has a heart valve problem.
Physical Exam:
afebrile 128/61 80 18
tired
facial features symmetric
eomi, perrl
tongue and pharynx midline
no facial numbness
no meningismus
some increased tone and possible spasm R neck muscles
clear BS
regular s1 and s2
RLQ and LLQ tender but not distended, no guarding
she has tenderness but no masses or guarding
no cord palpated
no peripheral edema
various skin abrasions
full motor strength in UE and ___, R hip extension/flexion
limited by pain.
upon discharge:
alert and oriented x 3
Pertinent Results:
___ 11:10PM BLOOD WBC-3.6* RBC-3.34* Hgb-10.5* Hct-33.6*
MCV-101* MCH-31.5 MCHC-31.3 RDW-15.1 Plt ___
___ 11:10PM BLOOD Neuts-56.5 ___ Monos-3.3 Eos-0.9
Baso-0.3
___ 11:10PM BLOOD ___ PTT-54.8* ___
___ 11:10PM BLOOD Glucose-116* UreaN-12 Creat-1.0 Na-136
K-3.8 Cl-106 HCO3-22 AnGap-12
___ 11:10PM BLOOD ALT-19 AST-32 AlkPhos-63 TotBili-0.4
___ 11:10PM BLOOD Albumin-4.2
CT Abdomen & Pelvis: ___
1. No acute abnormality in the abdomen or pelvis. No small-bowel
obstruction.
2. The urinary bladder is prominent, but there is no evidence of
prolapse on Preliminary Reportthis static study.
3. Intrahepatic biliary duct dilation is unchanged.
MRI Brain: ___
Subacute subdural hematoma with significant mass effect and
midline shift.
CT Head: ___
1. Stable size of large left subdural hemorrhage.
2. Midline shift is unchanged. Asymmetry of the suprasellar
cistern with
medial deviation of the left uncus, but no frank herniation.
CT Chest: ___
As compared to the previous radiograph, no relevant change is
seen. Moderate cardiomegaly. No pulmonary edema. No pleural
effusions. No pneumonia. Mild elevation of the right
hemidiaphragm.
CT Head: ___
1. Stable size of large left subdural hematoma. No new areas of
hemorrhage.
2. No change to midline shift or medial migration of the left
uncus with
effacement of the left suprasellar cistern.
Chest X-Ray: ___
As compared to the previous radiograph, a minimal atelectasis at
the left lung base has newly appeared. No other changes. Massive
tortuosity of the thoracic aorta. Normal lung volumes. No
pneumonia, no pneumothorax.
Chest X-Ray: ___
As compared to the previous radiograph, the pre-existing
platelike atelectasis at the left lung bases has completely
resolved. No new opacities. Otherwise unchanged appearance of
the cardiac silhouette and of the lung parenchyma.
CT Head: ___
1. Status post evacuation of left subdural hematoma, now with
left subdural fluid and a small amount of blood. Decreased mass
effect.
2. New subarachnoid hemorrhage within the suprasellar and right
prepontine cistern.
Brief Hospital Course:
___ with 2 problems:
1)Headache:
2)Abdominal Pain/R hip pain
#L SDH:
Recent CT at OSH ED on ___ negative for intracranial bleed.
This is important finding as she is anticoagulated and she
sufferred fall out of bed >2w ago. She reports having had CT
head following fall (that day). Her headache has not changed in
character since her CT on ___. She has associated R neck
muscle tightness/spasm suggesting possible muskuloskeletal
component. Important feature of PMH is resected pituitary
macroadenoma. I spoke to PCP to confirm that patient had visit
at OSH ED where CT head was performed and did not show
intra-cranial hemorrhage. Patient also saw her rheumatologist
recently who felt that patient did not have features consistent
with GCA and that her ESR was only modestly elevated and in the
past she has had chronic headache. Given the past pituitary
macroadenoma resection, a pituitary MRI was obtained and this
showed L SDH with 9mm mid-line shift. Neurosurgery consulted
and she was transferred to Neuro-ICU. She received FFP and
coumadin and ASA were stopped.
2)Abdominal pain
3)R hip pain
4)PMR:
Bilateral low quadrant abd painCT x2 this week of the abdomen
pelvis has been relieving. She has no obvious deformities or
easily appreciated hernias. She had unremarkable pelvic and
bimanual exam. There is no role for antibiotics. I spoke with
radiology who did not see evidence of avascular necrosis in her
hips/femur. I suspect possible worsening of her PMR causing hip
girdle pain and headache. I spoke with her rheumatologist who
concurs and advised repeating ESR/CRP and initiating prednisone
20mg daily.
5)Chronic PE:
--hold coumadin as INR >3
#DM2: listed in problem list but not on therapy and her A1c is
6.3 in her pcp ___
#hypertension: continue amlodipine 5mg, lisinopril 20mg,
metoprolol 25mg daily
I spoke with PCP directly on ___ and I spoke with
rheumatologist on ___ and then PCP coverage on ___.
Patient was transferred to the neurosurgery service. On ___, she
was taken to the OR for a left subdural hematoma evacuation.
She was extubated without incident and transferred to ICU for
further managment. Post op CT on ___ showed minimal residual
left SDH and improved shift. Clinically she improved. There
was minimal drainage from SD drain as a result it was removed in
routine fashion. ___ was d/c'd and was transferred to floor
in stable conditon. ___ was consulted.
On ___, the patient continued with complaints of right upper
extremity arthritic pain which made moving the upper extremity
difficult. Her SBP was 90 while lying this morning and 70 upon
sitting up. She received a 500cc normal saline bolus. She was
started on Bactrim for a positive urine culture.
On ___, the patient continued with right upper extremity pain
secondary to baseline arthritis. Aspirin 81mg was re-started.
She was seen by physical therapy who recommended on ___ that
the patient be discharged to rehab and rehab screen was
initiated.
On ___ she remained stable while awaiting rehab and was
mobilizing with ___ utilizing a walker.
On ___ she continued to ambulate with a walker with ___ and was
awaiting a rehab bed.
ON ___ Patient remained stable, awaiting rehab placement
On ___ Patient's sutures were removed. Her incision was c/d/i.
She was discharged to rehab in good condition with instructions
for follow up.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 1250 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 3 mg PO DAILY
6. QUEtiapine Fumarate 25 mg PO QHS
7. Simvastatin 10 mg PO DAILY
8. TraMADOL (Ultram) 100 mg PO BID
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
10. Aspirin 81 mg PO DAILY
11. Docusate Sodium 100 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Warfarin 3 mg PO DAYS (___)
14. Ferrous Sulfate 325 mg PO DAILY
15. Amlodipine 5 mg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
17. Alendronate Sodium 70 mg PO Frequency is Unknown
18. Warfarin 5 mg PO DAYS (MO)
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1250 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 20 mg PO DAILY
11. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6 hours PRN Disp
#*45 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
to complete 7 day course started ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*3 Tablet Refills:*0
17. Simvastatin 10 mg PO DAILY
18. QUEtiapine Fumarate 25 mg PO QHS
19. Vitamin D 800 UNIT PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L SDH
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:
Have a friend/family member check your incision daily for signs
of infection.
¨ Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
¨ You were on Coumadin prior to your injury, the decision to
restart this will be made at your followup appointment
¨ You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
¨ Clearance to drive and return to work will be addressed at
your post-operative office visit.
¨ Make sure to continue to use your incentive spirometer
while at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ Any signs of infection at the wound site: redness,
swelling, tenderness, or drainage.
¨ Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
19663837-DS-12
| 19,663,837 | 27,823,791 |
DS
| 12 |
2175-12-24 00:00:00
|
2175-12-30 18:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year old woman with PMR (on chronic prednisone),
h/o PE x2 (no longer on warfarin, s/t to ___), h/o SDH in ___
s/p evacuation who presents with 2 weeks of worsening unilateral
headaches without associated alarm signs, in the absensce of
trauma and anticoagulation, as well as malaise, lethargy,
anhedonia and decreased appetite/PO intake. Admitted for failure
to thrive, headache evaluation.
Past Medical History:
History of 2 pulmonary emboli, on lifelong warfarin, last PE
___
PMR on chronic prednisone
Hypertension
Hyperlipidemia
Type 2 Diabetes
Osteoporosis
Osteoarthritis
Aortic aneurysm -4.8cm ascending aortic aneurysm, currently
being followed with Q6 month scans as pt refused surgery
Insomnia
GERD
H. Pylori s/p triple therapy ___
Pituatary adenoma s/p resection
adhesive capsulitis
s/p appy
s/p cholecystectomy
s/p ovarian cyst removal
Social History:
___
Family History:
Mother died at age ___ of asthma, father died at age ___ of
pulmonary edema. Pt with one sister who died at ___ from an MI
and a brother who died in his ___ of a heart attack. Pt's
daughter has a heart valve problem.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VSS
General: Alert, oriented x3, no acute distress, ___ speaking
HEENT: Sclerae anicteric, MMM, oropharynx clear - dentures on
upper & lower, EOMI, PERRL, no TTP or 'bead like' over the
temporal areas bilaterally
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: CN II-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
bilaterally.
Skin: dermal thinning, multiple bruises, without rashes or
lesions
PHYSICAL EXAM ON DISCHARGE
Unchanged
Pertinent Results:
LABS ON ADMISSION
___ 11:10AM BLOOD WBC-7.3 RBC-3.77*# Hgb-11.6*# Hct-36.3#
MCV-96 MCH-30.9 MCHC-32.0 RDW-15.6* Plt ___
___ 11:10AM BLOOD Neuts-73.6* ___ Monos-2.7 Eos-0.9
Baso-0.3
___ 11:43AM BLOOD ___ PTT-33.3 ___
___ 11:10AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-142
K-3.9 Cl-104 HCO3-26 AnGap-16
___ 11:17AM BLOOD Lactate-2.3*
INTERVAL LABS, IMAGING STUDIES
___ CXR
No acute intrathoracic process.
___ NON-CONTRAST CT HEAD
No acute intracranial process. Mild small vessel disease.
___ MR head
1. Thickening and contrast enhancement of the dura along the
left convexity, compatible with sequela of prior left subdural
hematoma and surgical intervention in ___. No pathologic
extra-axial collection and no other acute abnormalities are seen
at this time.
2. Postsurgical changes in the sella are not adequately
assessed. A
previously noted small enhancing focus in the right aspect of
the sella is grossly unchanged, but could be better assessed by
dedicated pituitary MRI, if clinically warranted.
MICRO: Blood and urine cultures negative
LABS ON DISCHARGE
___ 06:30AM BLOOD WBC-4.7 RBC-3.51* Hgb-11.1* Hct-33.0*
MCV-94 MCH-31.6 MCHC-33.5 RDW-15.4 Plt ___
___ 06:30AM BLOOD Glucose-76 UreaN-17 Creat-0.9 Na-143
K-4.2 Cl-108 HCO3-26 AnGap-13
___ 06:30AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.1
Brief Hospital Course:
This is an ___ year old woman with PMR (on chronic prednisone),
h/o PE x2 (no longer on warfarin, s/t to ___), h/o SDH in ___
s/p evacuation who presents with 2 weeks of worsening unilateral
headaches without associated alarm signs, in the absensce of
trauma and anticoagulation, as well as malaise, lethargy,
anhedonia and decreased appetite/PO intake, consistent with
depression.
ACTIVE ISSUES.
# HEADACHE. The patient reports history of occasional headache
since the evacuation of her ___ in ___, but worsening of
headache symptoms over the past two weeks. This worsening of
headache was accompanied by URI-type symptoms, including sore
throat, cough and chills, without fever. She has no tenderness
to palpation over the temporal arteries bilaterally. Likely due
to dehydration/ URI. Analgesia for headache was achieved with
APAP 1 g TID. CT and MRI of the head was unrevealing; no
evidence of bleed. She will follow up with her neurosurgeon, as
was supposed to 4 weeks post-operatively (___). Advised to
follow up with ___ Neurology: Headache Clinic if headaches
persist.
# DEPRESSION. The patient and her daughter endorse worsening
sadness, anhedonia, decreased energy, decrease appetite and
difficulty sleeping since her long hospitalization and the death
of her sister. Her ___ was going to arrange a therapist to come
to the house, but this hasn't been done yet. She has never taken
any antidepressant medications, but is open to it. Started
mirtazapine 7.5 mg HS. Nutrition recommended increasing Ensure
supplementation to TID.
# CONFUSION. The patient's daughter reports intermittent
episodes of confusion since starting codeine for analgesia. CT
head was negative for intracranial pathology. The patient is A&O
x3 on interview and has remained so throughout her
hospitalization. The most likely etiology is polypharmacy,
including codeine. The patient does not have a history of any
memory difficulties or disorders. Codeine was discontinued in
favor of Tramadol, with lidocaine patches for arthritis pain.
CHRONIC, INACTIVE ISSUES.
# HISTORY OF SUBDURAL HEMATOMA (___). Was in the setting of
anticoagulation for history of pulmonary emboli and a fall.
Since the evacuation of her SDH, she has been on leviteracetam
for seizure prophylaxis. Leviteracetam continued. MRI head was
unrevealing. Will follow up with neurosurgery as an outpatient.
# OSTEOARTHRITIS. Patient with significant pain secondary to
arthritis - worse in the shoulders bilaterally, but also
affecting the hands. At home pain regimen recently changed from
tramadol to codeine, however, likely contributing to confusion
(as above). Codeine stopped and restarted Tramadol, APAP 1g TID
standing, with lidocaine patches as well to good effect.
# POLYMALGIA RHEUMATICA. Patient is stabilized on regimen of
prednisone 3 mg daily and methotrexate 2.5 mg weekly. Continued
regimen.
# HYPERTENSION. Patient carries history of refractory
hypertension and is on an antihypertensive regimen consisting of
lisinopril 20 mg daily, amlodipine 5 mg daily, metoprolol
succinate 20 mg daily. Continued regimen.
# HYPERLIPIDEMIA. Stable. Continued home simvastatin 10 mg HS
and ASA 81 mg.
# HISTORY OF PULMONARY EMBOLI. The patient carries this
diagnosis. In the past, she was treated with warfarin, however,
anticoagulation was stopped in the setting of a fall and brain
bleed. VenoDynes used for DVT prevention.
# OSTEOPOROSIS. Stable. Continued home alendronate 70 mg q
___.
# GERD. Stable. Continued omeprazole 20 mg daily.
***** TRANSITIONAL ISSUES *****
- Will need follow up with PCP ___: mirtazapine dosing increase
- Follow up with Dr. ___ - was due in ___
after evacuation of ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
2. Alendronate Sodium 70 mg PO QTHUR
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Vitamin D 400 UNIT PO BID
7. Codeine Sulfate ___ mg PO Q4-Q6H PRN pain
8. Cyanocobalamin 1000 mcg PO DAILY
9. diclofenac sodium 1 % topical qid prn
10. Docusate Sodium 100 mg PO BID
11. Ferrocite (ferrous fumarate) 324 mg (106 mg iron) oral daily
12. FoLIC Acid 1 mg PO DAILY
13. LeVETiracetam 500 mg PO BID
14. Xylocaine Ointment 5% 1 Appl TP TID:PRN pain
15. Lisinopril 20 mg PO DAILY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. PredniSONE 3 mg PO DAILY
19. QUEtiapine Fumarate 25 mg PO QHS
20. Simvastatin 10 mg PO QPM
21. TraMADOL (Ultram) 50 mg PO BID
22. Methotrexate 2.5 mg PO QMON
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
2. Alendronate Sodium 70 mg PO QTHUR
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. LeVETiracetam 500 mg PO BID
10. Lisinopril 20 mg PO DAILY
11. Methotrexate 2.5 mg PO QMON
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. PredniSONE 3 mg PO DAILY
15. QUEtiapine Fumarate 25 mg PO QHS
16. Simvastatin 10 mg PO QPM
17. TraMADOL (Ultram) 50 mg PO BID
18. Vitamin D 400 UNIT PO BID
19. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
20. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth before bed Disp #*30
Tablet Refills:*0
21. Ferrocite (ferrous fumarate) 324 mg (106 mg iron) oral daily
22. Xylocaine Ointment 5% 1 Appl TP TID:PRN pain
23. diclofenac sodium 1 % TOPICAL QID prn
24. Ensure TID with meals
Ensure supplements with meals, TID
25. Lidocaine 5% Patch 2 PTCH TD QAM to shoulders for pain
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Please apply to
affected area daily for 12 hours, then remove for 12 hours daily
Disp #*15 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: headache, depression
Secondary diagnoses: ___ year old with multiple medical problems,
including h/o prior intracranial hemorrage s/p evacuation in
___, pulmonary emboli, HTN and an ascending aortic aneurysm
who presents with 2 weeks of headache & malaise.
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:
Sra. ___,
Fue admitido ___ ___
___. Se han hecho un MRI (escan) ___ y no habia
ningun tumor o sangre. Para ___, se ___ con Tylenol con ___. Nos parecia ___
___, por eso empezamos un medicamento (mirtazapine) para
___ ___ ayudar con ___, sueno y humor.
Hemos hecho una cita con ___ general y neurocirujano (vea
abajo). Sigue con ellos.
Fue un placer cuidarle mientras estara ___ hospital. Cuidese!
- ___ medico de ___
----
Dear Ms. ___,
You were admitted to ___ for headaches. You had an MRI that
showed no masses or bleeds. Your headaches were treated with
Tylenol with good effect. You were found to be depressed, for
which we started an antidepressant called mirtazapine. Follow up
with your primary care doctor & neurosurgeon (see appointments
below)
It was a pleasure caring for you! Take good care of yourself.
- Your team at ___
Followup Instructions:
___
|
19663837-DS-5
| 19,663,837 | 25,295,755 |
DS
| 5 |
2173-10-18 00:00:00
|
2173-10-18 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache/fatigue
Incidental Pulmonary Embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMH of pituitary adenoma s/p
reseaction ___ who presented to the ED with complains of
headache and lethargy. She has had a frontal HA with some neck
pain, decreased PO intake. Per her daughter, today the pt has
been quite thristy and eating well. No sick contacts. On the way
here, developed decreased sensation to left arm and leg. Denied
chest pain, shortness of breath in the ED. ECG in the ED showed
new TWI V2-6. She ws initially observed in the ED and had 2
negative troponins and a negative p-MIBI stress test. Per ED
ntoes, her HA improved during her time there. Given the Hx of an
abdominal aortic aneurysm for which the pt has previosuly
declined surgery, a CTA was persued after discussion with the
patient's family. There is no prior imaging in our system, but
per family report, the scan done in the ED showed the AAA to be
stable in size. The scan did show a R segmental PE. Pt given a
4200 units bolus of heprin and currently on gtt at 950 units/hr.
She is being admitted for anti-coagulation for her PE.
Neurosurgery was consulted and felt that her recent surgery was
not a contraindication to anti-coagulation.
In the ED, initial VS were: 97.4 72 121/70 20 98%. Prior to
transfer, T 97.4, HR 74, RR 16, BP 122/74, 100% RA
On arrival to the floor, pt has mild HA but otherwise no
complaints. She is accompanied by her daughter.
REVIEW OF SYSTEMS:
(+) Nasal congestion, HA as noted above, abdominal bloating
(-) fever, chills, vision changes, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, hematuria, edema.
Past Medical History:
- HTN
- HL
- DM2
- osteoporosis
- arthritis; needs bilateral shoulder surgery for "bone on bone"
arthritis
- 4.8cm ascneding aortic aneurysm, currently being followed with
Q6 month scans as pt refused surgery
- s/p CCY
- s/p appy
- s/p R knee repair surgery
Social History:
___
Family History:
mother died at age ___ of asthma, father died at age ___
of pulmonary edema.
Pt with one sister who died at ___ from an MI and a brother who
died in his ___ of a heart attack. Pt's daughter has a heart
valve problem.
Physical Exam:
PHYSICAL EXAM ON ADMISSION ___:
VS - Temp 97.4F, BP 159/65, HR 52, R 18, O2-sat 100% RA
GENERAL - well-appearing elderly hispanic F in NAD, comfortable,
appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear, No
frontal or maxillary sinus tenderness.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, alert, appropraite, moving all extremities
spontaneously
PHYSICAL EXAM ON DISCHARGE ___:
VS - Temp 97.4F, BP 159/65, HR 52, R 18, O2-sat 100% RA
GENERAL - well-appearing elderly hispanic F in NAD, comfortable,
appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear, No
frontal or maxillary sinus tenderness.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, alert, appropraite, moving all extremities
spontaneously
Pertinent Results:
LABS:
___ 10:40AM BLOOD WBC-7.7 RBC-4.46 Hgb-12.8 Hct-38.8 MCV-87
MCH-28.8 MCHC-33.1 RDW-14.7 Plt ___
___ 07:30AM BLOOD WBC-7.5 RBC-3.72* Hgb-11.0* Hct-33.6*
MCV-90 MCH-29.6 MCHC-32.8 RDW-15.1 Plt ___
___ 10:40AM BLOOD Neuts-53.8 ___ Monos-3.5 Eos-0.7
Baso-0.5
___ 10:40AM BLOOD ___ PTT-33.2 ___
___ 10:40AM BLOOD Glucose-118* UreaN-8 Creat-1.0 Na-139
K-3.4 Cl-101 HCO3-22 AnGap-19
___ 07:30AM BLOOD Glucose-98 UreaN-10 Creat-0.9 Na-149*
K-3.3 Cl-115* HCO3-22 AnGap-15
___ 01:15PM BLOOD Creat-0.9 Na-141 K-3.6 Cl-107
___ 10:40AM BLOOD ALT-39 AST-30 AlkPhos-107* TotBili-0.4
___ 10:40AM BLOOD Lipase-31
___ 04:20PM BLOOD cTropnT-<0.01
___ 10:40AM BLOOD cTropnT-<0.01
___ 10:40AM BLOOD Albumin-5.0
___ 07:30AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0
___ 07:30AM BLOOD Osmolal-293
___ 10:53AM BLOOD Lactate-3.4*
___ 04:29PM BLOOD Lactate-2.2*
___ 07:48AM BLOOD Lactate-1.9
___ 01:03PM URINE Mucous-RARE
___ 01:03PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-6
TransE-<1
___ 01:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 01:03PM URINE Color-Straw Appear-Clear Sp ___
MICROBIOLOGY:
URINE CULTURE (Final ___: <10,000 organisms/ml.
RADIOLOGY:
CT OF HEAD WITHOUT CONTRAST ___:
IMPRESSION: Post-surgical appearance of transsphenoidal
hypophysectomy
without evidence of recurrence. Mucosal thickening evident
within the
sphenoid sinus. No intracranial hemorrhage. Prominent sulci
and ventricles consistent with age-related parenchymal
involution.
CXR ___:
IMPRESSION: No acute cardiac or pulmonary process.
CTA WITH AND WITHOUT CONTRAST ___:
IMPRESSION:
1. Segmental pulmonary embolism involving the superior right
lower lobe
pulmonary artery. No pulmonary infarct or CT evidence of right
heart strain.
2. Minimal bibasilar atelectasis.
3. 4.6 cm ascending aortic aneurysm. No prior imaging to
assess for interval
change in size. No signs of acute aortic syndrome.
CARDIOLOGY:
EKG ___:
Sinus rhythm. Prolonged Q-T interval. Possible old inferior wall
myocardial infarction. T wave changes in the precordial leads.
Consider anterolateral ischemia. Compared to the previous
tracing of ___ precordial T wave changes are new.
CARDIOVASCULAR STRESS TEST ___
INTERPRETATION: This ___ yo NIDDM woman with a PMH of HTN & HLD
was
referred to the lab for evaluation of chest pain and an abnormal
EKG.
The patient was infused with 0.142 mg/kg/min of IV Dipyridamole
over 4
minutes. The patient presented with her typical left arm pain
(present
for over ___ year). This discomfort was unchanged throughout the
procedure
and she denied any other arm, back, neck, or chest discomforts.
There
were no significant ST segment changes seen during the infusion
or
recovery. The rhythm was sinus with frequent isolated APBs.
Appropriate
hemodynamic response to the infusion. Two minutes post-isotope
injection
the infusion was reversed with 125 mg IV Aminophylline.
IMPRESSION: Non-anginal symptoms in the absence of significant
ST
segment changes. Nuclear report is sent separately.
P-MIBI STRESS TEST ___:
INTERPRETATION:
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 66%
There are no prior studies for comparison.
IMPRESSION:
1. No focal myocardial perfusion defects.
2. Normal wall motion with LVEF of 66%.
LABS ON DISCHARGE:
___ 07:40AM BLOOD WBC-7.9 RBC-3.81* Hgb-11.0* Hct-33.9*
MCV-89 MCH-28.8 MCHC-32.5 RDW-15.2 Plt ___
___ 07:40AM BLOOD ___ PTT-46.6* ___
___ 07:40AM BLOOD Glucose-80 UreaN-11 Creat-1.0 Na-146*
K-3.5 Cl-110* HCO3-25 AnGap-15
___ 07:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
___ 05:45PM BLOOD Creat-1.0 Na-142 K-3.7 Cl-109*
Brief Hospital Course:
___ year old female with known 4.8cm Abdominal Aortic Aneurysm
(AAA) and recent transpheoidal resection for pitutary adenoma
who presented to the Emergency Department with a headache and
fatigue, found to have a right segmental pulmonary embolism and
started on anti-coagulation.
#. Pulmonary Embolism: Asymptomatic, found incidently during
imaging to evaluate her known AAA. Patient had a low probability
Wells criteria as only recent surgery was in past ___ weeks. T
wave inversion on EKG likely the result of the PE given
unremarkable p-MIBI. Age of clot is unknown, so unclear if acute
PE or more chronic thromboembolic disease. Recent transphenoidal
pitutary mass resection is not a contraindication to
anti-coagulation (discussed with her neurosurgeon). Patient
asymptomatic and oxygenatining well during hospital course.
Initially placed on heparin drip but transitioned to lovenox as
a bridge to coumadin. Patient educated on warfarin during stay.
#. Headache: Patient complained of nasal stuffiness and sinus
thickening was noted on CT, likely related to allergic rhinitis
or viral URI. Sx not severe enough to be concerning for
bacterial sinusitis. Patient was treated with acetominophen,
nasal saline and fluticasone. Her headache improved with
symptomatic treatment.
# Acute Kidney Injury: Cr elevated from 1.0 from baseline of
0.5-0.7. Report of poor oral intake at home. Elevated lactate
also consistent with hypovolemia, improved with IV Fluids in the
emergency room. Fractional excretion of sodium was found to be
less than 1% and free water deficit was calculated to be down 1
liter. Patient was given free fluid prior to discharge
STABLE ISSUES:
# H/o pituitary adenoma: Followed by enodcrine and Neurosurgery.
CT head unchanged from prior, seen by Neurosurgery in the
emergency room who recommended outpatient follow-up as
previously scheduled. Continued on home prednisone
# AAA: Stable per family report. Patient has declined surgery in
the past, but per daughter, endovascular surgical repair had not
been discussed. Patient continued on home anti-hypertensives
and scheduled for outpatient vascular surgery evaluation for
second opinion.
# osteoarthritis: Continued on home Tramadol and acetaminophen
PRN pain
# insomnia: Continued on home Seroquel
# CODE: full (confirmed)
# CONTACT: Daughter ___ (___)
___ ISSUES:
[ ]Please follow INR and stop lovenox when therapeutic at
2.0-3.0
[ ]Patient's family was unwilling to give BID dosing of Lovenox
so ___ will administer for first 3 days. Will need to consider
adjustment of therapy if Warfarin not therapeutic by this time
[ ]Please adjust coumadin dose as needed. Thereapy is planned
for 3 months.
[ ]Please continue to educate patient as needed about diet and
warfarin interactions.
[ ]Will need abdominal Ultrasound every 6 months for aneurysm
monitoring.
[ ]Vascular surgery appointment for second opinion about
endovascular repair
[ ]Please follow up with neurosurgery appointment
[ ]Please consider stopping seroquel due to QTc prolongation
noted on EKG.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Quetiapine Fumarate 25 mg PO HS
2. PredniSONE 15 mg PO DAILY
3. Carvedilol 3.125 mg PO BID
hold for SBP < 100, HR < 55
4. Lisinopril 10 mg PO DAILY
hold for SBP < 100
5. FoLIC Acid 1 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
7. Omeprazole 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
hold for loose stools
9. Vitamin D 800 UNIT PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Aspirin 81 mg PO DAILY
12. NIFEdipine CR 90 mg PO DAILY
hold for SBP < 100, HR < 55
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Carvedilol 3.125 mg PO BID
hold for SBP < 100, HR < 55
4. Docusate Sodium 100 mg PO BID
hold for loose stools
5. FoLIC Acid 1 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
hold for SBP < 100, HR < 55
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 15 mg PO DAILY
9. Quetiapine Fumarate 25 mg PO HS
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q8H:PRN pain, HA
RX *acetaminophen 650 mg 1 tablet(s) by mouth Q6hrs Disp #*30
Tablet Refills:*0
13. Enoxaparin Sodium 60 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL Subcutaneous abdominal injection
every twelve (12) hours Disp #*10 Syringe Refills:*0
14. Warfarin 3 mg PO DAILY16
With goal of ___ and discontinue LMWH after therapeutic for
24hrs
RX *warfarin 3 mg 1 tablet(s) by mouth Daily at 4pm Disp #*10
Tablet Refills:*0
15. Lisinopril 10 mg PO DAILY
hold for SBP < 100
16. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
daily Disp #*15 Packet Refills:*0
17. Senna 1 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___:
It was a pleasure taking care of you during your hospitalization
at ___. You had come in because you were experiencing a
headache and fatigue. In the emergency room they performed a
scan of your head which showed nothing of concern. Your headache
was well controlled with acetaminophen and nasal sprays.
However, during the work-up some concern was raised over your
abdominal aneurysm, and scan was done of your torso whch showed
a blood clot in your right lung. You were admitted so that we
could start you on a blood thinner. You will have to take shots
called Lovenox twice a day and a pill called warfarin once a day
until your lab tests show that you are therapeutic. You will
have to be on therapy for 3 months. You were also found to be a
little dehydrated while you were here and we gave IV fluids for
that. We are also providing you with you instructions on diet
while on this medication.
We have made the following changes to your medication list:
Please START taking Lovenox 60 mg subcutaneous injection twice a
day until your health care provider says its ok to stop. Please
START taking warfarin (coumadin) 3mg by mouth every day until
notified by your health care provider. We are also giving you
prescriptions for stool softners called senna and miralax to
help with your constipation.
Please continue taking the rest of your medications as
prescribed.
Please follow up with your appointments as outlined below.
Thank you,
Followup Instructions:
___
|
19663837-DS-6
| 19,663,837 | 28,496,379 |
DS
| 6 |
2173-11-02 00:00:00
|
2173-11-05 21:01:00
|
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, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female w/ history of HTN, HLD, DM, AA (4.8 cm), pituitary
tumor s/p resection, SVT, and found to have an asymptomatic PE
___ for which she has been receiving lovenox, coumadin. Was
getting ___, had heart rate reportedly of 35 for 10 minutes. ___
felt light headed, was reportedly pale at the time. ___ also
reports episode of non radiating chest pain, present under
xyphoid process, lasting 1 second. Had also chills, nausea,
which has been constant since. Denies fevers, sweating. Denies
shortness of breath at rest. ___ was dc'd on lovenox and coumadin
but has not been receiving coumadin and may not have been
getting lovenox.
In the ED, initial vs were:97 67 139/66 18 99% RA
Ambulatory O2 sat: dropped to 84% on RA with minimal ambulation
and very SOB. She was given lovenox 60 mg x2 in the ED and
restarted on coumadin. Transfer VS:98.2 76 122/71 97% r.a.
On arrival to the floor, patient reports ___ right scapular
pain that is worse with deep inspiration which started 2 hrs
ago. She denies shortness of breath at rest. She denies fever,
chills, headache, abdominal pain, N/V, dysruia, or diarrhea. No
leg pain. She reports taking her medicines at home.
Past Medical History:
- HTN
- HL
- DM2
- osteoporosis
- arthritis; needs bilateral shoulder surgery for "bone on bone"
arthritis
- 4.8cm ascneding aortic aneurysm, currently being followed with
Q6 month scans as pt refused surgery
- s/p CCY
- s/p appy
- s/p R knee repair surgery
Social History:
___
Family History:
mother died at age ___ of asthma, father died at age ___
of pulmonary edema.
Pt with one sister who died at ___ from an MI and a brother who
died in his ___ of a heart attack. Pt's daughter has a heart
valve problem.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 99.1, 152/82, 72, 20, 98% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, rhonchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e, no calf
tenderness
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE EXAM
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM CTAB no wheezes, rales, rhonchi appreciated
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e, no calf
tenderness
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission:
___ 06:15PM BLOOD WBC-6.9 RBC-3.85* Hgb-11.6* Hct-34.4*
MCV-89 MCH-30.0 MCHC-33.6 RDW-14.9 Plt ___
___ 06:15PM BLOOD Neuts-46.9* Lymphs-48.7* Monos-3.4
Eos-0.6 Baso-0.4
___ 07:12PM BLOOD ___ PTT-39.0* ___
___ 06:15PM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-16
___ 06:15PM BLOOD cTropnT-<0.01
___ 06:15PM BLOOD proBNP-257
___ 08:35AM BLOOD CK(CPK)-54
___ 06:15PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.3
___ 07:48PM BLOOD TSH-0.34
DISCHARGE
___ 06:45AM BLOOD WBC-8.5 RBC-3.60* Hgb-10.4* Hct-32.7*
MCV-91 MCH-28.9 MCHC-31.7 RDW-15.7* Plt ___
___ 06:45AM BLOOD Glucose-73 UreaN-13 Creat-0.9 Na-143
K-4.0 Cl-107 HCO3-26 AnGap-14
___ 06:45AM BLOOD ALT-147* AST-52* AlkPhos-104 TotBili-0.1
___ 06:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
___ 06:45AM BLOOD ___
___ 08:35AM BLOOD ___ PTT-87.7* ___
OTHER PERTINENT LABS
___ 08:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:50AM BLOOD HCV Ab-NEGATIVE
MICRO
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING
___ MRCP
INDICATION: Known 4.8 cm abdominal aortic aneurysm and recent
transsphenoidal resection for pituitary adenoma. Recent
diagnosis of PE. Please evaluate for reason for CBD dilation
and transaminitis.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired
on a 1.5
Tesla magnet including dynamic 3D imaging obtained prior to,
during, and after the uneventful intravenous administration of 7
mL of Gadavist. The patient also received 2.5 mL of Gadavist
diluted with 75 mL of water p.o.
Unfortunately, the examination was severely limited by motion
artifact from breathing and the patient ended the examination
before the 3D coronal MRCP sequence was performed.
FINDINGS:
The common bile duct measures 0.8 cm in diameter which is within
normal limits for the patient's age. No intrahepatic duct
dilatation. The patient is status post cholecystectomy.
There is a 0.9-cm T2 hyperintense cystic lesion within segment
II of the liver (sequence 8, image 12), which does not enhance
post-contrast and likely represents a small cyst. The liver is
otherwise unremarkable. The portal and hepatic veins are
patent. The hepatic artery is patent with conventional hepatic
arterial anatomy.
There is a 1.1 cm T1 hyperintense cystic lesion within the lower
pole of the right kidney (sequence 7B, image 38), which is of
low signal on the
fat-saturated T1 and is consistent with an angiomyolipoma.
There are multiple simple cysts within both kidneys, the largest
of which measures 2.9 cm in diameter in the lower pole of the
right kidney. The kidneys are otherwise unremarkable.
The adrenals, pancreas and spleen are within normal limits.
There is a small sliding hiatus hernia. The abdominal aorta is
of normal caliber throughout its length. The visualized small
and large bowel is unremarkable. No retroperitoneal adenopathy.
Note is made of a mild lower thoracic and upper lumbar
scoliosis convex to the left. The lung bases are clear. No
destructive osseous lesions.
IMPRESSION:
1. No evidence of biliary dilation. No biliary obstruction.
2. 1.1 cm angiomyolipoma within the lower pole of the right
kidney.
3. Small sliding hiatus hernia.
___ CT-A Thorax
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet
to upper
abdomen were displayed with 1.25- and 2.5-mm slice thickness.
Intravenous
contrast was administered. Coronal and sagittal reformations
were prepared.
Additionally, maximum intensity projection oblique reformations
were also
prepared.
CT CHEST WITH INTRAVENOUS CONTRAST: The thyroid gland is
homogeneous without discrete nodule. No supraclavicular,
axillary, mediastinal, or hilar lymphadenopathy is identified.
Mild aneurysmal dilatation of the ascending thoracic aorta is
unchanged as compared to prior examination measuring 4.7 x 4.7
cm (2:42). There is mild calcified plaque in the aortic arch
and descending thoracic aorta, though no sign of acute aortic
syndrome. There has been recanalization of the right lower lobe
superior segmental pulmonary artery at the site of recent
pulmonary emboli. No new pulmonary embolism is identified.
There is no dilatation of the main pulmonary artery. The heart
size is normal, and there is no pericardial effusion.
The tracheobronchial tree is patent to subsegmental levels.
There is no
bronchiectasis or bronchial wall thickening. There is
subsegmental basilar
atelectasis, which is similar to prior examination. No
confluent
consolidation is identified. There is no focal pulmonary
nodule. Pleural
surfaces are clear without effusion.
Limited evaluation of the abdominal viscera demonstrates
predominantly central intrahepatic biliary ductal dilatation
with prominence of the common bile duct measuring 7 mm (2:100).
These findings are stable compared to prior CT from ___, though are of uncertain etiology. Correlation with
clinical signs and symptoms, and laboratory evaluation is
recommended. Ultrasound could be considered if clinically
indicated. Secretions are seen within the mid-to-distal
esophagus, which may put the patient at risk for aspiration.
BONES AND SOFT TISSUES: No bone destructive lesion or acute
fracture is
identified.
IMPRESSION:
1. Stable ascending aortic aneurysm measuring up to 4.7 cm. No
acute aortic syndrome.
2. Recanalization of superior right lower lobe segmental artery
at site of prior pulmonary embolism.
3. Unchanged dependent bibasilar atelectasis. No confluent
consolidation or pleural effusion.
4. Stable mild intra- and extra-hepatic biliary ductal
dilatation of
uncertain etiology. Correlation with clinical signs and
symptoms and
laboratory evaluation is recommended. If clinically indicated,
ultrasound could be considered.
5. Secretions in the mid-to-distal esophagus, perhaps an
aspiration risk.
___ ECHO
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic arch is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric LVH with normal regional and global
ventricular systolic function. Mildly dilated right ventricle
with normal systolic function. Mild aortic regurgitation.
Negative bubble study.
___ Lower extremity ultrasound:
IMPRESSION:
No evidence of deep venous thrombosis in bilateral lower
extremities.
___ CXR:
IMPRESSION: No radiographic evidence for acute cardiopulmonary
process.
Brief Hospital Course:
Brief Course:
___ y.o female with known 4.8cm Abdominal Aortic Aneurysm (AAA)
and recent transpheoidal resection for pitutary adenoma, and
recent diagnosis of PE on coumadin/Lovenox who presented with
pleuritic chest pain, fatigue, dizziness and exertional dyspnea.
Her symptoms were thought to be due to a pulmonary process given
the pleuritic nature of the pain. Patient's pain was controlled
with PO oxycodone. Various studies were conducted, including
CT-A, which was negative for PE. Given her INR was
subtherapeutic on admission, patient was bridged to coumadin
with a heparin drip. She was discharged after several days with
pain much improved and therapeutic on coumadin.
Active Issues:
# Scapular pain: Pleuritic nature was suggestive of pulmonary
process, initally thought to be from progression of prior PE
given fact that patient was subtherapeutic on coumadin on
admission. Pneumonia or effusion less likely given CXR negative
for acute process. ACS was in differential, but troponins were
negative and EKG showed nonspecific t wave changes but no st
segment abnormalities. Pain was not positional, no rubs on exam,
no ekg findings to suggest pericarditis. Equal pulses and not
extremely hypertensive to suggest aortic dissextion. No
abdominal signs or symptoms to suggest referred pain from gall
bladder pathology. Patient was treated for PE with heparin drip
and bridged to coumadin. Pain was controlled with home regimen
of tramadol, tyelonol, oxycodone prn. LENIS were negative for
DVT. CT-A was conducted which revealed resolution of prior PE
and stable AAA. Pain likely represented combination of
pulmonary process (?infarct) from prior PE and known history of
should osteoarthritis. Pain was well controlled at time of
discharge and patient is not being discharged on any additional
pain medications.
# Pulmonary Embolism: Found incidentally during imaging to
evaluate her known AAA on prior admission. Patient presented
subtherapeutic on coumadin. Patient's daughter claimed she was
taking coumadin as directed and receiving lovenox injections.
Repeat CT-A showed resolution of PE. Patient was bridged to
coumadin with heparin drip, as above, and is going home with ___
services to check her INR. INR will be managed by ___ services,
which have already been set up by patient on prior discharge.
Patient has close f/u with PCP as well.
# Transaminitis: Patient was noted to have incidental common
bile duct dilation on CT-A. LFTs showed a mild transaminitis
without an obstructive picture. Hepatitis serologies were
negative. An MRCP was done on day of discharge which showed no
biliary dilation. Patient has PCP as well as GI f/u as below to
further address results.
STABLE ISSUES:
# H/o pituitary adenoma: Followed by endocrine and Neurosurgery.
Continued on home prednisone
# AAA: Patient has declined surgery in the past, but per
daughter, endovascular surgical repair had not been discussed.
Patient continued on home anti-hypertensives and scheduled for
outpatient vascular surgery evaluation for second opinion. CT-A
done in house on ___ showed stability of AAA. Will need
abdominal Ultrasound every 6 months for aneurysm monitoring.
# Osteoarthritis: Continued on home Tramadol and acetaminophen
PRN pain.
# Insomnia: Continued on home Seroquel.
Transitional Issues:
# Please make sure cancer screening is up to date to address
possible provocations of PE
# Abdominal ultrasound every 6 months for AAA monitoring
# Please address MRCP results and any follow-up as clinically
indicated
# CODE: full
# EMERGENCY CONTACT:Daughter ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Carvedilol 3.125 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
hold for sbp<100, hr<55
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 15 mg PO DAILY
9. Quetiapine Fumarate 25 mg PO QHS
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q8H:PRN pain
13. Enoxaparin Sodium 60 mg SC Q12H
14. Warfarin 3 mg PO DAILY16
15. Lisinopril 10 mg PO DAILY
hold for sbp<100
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 1 TAB PO BID:PRN constipation
18. Methotrexate 2.5 mg PO QMON
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Carvedilol 3.125 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Lisinopril 10 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 15 mg PO DAILY
9. Quetiapine Fumarate 25 mg PO QHS
10. Senna 1 TAB PO BID:PRN constipation
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Warfarin 5 mg PO HS
RX *warfarin [Coumadin] 2.5 mg 2 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*1
13. Calcium Carbonate 500 mg PO BID
14. FoLIC Acid 1 mg PO DAILY
15. Methotrexate 2.5 mg PO QMON
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Pleuritic chest pain
Secondary: Pulmonary embolism, transaminitis
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
hospitalized with shortness of breath and pain in your chest.
You underwent imaging of your lung which did not show a clot.
You were put on blood thinning medication and your coumadin was
dosed to an appropriate level. You will be going home with a
visiting nurse to help you check your coumadin (INR) levels.
You also underwent imaging of your abdomen with the final report
pending at this time. The result will be communicated to you
once it is final.
Please make the following changes to your medications:
Please STOP Lovenox injections
Please START Coumadin 5 mg daily. The dosage of this medication
will be adjusted by your visiting nurse.
Please continue the rest of your medications as prescribed.
Followup Instructions:
___
|
19664042-DS-20
| 19,664,042 | 27,138,533 |
DS
| 20 |
2113-09-27 00:00:00
|
2113-10-02 16:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending: ___.
Chief Complaint:
"abdominal pain."
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
This is a ___ F with h/o thyroid ca s/p thyroidectomy and
seizure d/o now transferred here from OSH for abdominal pain.
Pt states her acute onset lower back pain and diffuse epigastric
pain started around 1030 am today. Pt called ___ and was seen at
___. There, lab work revealed lipase of ___, amylase of
682, and alkaline phosphatase of 115, GGT 57, AST 31, ALT 21. No
imaging was performed at the outside hospital. Pt was then
transferred to ___ for possible ERCP.
.
In the ED, initial VS were T 97.1 HR 70 BP 112/66 RR 16 O2 sat
100% RA. Patient reported mild nausea, but no vomiting, no
fevers/chills. Her abdominal pain had largely abated. RUQ scan
showed a dilated CBD but no gallstones were seen in gallbladder
or CBD. ERCP was consulted who recommended admission to
Medicine ___ for treatment of acute pancreatitis, monitoring of
LFTs and no plans for ERCP for now. Pt was started on a 1L ___
NS. On transfer, VS were T 98 HR 74 BP 103/65 RR 18 O2 sat 96%
RA.
.
Upon arrival to the floor, pt is resting comfortably in bed.
Admits to ___ pain in epigastric area and low back. Also
endorses nausea but no vomiting. Denies fevers. Denies trauma
to area, denies scorpion bites.
.
ROS: per HPI, denies chest pain, SOB, cold, cough, weight loss.
denies abd pain prior to this episode. denies rashes. denies
diarrhea/constipation, bloody or dark stools, dysuria. denies
seizure activity in decades.
Past Medical History:
-s/p thyroidectomy for thyroid cancer diag decades ago, also
underwent radioablation but no chemo
-seizure d/o
Social History:
___
Family History:
father with CAD and multiple MIs (earliest was at age ___, died
at age ___, was a smoker
mother with HTN
Physical Exam:
VS- T 95.9 BP 93/51 HR 73 RR 20 O2 sat 96% RA
Gen- well-appearing, NAD
HEENT- EOMI, PERRL, MMM, OP clear
Neck- no LAD, no masses
CV- RRR, no murmurs
Resp- CTAB, no wheezes or crackles
Abd- soft, +ttp in epigastric area, no guarding or rebounding
Ext- no edema
Neuro- strenght and sensation intact throughout
Skin- no rashes, bruises
Discharge Exam
In NAD, able to ambulate without difficulty
Abdomen has active BS, soft, not TTP, no rebound
Pertinent Results:
LABS:
___ 06:48PM BLOOD WBC-6.9 RBC-3.80* Hgb-11.9* Hct-36.1
MCV-95 MCH-31.5 MCHC-33.1 RDW-12.6 Plt ___
___ 06:48PM BLOOD Neuts-61.1 ___ Monos-3.3 Eos-1.4
Baso-0.3
___ 06:48PM BLOOD Glucose-72 UreaN-12 Creat-0.8 Na-142
K-4.0 Cl-108 HCO3-28 AnGap-10
___ 06:48PM BLOOD ALT-19 AST-30 AlkPhos-94 TotBili-0.2
___ 06:48PM BLOOD Lipase-2163*
___ 06:48PM BLOOD Albumin-4.3
___ 07:00PM BLOOD Lactate-0.7
MICRO:
___ URINE CULTURE-Final-no growth
___ BLOOD CULTURE-Final-no growth
___ BLOOD CULTURE-Final-no growth
IMAGING:
RUQ U/S: IMPRESSION:
1. Borderline dilatation of the CBD up to 7-mm without
intrahepatic biliary dilatation or evidence of intraluminal
stones; however, evaluation of the distal CBD is somewhat
limited, and if there is continued concern for distal biliary
obstruction, an MRCP can be obtained for further evaluation.
2. No evidence of cholelithiasis or acute cholecystitis. Tiny
gallbladder
polyp.
3. Small amount of free fluid.
MRCP:
IMPRESSION:
1. Pancreatic edema, diffuse anasarca and trace ascites
consistent with acute pancreatitis. There is a 2 x 0.9 cm area
of fluid tracking between the superior mesenteric artery and
vein, possibly reflecting early pseudocyst formation versus
inflammatory exudate.
2. Mild dilatation of the common bile duct with a probable
filling defect in the distal third consistent with a 5-mm stone.
This is difficult to visualize on the thick-slab MRCP images due
to the edema of the pancreatic head and motion artifact.
3. 3-mm cyst in the pancreatic tail, given the patient's age,
recommend
followup MRCP in one year to ensure stability. The fluid between
the SMA and SMV can also be followed at that time (if not
already followed sooner).
4. Focal fatty change in segment ___. Additional hepatic lesions
are
consistent with cysts or hamartomas.
5. Simple renal cyst.
ERCP:
Impression: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the common bile duct
with the CBD measuring 10 mm.
Given concern for gallstone pancreatitis, decision was made to
perform a sphincterotomy.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweep x 2 was performed with successful extraction of
sludge and a small stone fragment
EKG ___
Sinus rhythm with atrial premature beats. Low voltage
throughout.
Predominantly inferior T wave abnormalities. No previous tracing
available for
comparison.
Read by: ___.
___ Axes
Rate PR QRS QT/QTc P QRS T
64 0 76 ___
Brief Hospital Course:
This is a ___ yo female with h/o thyroid ca s/p thyroidectomy and
seizure d/o now here with acute pancreatitis.
# Acute gallstone pancreatitis: Initially presented from OSH
with epigastric/back pain. Her symptoms had resolved on arrival
here. Her lipase was elevated but trended down. RUQ US
suggested mild ductal dilatation. As her symptoms did not
continue to improve with supportive care, MRCP was performed,
which showed a gallstone in the distal CBD. ERCP was performed
with sphincterotomy and successful removal of stone and sludge.
She did well post procedure with gradual advancement of her
diet. Her LFTs remained stable
- NO ASA/NSAIDS for 5 days post procedure
- Low fat foods recommended (BRAT diet for ___ days and then
advance as tolerated)
- Recommended consideration of cholecystetomy within the next
___ months. Information provided to see a surgeon in the ___
system.
# Pancreatic Cyst: Indentified on MRCP. ___ year follow up
recommended with an MCRP. Discussed with patient and
___ sent to PCP.
# Seizure d/o:
- continued home Dilantin
# S/p thyroidectomy: TSH found to be 17. Unclear if poor
adherence to home regimen vs underdosed. Recommended close
follow up with PCP.
- continued home Levothyroxine
Medications on Admission:
Dilantin 300mg QAM
Levothyroxine 150mcg daily
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Outpatient Lab Work
Please draw a CBC and a TSH and fax to your PCP:
___ ___ in 1 week prior to follow up with
your PCP
5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea for 7
days.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation for 7 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute gallstone pancreatitis
Headache, caffeine withdrawal
Seizure disorder
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with epigastric and back pain caused by acute
pancreatitis. You were found to have a gallstone in the common
bile duct, the likely cause of her pancreatitis. You underwent
successful ERCP with removal of the stone. Please consider
gallbladder removal in the near future to prevent recurrence.
Please follow up with a general surgeon.
Please avoid fatty foods for the next 7 days. DO NOT use
Aspirin or NSAID medications for the next 3 days given risk of
bleeding following procedure.
Your TSH was found to be high, indicating that you may need to
increase your Levoxyl dose. Please discuss this with your PCP.
Medication changes:
1. Oxycodone 5mg every 6 hours as needed for pain. DO NOT use
with alcohol or while driving
2. Docusate prn
3. Zofran prn
Followup Instructions:
___
|
19664474-DS-13
| 19,664,474 | 21,697,276 |
DS
| 13 |
2169-08-17 00:00:00
|
2169-08-18 19:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Doxil
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old F with PMH significant for metastatic
breast cancer and recent malignant pericardial effusion s/p
pericardial window who presents with dyspnea. Patient was seen
in outpatient ___ clinic today for progressive dyspnea on
exertion. At that time was noted to desaturate to 87% on room
air with ambulation. Patient reports that since being discharged
from ___ several days ago she has had progressive worsening of
dyspnea on exertion.
She was then sent to cardiology clinic where she had a bedside
echocardiogram performed which demonstrated concern for
constrictive pericarditis. Echo showed a septal bounce with
respiratory variation in MV and TV inflows and respirophasic
reversal in hepatic vein tracings c/w constriction. There was
also a small amount of pericardial fluid posteriorly and there
is some echo dense material in the pericardial space which may
be organized fluid. No signs of tamponade. LV systolic function
was normal. She denies any chest pain, fever. She does endorse
some mild dry cough.
In the ED, initial vs were: 98.8 99 130/50 20 100%. Labs were
remarkable for Hct 28.8 (at baseline), D-Dimer: 3341. A CTA
showed no evidence of PE. ECG showed sinus at ___levations with PR depressions. Patient was given nothing in ED.
Thoracic surgery was consulted and recommended no intervention
at this time. Vitals on Transfer: 98.6 82 118/65 20 99% RA
On the floor pt reports she feels well and does not currently
feel SOB. She denies any chest pain. Reports that she has been
having night sweats for the past few nights.
Past Medical History:
Metastatic breast cancer: Diagnosed ___, s/p mastectomy, XRT
and chemo. ER and HER2 positive. Recurrent and metastatic to
skin, liver, sternum. Most recent treatment ___
Basal cell skin cancer.
Chronic infection of a left-sided Port-A-Cath which was
ultimately removed in ___. A right-sided Port-A-Cath was
placed on ___.
Goiter.
Pseudoexfoliation glaucoma.
Actinic Keratosis of the left shoulder s/p biopsy on ___.
Social History:
___
Family History:
Her paternal aunt was diagnosed with breast
cancer at age ___ and a paternal second cousin was diagnosed with
breast cancer at age ___.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
Vitals- 98.2 101/69 94 18 98%RA
General- pleasant female, alert, oriented, no acute distress
HEENT- NCAT, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- decreased breath sounds in bases with ___ crackles
CV- Regular rate and rhythm, normal S1, S2, no murmurs
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Physical Exam:
Vitals: T 97.7, BP ___ (SBPs 88-106), HR 74, RR 18, SaO2 100%
RA resting, 81-85% ambulating RA, 90-92% ambulating on 2L O2
General: lying comfortably in bed, pleasant, NAD
HEENT: sclera anicteric, OP clear, MMM
Neck: supple, no lymphadenopathy
Lungs: CTAB, percuss dullness to T8 level L, T10 on R.
CV: Normal rate, regular rhythm, nl S1/S2, no murmurs.
Abdomen: soft, nontender, nondistended, nl BS
Ext: warm, well perfused without edema
Neuro: ambulating without difficulty, normal gait
Pertinent Results:
Admission labs:
___ 06:10PM ___ PTT-30.3 ___
___ 06:10PM PLT COUNT-264
___ 06:10PM NEUTS-77.9* LYMPHS-12.1* MONOS-9.0 EOS-0.5
BASOS-0.4
___ 06:10PM WBC-7.1 RBC-3.35* HGB-8.8* HCT-28.8* MCV-86
MCH-26.3* MCHC-30.6* RDW-15.3
___ 06:10PM GLUCOSE-106* UREA N-12 CREAT-0.4 SODIUM-134
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-10
___ 06:46PM D-DIMER-3341*
Interim labs:
___ 07:33AM BLOOD WBC-2.6*# RBC-3.23* Hgb-8.8* Hct-27.2*
MCV-84 MCH-27.3 MCHC-32.5 RDW-15.1 Plt ___
___ 05:00AM BLOOD Neuts-70.6* Lymphs-17.2* Monos-9.7
Eos-1.9 Baso-0.7
___ 07:33AM BLOOD Glucose-93 UreaN-12 Creat-0.4 Na-140
K-3.9 Cl-105 HCO3-28 AnGap-11
Discharge labs:
___ 06:15AM BLOOD WBC-3.2* RBC-3.19* Hgb-8.6* Hct-27.1*
MCV-85 MCH-26.8* MCHC-31.5 RDW-15.1 Plt ___
EKG ___
Sinus rhythm. Marked J point elevation and diffuse PR segment
depression.
Consider acute intercurrent pericardial disease.
Imaging:
CXR ___
IMPRESSION:
1. Small bilateral effusions with bibasilar atelectasis. No
definite signs of pneumonia or overt CHF.
2. Known metastatic osseous disease.
Chest CTA w/wo contrast ___
IMPRESSION:
1. No pulmonary embolus.
2. Small pericardial effusion increased from ___
after drain
removal. Reflux of contrast into the IVC raises the concern for
increased right heart pressure and correlation should be made to
echocardiography.
3. Small bilateral pleural effusions, decreased from ___.
4. Unchanged multiple osseous sclerotic metastases and
pulmonary nodules.
TTE ___
IMPRESSION: Normal global and regional biventricular systolic
function. A septal "bounce" is seen. No significant valvular
regurgitation. Residual small amount of fluid near the
inferolateral wall. There are echodense pericardial elements
seen over the right ventricle (appearance could also be due to
pericardial fat). The pericardium appears somewhat adherent to
the mid to distal inferolateral segments also. The presence of a
septal bounce, possible adherent pericardium, relatively short E
wave deceleration time and a small A wave suggest possible
constrictive/effusive-constrictive physiology.
Compared with the prior study (images reviewed) of ___,
the current study is more complete. The extent of septal bounce
has decreased significantly.
Cardiac MRI ___
Final read pending
Brief Hospital Course:
Ms. ___ is a ___ year old woman with metastatic breast cancer
and recent malignant pericardial and pleural effusions s/p
pericardial window and chest tube drainage, who presents with
worsening DOE and outpatient echo concerning for constrictive
pericarditis.
# Constrictive Pericarditis: The patient is s/p pericardial
window on ___, with drainage of malignant effusion. A
bedside echo had been done at outpatient cardiologist's office
for worsening DOE following previous hospitalization. A TTE in
house confirmed findings of outpatient echo showing septal
bounce, small effusion, possible adherent pericardium, c/w
constrictive physiology. Atrius cardiologists followed her care
throughout her stay, with guidance on management. She was
started on Colchicine and added on Ibuprofen when symptoms were
not improving. As she developed leukopenia and diarrhea
secondary to the Colchicine, this was stopped. As she did not
have any pain associated with the pericarditis that was thought
to be non-inflammatory in nature, a short course of ibuprofen
was deemed sufficient and she is discharged with instructions to
continue at a lowered dose for 1 week. She received a cardiac
MRI during her stay, which on verbal report showed constrictive
pericarditis with a focal area suspicious for percardial
adhesion. Final read is still pending. Ms ___ was
occasionally tachycardic with low blood pressures that were
reportedly at her baseline, without significant symptoms at rest
(discussion below on symptoms with exertion).
# Dyspnea/hypoxemia on exertion: Her presenting symptoms were
thought likely due to constrictive pericarditis, but she was
noted to become significantly hypoxemic with ambulation which is
not entirely consistent with isolated constrictive pericarditis.
A CTA was negative for PE, and not concerning for PNA or
pulmonary edema. She does have multiple pulmonary nodules, but
these are small, stable, and unlikely to cause an oxygenation
defect. She continues to have pleural effusions which is to be
expected with a pericardial window, and are also small and
stable. She dose appear to have post-XRT lung scarring in her
right upper lobe, which is the most likely finding to cause
hypoxemia when recruited with exertion. Chronic peripheral PEs
not easily seen on CTA may also be contributory and a V/Q scan
would be recommended to evaluate for this. Overall, this is
likely multifactorial due to above and no further examinations
or interventions were performed during this hospitalization. She
is being discharged with home O2 to utilize for symptomatic
relief as needed. Ongoing workup would be indicated if symptoms
persist or worsen.
# Leukopenia: Ms ___ developed leukopenia during this
hospitalization, likely secondary to colchicine use. She was not
neutropenic. Colchicine was discontinued. A repeat CBC should be
obtained to monitor recovery.
# Malignant pleural effusions: S/p chest tube drainage last
admission. She was seen by CT surgery who reviewed the imaging
and did not think that there was a need for surgical
intervention given stability of effusions. She will have
outpatient follow up with Dr ___.
# Breast Cancer: Diagnosed in ___ s/p R mastectomy, XRT and
chemo, but now recurrent with metastatic disease to liver, bone,
and skin on chest. Atrius Oncology was made aware of her
admission, although no acute oncologic issues arose during this
hospitalization.
# Glaucoma: Continued home regimen of latanoprost and
brimonidine eye drops
# Anemia: Chronic with Hct stable at ___.
Transitional issues:
#Follow up CBC to monitor recovery of leukopenia
#Ongoing management with oncology, cardiology and thoracic
surgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
5. Senna 1 TAB PO BID
6. Simethicone 40-80 mg PO QID:PRN bloating
7. Docusate Sodium 100 mg PO BID
8. Sarna Lotion 1 Appl TP QID:PRN itching
Discharge Medications:
1. Oxygen
2L via NC continuous pulse dose for portability dx pleural
effusion.
2. pulse oximeter
for saturation monitoring to maintain ambulatory sats above 92%.
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. Docusate Sodium 100 mg PO BID
6. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Sarna Lotion 1 Appl TP QID:PRN itching
9. Senna 1 TAB PO BID
10. Ibuprofen 400 mg PO Q 12H
RX *ibuprofen 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
11. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Constrictive pericarditis
Pleural effusion
Breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___
It was a pleasure taking care of you at ___
___. You were admitted for shortness of breath with
exercise, and a concern of a condition called "constrictive
carditis", or a constriction of the lining around your heart.
This was evaluated by an echocardiogram and a cardiac MRI that
confirmed this. You were also found to have very low oxygen in
your blood with walking, which is not entirely explained by the
pericarditis. It seems like a combination of the fluid at the
base of your lungs (which is very stable from the last
admission), some radiation scarring in the lungs, and the
constrictive pericarditis are all playing a role. You are being
discharged with a home oxygen tank to use when you need it.
Please continue to follow up with your providers as indicated
below, to address these ongoing issues.
Followup Instructions:
___
|
19664531-DS-12
| 19,664,531 | 24,811,812 |
DS
| 12 |
2139-02-17 00:00:00
|
2139-02-17 20:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fell at rehab.
Major Surgical or Invasive Procedure:
___: Right hip trochanteric fixation nail.
History of Present Illness:
Mr. ___ is ___ with stage IV Hodgkin Lymphoma
(undergoing chemotherapy, last treatment w/ Brentuximab on
___, ___, aortic stenosis, A-fib on warfarin who was recently
admitted on ___ for CHF exacerbation. He was discharged
euvolemic to rehab where he fell. He does not remember the
details of his fall, but was found to have a right hip fracture
on imaging and he is transferred here for further management.
His TAVR workup is still pending.
Past Medical History:
- heart failure
- HTN
- HLD
- Aortic stenosis
- Hodgkin's Lymphoma
- arthritis
- asthma
- BPH s/p surgery
- h/o bigeminy
- h/o colon polyps
- h/o thyroid cancer s/p thyroidectomy
- insomnia
- right knee arthritis
Social History:
___
Family History:
Mother - esophageal cancer
Sisters - scleroderma
Son - MI, congenital heart defect, deceased
Daughter - breast cancer
Physical Exam:
==========================
ADMISSION PHYSICAL
==========================
VS: T98.2, 127/67, 74, 20, 99RA
Weight: 68.8kg
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, loud ___ holosystolic murmur with radiation to
carotids.
LUNGS: Res were unlabored, no accessory muscle use. No crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. right hip ER, no external bruising, no
tenderness to palpation
SKIN: scattered ecchymosis
PULSES: Distal pulses palpable and symmetric
==========================
DISCHARGE PHYSICAL
==========================
VS: 98.4 100/67 74 99%RA
Wt: 68.8kg
GENERAL: more alert, conversive, still AO x 1
HEENT: moist mucous membranes
NECK: JVP not elevated
CARDIAC: irregular, S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Resp were unlabored, no accessory muscle use. Lungs CTAB
ABDOMEN: Soft, NTND, normal active bowel sounds
EXTREMITIES: no pitting edema, warm, surgical dressing removed,
3 small incisions with staples present, wound free of drainage
or erythema, surrounding bruising of right lateral thigh,
+pulses, intact sensation, right thigh not tense
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 08:21AM BLOOD WBC-5.6 RBC-4.10* Hgb-11.3* Hct-36.7*
MCV-90 MCH-27.6 MCHC-30.8* RDW-18.2* RDWSD-59.3* Plt ___
___ 08:21AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear Dr-1+
Acantho-OCCASIONAL
___ 08:21AM BLOOD ___ PTT-44.8* ___
___ 08:21AM BLOOD Glucose-85 UreaN-30* Creat-1.7* Na-136
K-4.3 Cl-97 HCO3-28 AnGap-15
___ 08:21AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2
==========================
DISCHARGE LABS
==========================
___ 06:15AM BLOOD WBC-5.4 RBC-3.07* Hgb-8.6* Hct-27.9*
MCV-91 MCH-28.0 MCHC-30.8* RDW-16.8* RDWSD-54.6* Plt ___
___ 06:15AM BLOOD ___ PTT-43.2* ___
___ 06:15AM BLOOD Glucose-89 UreaN-36* Creat-1.3* Na-139
K-3.8 Cl-101 HCO3-26 AnGap-16
___ 06:15AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.4*
Mg-2.3
==========================
OTHER IMPORTANT LABS
==========================
___ 07:20AM BLOOD Ret Aut-3.1* Abs Ret-0.08
___ 07:13AM BLOOD ALT-7 AST-22 LD(LDH)-260* AlkPhos-51
TotBili-4.2* DirBili-0.6* IndBili-3.6
___ 07:13AM BLOOD Hapto-82
___ 07:20AM BLOOD VitB12-821 Folate-8.9
___ 07:20AM BLOOD TSH-7.9*
___ 07:20AM BLOOD T4-10.3
___ 02:44PM BLOOD Type-ART pO2-286* pCO2-34* pH-7.52*
calTCO2-29 Base XS-5 Intubat-INTUBATED
==========================
IMAGING
==========================
___ CT SPINE WITHOUT CONTRAST
1. No fracture. Multilevel degenerative changes, unchanged from
___.
2. Moderate to severe right neuroforaminal stenosis at C5-C6 and
C6-C7.
3. Bilateral small right greater than left pleural effusions,
new since ___,
partially visualized.
4. Opacity at the right lung apex may suggest infection or
aspiration.
___ CT HEAD W/O CONTRAST
No fracture or intracranial hemorrhage. Chronic sinus disease
with stable
postsurgical changes since ___ DX HIP & FEMUR
Acute, comminuted and impacted intratrochanteric fracture of the
proximal
right femur. Subtle regularity of the right inferior pubic ramus
raising the possibility of
a nondisplaced fracture.
___ CHEST (SINGLE VIEW)
Probable layering right pleural effusion. Dense retrocardiac
opacity,
potentially atelectasis versus infection.
___ KNEE (2 VIEWS) RIGHT
No fracture or dislocation. Severe tricompartmental
degenerative changes.
___ CT ABD & PELVIS W/O CON
1. Hyperdensity in expansion of the right pectineus in the
anteromedial thigh,
compatible with hematoma. No retroperitoneal hemorrhage
identified.
2. Known fracture of the right femur, status post intramedullary
nail fixation
with the expected postsurgical changes.
3. Small to moderate bilateral simple pleural effusions,
slightly increased
compared to ___.
4. CT findings compatible with anemia.
___ CT HEAD W/O CONTRAST
1. No evidence of acute territorial infarct, hemorrhage, edema,
or mass.
2. Stable chronic sinus disease particular in the right sphenoid
sinus.
==========================
OPERATIVE REPORT
==========================
Surgeon: ___, M.D. ___
PREOPERATIVE DIAGNOSIS: Right intertrochanteric hip
fracture.
POSTOPERATIVE DIAGNOSIS: Right intertrochanteric hip
fracture.
PROCEDURE: Right hip trochanteric fixation nail.
INDICATIONS: The patient is a pleasant gentleman, who
sustained a fall and has a right intertrochanteric hip
fracture. Given the fracture pattern, the decision was made
to proceed with operative fixation using a TFN.
DESCRIPTION OF PROCEDURE: The patient was identified in the
preoperative holding area. All risks and benefits of surgery
explained. Informed consent was obtained. Right hip marked.
Brought to the operating room, given general anesthesia,
placed on the fracture table. Gentle traction and internal
rotation was pulled on the hip, and x-rays confirmed good
reduction. The right hip was then prepped and draped in a
normal sterile fashion. A time-out was performed. A 2 cm
incision was made proximal to greater trochanter and a
guidewire inserted down through the greater trochanter, and
noted to be in good position on AP and lateral views. This
was overreamed and then a short TFN inserted. Using the 130-
degree guide, a guidewire was inserted up into the femoral
neck and noted to be in good position on the AP and lateral
views. This was overreamed and a compression screw inserted
and locked proximally. One locking screw was placed
distally. Intraoperative films showed good overall
alignment. No hardware in the joint. The wounds were
irrigated out and closed with 0 Vicryl, ___, and staples. A
sterile dressing was applied and he was taken off the
fracture table, awakened, and brought back to the recovery
room in stable condition.
Brief Hospital Course:
*******TRANSITIONAL ISSUES********
-- DISCHARGED OFF DIURETICS as he was dehydrated-euvolemic off
Lasix. However, he was recently admitted for heart failure
exacerbation. Please weigh patient daily and consider adding
back lasix ___ PO daily if weight increasing; can call
Cardiology if concerns.
-- DISCHARGED ON WARFARIN; must trend INR and adjust dose.
-- follow up: Cardiology (CHF), Ortho (hip fracture), Oncology
(lymphoma), TAVR Team (for further evaluation)
-- limit narcotic and other deliriogenic medications as patient
developed delirium in hospital
-- labs and INR next check: ___
-- discharge weight: 151 lbs
-- full code
-- contact: ___, Wife/ HCP (___)
Mr. ___ is a ___ year-old male with Hodgkin lymphoma stage
IV on palliative chemotherapy (brentuximab, last dose ___
and severe aortic stenosis c/b valvular heart failure, atrial
fibrillation on warfarin, who was admitted to ___ on ___
after falling at ___ rehab after an ___ discharge for
heart failure exacerbation which resulted in a right
intertrochanteric fracture now s/p right short trochanteric
fixation nail.
Please refer to ___ discharge summary for a more complete
assessment of Mr. ___ chronic medical problems.
#Hip fracture: Patient tolerated the operation well. His
post-operative course was complicated by the need for two blood
transfusions. His anemia was likely from post-surgical bleeding,
hematoma of the right pectineus muscle, and poor bone marrow
response to blood loss given his advanced age and known
lymphoma. Given his fall on anticoagulation, CT scanning of his
head and abdomen were also performed, which were negative for
acute pathology. He also developed delirium, which was improved
at the time of discharge after limiting narcotic pain medication
and discontinuing zolpidem. His pain was well controlled with
acetaminophen around the clock and minimal low dose narcotics
for breakthrough pain Physical therapy recommended a discharge
to rehab for further recovery.
#Heart failure: Patient was recently discharged ___ for a
heart failure exacerbation and upon readmission was euvolemic.
His diuresis was held during the hospitalization with little to
no accumulation in excess volume and his BP remained stable. He
was discharge at a weight of 68.8kg. This will need to be
closely followed as an outpatient.
#TAVR workup: On hold pending hip fracture recovery.
# Delirium: pt had significant delirium during this
hospitalization, for which the following was done:
- Geriatrics consultation
- Ambien discontinued
- Oxycodone discontinued as pain was controlled with Tylenol
- additional bowel medications prescribed
- nonpharmacologic delirium precautions taken
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 1 puff
daily
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
8. Levothyroxine Sodium 112 mcg PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. Pravastatin 40 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 3 mg PO 3X/WEEK (___)
13. Zolpidem Tartrate 5 mg PO QHS
14. Torsemide 20 mg PO DAILY
15. Warfarin 2 mg PO 4X/WEEK (___)
16. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Metoprolol Tartrate 6.25 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Senna 17.2 mg PO HS
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Allopurinol ___ mg PO DAILY
7. Amiodarone 200 mg PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Cyanocobalamin 100 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 1
puff daily
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
13. Levothyroxine Sodium 112 mcg PO DAILY
14. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
15. Pravastatin 40 mg PO QPM
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 3 mg PO 3X/WEEK (___)
18. Warfarin 2 mg PO 4X/WEEK (___)
19.Outpatient Lab Work
ICD10: I50.9, I48.1
Please check patient's chemistry 10 panel and INR panel at least
every 3 days, or more frequently as indicated and discussed with
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Right intertrochanteric hip fracture
Secondary diagnosis: Hodgkin lymphoma stage IV, severe aortic
stenosis, systolic heart failure, atrial fibrillation, chronic
kidney disease stage II, hypothyroidism, benign prostatic
hyperplasia, hypertension, dyslipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the hospital after falling
at rehab. We diagnosed you with a hip fracture and you had
surgery to repair the injury.
Physical therapy will be very important in your recovery
process.
Your heart valve workup is still pending, and will be continued
once physical therapy is complete.
Please take your medications as prescribed and attend all follow
up appointments.
We wish you the best,
Your ___ medical team
Followup Instructions:
___
|
19664531-DS-14
| 19,664,531 | 26,564,117 |
DS
| 14 |
2139-05-25 00:00:00
|
2139-05-25 19:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg swelling
Major Surgical or Invasive Procedure:
Left thigh hematoma drainage
History of Present Illness:
Mr. ___ is a ___ year old man with Hodgkin's lymphoma (on
palliative Brentuximab, last ___, recent right hip fracture
s/p surgery in ___, severe aortic stenosis s/p TAVR, left
femoral artery pseudoaneurysm after his TAVR s/p embolization by
___ on ___, afib on Coumadin, who presented with left leg
swelling.
He was recently discharged (___) to rehab following
admission for TAVR, with course complicated with left femoral
artery pseudoaneurysm s/p embolization by ___ on ___. Over
the course of the week prior to admission, he noticed
progressively worsening left thigh swelling with associated pain
but not warmth or erythema. Per report, his rehab facility was
under the impression that this was due to cellulitis and started
him on Keflex with no improvement. He is able to move both
extremities equally. Given concern for worsening swelling, he
was brought to ___ for further evaluation.
REVIEW OF SYSTEMS: No fevers, chills, changes in vision,
headache. No cough, no shortness of breath, no dyspnea on
exertion. No chest pain or palpitations. No nausea or vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits. He reported chronic left leg swelling attributed to
congestive heart failure and usually treated with diuretics. His
left leg swelling is at baseline.
In the ED, initial vitals:
98.8; 82; 102/55; 16; 100% RA
- Exam notable for: a very large, tense/hard left thigh compared
to right. No obvious bruising on flank. Distal sensation and
pulses intact in left leg. No erthythema, warmth.
- Labs notable for:
K: 5.4
Cr: 2.6
INR: 3.8
CBC: 15.6>5.9/19.0<220
- Imaging notable for:
Femoral U/S showing:
1. Extensive left thigh hematoma measuring at least 14.4 x 9.8 x
8.3 cm,dramatically increased from ___.
2. No pseudoaneurysm visualized on limited study.
- Patient given 2U PRBCs
- Pt was discussed with cardiology, who recommended against
reversal of anticoagulation. Patient was also discussed with ___,
unable to do cross sectional imaging due to elevated renal
functions (58/2.6 <- 33/1.3).
Pt was admitted to ___ for further workup/evaluation.
- Vitals prior to transfer: 98; 16; 129/70; 16; 100% RA
On arrival to the floor, patient was comfortable and in no acute
distress. He was accompanied by his wife, and they confirm the
history above.
Past Medical History:
Severe aortic stenosis s/p TAVR on ___ TAVR (___)
Chronic systolic heart failure (EF 40%)
Hypertension
Hyperlipidemia
Stage IV Hodgkins Lymphoma undergoing chemotherapy
Atrial fibrillation on Coumadin
Asthma
Osteoarthritis
Gout
BPH (unknown prior surgery)
Bigeminy
Colon polyps
Thyroid cancer
s/p thyroidectomy
Right trochanteric hip fracture
Social History:
___
Family History:
Mother - esophageal cancer
Sisters - scleroderma
Son - MI, congenital heart defect, deceased
Daughter - breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 98.3 151/58 75 18 99%RA
General: Alert, oriented, no acute distress
HEENT: anicteric, MMM, oropharynx clear, neck supple, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis bilaterally. Significant
unilateral left thigh swelling (24 inches in diameter),
minimally tender, with no associated warmth or erythema.
Unilateral left leg pitting edema +1, at baseline per patient
and wife. ___ are intact bilaterally. Warm legs with cold
toes bilaterally. Active and passive ROM is intact in both legs.
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAMINATION:
Vitals: 98 140/60 70's 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Anicteric, MMM, oropharynx clear, neck supple, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis bilaterally. Inilateral
left thigh swelling (decreased swelling compared to prior),
non-tender, with no associated warmth or erythema, drain in
place. Unilateral left leg pitting edema +1, at baseline per
patient and wife. ___ are intact bilaterally. Warm legs with
cold toes bilaterally. Active and passive ROM is intact in both
legs.
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 01:19AM BLOOD WBC-15.6*# RBC-2.18* Hgb-5.9* Hct-19.0*#
MCV-87 MCH-27.1 MCHC-31.1* RDW-14.5 RDWSD-45.8 Plt ___
___ 01:19AM BLOOD Neuts-81.2* Lymphs-8.7* Monos-9.4
Eos-0.0* Baso-0.0 Im ___ AbsNeut-12.66*# AbsLymp-1.36
AbsMono-1.46* AbsEos-0.00* AbsBaso-0.00*
___ 01:19AM BLOOD ___ PTT-50.8* ___
___ 01:19AM BLOOD Plt ___
___ 01:19AM BLOOD Glucose-156* UreaN-58* Creat-2.6*# Na-135
K-5.4* Cl-91* HCO3-26 AnGap-23*
___ 04:15PM BLOOD ALT-12 AST-21 LD(LDH)-237 AlkPhos-66
TotBili-2.5*
___ 11:00AM BLOOD Calcium-7.6* Phos-6.0* Mg-2.7*
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-8.1 RBC-2.89* Hgb-8.1* Hct-26.3*
MCV-91 MCH-28.0 MCHC-30.8* RDW-15.3 RDWSD-50.3* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD ___ PTT-31.6 ___
___ 06:45AM BLOOD Glucose-97 UreaN-33* Creat-1.2 Na-136
K-4.2 Cl-102 HCO3-25 AnGap-13
___ 06:45AM BLOOD ALT-9 AST-15 LD(LDH)-290* AlkPhos-71
TotBili-2.0*
___ 06:45AM BLOOD Calcium-7.9* Phos-2.1* Mg-2.3
STUDIES/IMAGING
EKG: Regular sinus rhythm at a rate of 76 beats per minute,
prolonged PR 216 ms consistent with AV conduction delay.
Prolonged QRS 150 ms and prolonged QTc 500 ms.
___:
___ Left femoral vascular ultrasound:
1. Extensive left thigh hematoma measuring at least 14.4 x 9.8 x
8.3 cm, dramatically increased from ___.
2. No pseudoaneurysm visualized on limited study.
___ Left thigh ultrasound without contrast:
There is large proximal left thigh hematoma, measures mildly
larger since ultrasound from ___ 04:35, which may
be secondary to differences in technique or hematoma increase.
___ Left lower extremity ultrasound:
1. No evidence of deep venous thrombosis in the common femoral
or proximal
femoral veins.
2. Sonographic evaluation of the femoral veins is limited by the
large
adjacent hematoma, which was better assessed on the recent CT.
3. The left popliteal and calf veins are patent.
Brief Hospital Course:
___ year old man with Hodgkin's lymphoma (on palliative
Brentuximab, last ___, afib on Coumadin, severe aortic
stenosis s/p TAVR, left femoral artery pseudoaneurysm after his
TAVR s/p thrombin injection by ___ on ___, who presented
with left leg swelling and anemia, found to have extensive left
thigh hematoma in the setting of elevated INR s/p full reversal
with PO vitamin K and FFP and evacuation by vascular surgery on
___.
# CORONARIES: No significant CAD
# PUMP: LVEF 40%, severe AS s/p TAVR (___) BiV PPM and ICD
# RHYTHM: NSR
ACUTE ISSUES
# LLE hematoma: Patient had a significant left thigh hematoma
(thigh measuring 27 inches in diameter) with a significant drop
in hemoglobin (5.9 on admission) in the setting of
supratherapeutic INR. Patient required a total of 7 units of
pRBC transfusion, and INR was reversed with PO vitamin K as well
as FFP. He did not have signs of compartment syndrome.
Interventional radiology could not proceed with imaging and ___
therapies given elevated creatinine on admission. Vascular
surgery was consulted and patient underwent hematoma evacuation
on ___ with subsequent stabilization of the blood counts.
# ___ on CKD (baseline creatinine 1.6-1.7): ___ is likely
pre-renal due to hypovolemia in setting of bleeding as well as
dehydration from diuretics. The creatinine peaked at ___ without
acute RRT needs. The creatinine improved following PRBC
transfusion and holding home torsemide. Creatinine at discharge
was 1.2.
# HFrEF: At admission, patient was euvolemic with clear lungs
and mild left leg swelling (similar to baseline). With active
bleeding and acute kidney injury, torsemide and metoprolol were
held. Torsemide was not started on discharge because patient
remained euvolemic off any diuretics.
# AS s/p TAVR: Patient missed outpatient TTE, this was obtained
while in-patient.
CHRONIC ISSUES
# AFib: Remained in NSR with first degree AV delay.
# Hodgkin's Lymphoma: Stage IV based on bone marrow involvement,
high risk disease, currently on palliative brentuximab (last
___. Not active this admission.
# Hypothyroidism: s/p thyroidectomy, clinically stable on
levothyroxine.
***TRANSITIONAL ISSUES:***
- Monitor the left thigh for recurrence of hematoma
- Make sure to monitor INR very carefully to avoid further
episodes of bleeding in the setting of supratherapeutic INR (INR
goal 2 to 3)
- Home torsemide 20mg was stopped; please monitor volume status
and restart diuresis as needed
- F/U with Dr. ___ vascular surgery as scheduled
- F/U with TAVR team as scheduled
- LFT were elevated, but similar to baseline, please continue to
monitor
NEW MEDICATION:
Aspirin 81mg daily
STOPPED MEDICATIONS:
Metoprolol tartrate 6.25 mg PO BID
Torsemide 20 mg daily
Clopidogrel 75 mg daily
Cephalexin
Probiotics
Potassium chloride
# CODE: Full (confirmed)
# CONTACT: ___ (daughter) ___, home ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 200 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Metoprolol Tartrate 6.25 mg PO BID
9. Pravastatin 40 mg PO QPM
10. Senna 17.2 mg PO QHS
11. Warfarin 3 mg PO 3X/WEEK (___)
12. Warfarin 2 mg PO 4X/WEEK (___)
13. melatonin 3 mg oral QHS
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
15. Clopidogrel 75 mg PO DAILY
16. Torsemide 20 mg PO DAILY
17. Potassium Chloride 10 mEq PO DAILY
18. Cephalexin 500 mg PO Q8H
19. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 5 billion cell
oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Amiodarone 200 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 200 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
9. Levothyroxine Sodium 150 mcg PO DAILY
10. melatonin 3 mg oral QHS
11. Pravastatin 40 mg PO QPM
12. Senna 17.2 mg PO QHS
13. Warfarin 3 mg PO 3X/WEEK (___)
14. Warfarin 2 mg PO 4X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Left leg hematoma
Supratherapeutic INR
Acute on chronic kidney injury
SECONDARY DIAGNOSES:
TAVR
Atrial fibrillation
Hodgkin's Lymphoma
CKD
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 were you admitted to the hospital?
======================================
- You came to the hospital because you had a swollen leg.
Imaging of your leg showed a large collection of blood
(hematoma), which happened because your blood was too thin from
warfarin.
What happened while you were here?
==================================
- Your blood level was closely monitored and you received
multiple blood transfusions to help raise your blood levels.
- You were evaluated by the Vascular Surgery team, who operated
on you and removed the collection of blood.
- The Coumadin effect on your blood was initially reversed in
the setting of bleeding; once you were stable, Coumadin was
started again.
What should you do when you leave?
==================================
- Monitor your left thigh and inform your care provider if your
thigh symptoms worsen.
- Make sure to keep all your doctor appointments.
- Weigh yourself every morning, call a doctor if weight goes up
more than 3 lbs.
- Make sure to take all your medications as prescribed.
NEW MEDICATION:
Aspirin 81mg daily
STOPPED MEDICATIONS:
Metoprolol tartrate
Torsemide
Clopidogrel
Cephalexin
Probiotics
Potassium chloride
We wish you all the best in your recovery!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19664531-DS-19
| 19,664,531 | 26,986,256 |
DS
| 19 |
2140-07-24 00:00:00
|
2140-07-24 13:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall; weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with PMH as noted s/p fall at home. Pt was walking
in the bathroom, legs gave out, and he fell. He struck his head
on a metal railing with bleeding from a scalp
laceration/abrasion. The patient's wife told the ___ that he has
been having frequent falls and that he has had generalized
weakness at home.
In the ___, CT revealed a T1 compression fracture. No other
fractures noted. Physical exam revealed a scalp abrasion.
Rectal exam was guaiac negative.
He was seen by the trauma surgery team, who recommended
admission
for further evaluation.
ROS notable for decreased stooling x5 days, + rectal pain with
blood during last BM.
Also of note, pt with left eye discharge for 'months' per
patient. + occasionally itchy. No pain, redness, or change in
vision.
Per his daughter (contacted via telephone), he has had several
falls. He lives with his wife and has a home health aid ___
hrs per week).
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: [X] All normal
GU: [X] All normal
SKIN: As per HPI
MUSCULOSKELETAL: As per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
10 point review of systems negative except as noted above
Past Medical History:
Hodgkins lymphoma, stage IV, on brentuximab
HTN/CAD/severe AS s/p TAVR ___
Femoral artery pseudoaneurysm
L putamen infarct
Hypothyroidism secondary to papillary carcinoma s/p
thyroidectomy/I-131
Asthma
Nasal polyps
Colon polyps
BPH s/p prostate surgery x2
L hip ORIF (___)
Social History:
___
Family History:
Mother - esophageal cancer
Sisters - scleroderma
Son - MI, congenital heart defect, deceased
Daughter - breast cancer
Physical Exam:
Admission exam
afeb 185/94 71 18 98% (RA)
GENERAL: NAD
Mentation: Alert, speaks in full sentences
Eyes: L eye with stringy discharge; minimal erythema. EOMI.
Scalp: Dressing c/d/i
Ears/Nose/Mouth/Throat: MMM
Neck: Supple
Resp: CTA bilat
CV: RRR, II/VI SEM
GI: Soft, NT/ND
Rectal: Guaiac neg (per ___ exam)
Skin: L elbow with skin tear, bleeding.
L knee with eschar
Buttocks with abrasion, no bleeding or discharge.
Extremities: No edema
Lymph/Heme/Immun: No cervical ___ noted
Neuro:
- Mental Status: Alert & oriented x3. Able to relate history
without difficulty; can do days of the week backward
Discharge exam:
_____________________
Pertinent Results:
======================
Pertinent results:
WBC 13 -> 10 -> ___ range
Hgb ___
Plt 120s-140s
INR 1.8-2.7
Cre 1.1-1.5, BUN ___ (up and down)
B12 770
TSH 3.6
UA - no WBC/leuk
Urine Cx - aerococcus
CXR ___ No significant change from the prior study from ___. No definite new focal consolidation.
CT C-spine ___
Mild-to-moderate compression fracture of the superior endplate
of the T1
vertebral body, new since the prior study of ___, but
of otherwise indeterminate age. Findings may be subacute, but
acute component is difficult to entirely exclude. Correlate
clinically for acuity. MRI could help further assess acuity.
No acute fracture seen elsewhere. No dislocation. Multilevel
degenerative
changes.
XR knee ___
No acute fracture or dislocation. Small left suprapatellar
joint effusion.
Severe right knee osteoarthritic changes, as above.
XR elbow ___
No acute fracture or dislocation.
CT C/A/P ___. No evidence of lymphadenopathy in the chest, abdomen, and
pelvis by CT size criteria. Scattered mildly prominent lymph
nodes as described are stable compared to the prior examination.
2. Unchanged chronic findings, as described.
CXR ___
No acute cardiopulmonary abnormality.
======================
Brief Hospital Course:
___ gentleman with severe AS s/p TAVR complicated by
femoral artery pseudoaneurysm, HFpEF, A. fib on Coumadin, HTN,
hx/o PMR, hx/o thyroid cancer, and stage IV Hodgkin's Lymphoma
s/p 6 cycles of Brentuximab who presented after a fall, found to
have T1 compression fracture.
#Fall with abrasions, multiple recent falls
#T1 compression fracture of indeterminate age
#Generalized weakness
#Suspected mild peripheral neuropathy
Appreciate ___ evaluation. Likely worsening deconditioning in
setting of multiple chronic illnesses and chemotherapy. After
discussion with primary oncologist Dr. ___ some
concern for neuropathy due to brentuxumab. Neurology consulted.
Likely some mild distal neuropathy, although this may have
already been present prior to chemotherapy. Defer any EMG/NCS
testing to outpatient setting. Family initially hesitant about
rehab given potential delay in chemo and prior bad experiences
in rehab (patient fell and broke hip), but ultimately agreeable.
Started on calcium in addition to vitamin D. Should have vitamin
D level checked as outpatient and consider osteoporosis therapy
if appropriate.
#Mild leukocytosis, drowsiness, ___
#Suspected mild acute metabolic encephalopathy on chronic
cognitive impairment
Developed mild leukocytosis on ___ and noted to be slightly
more drowsy than recent days. Had feverx1 overnight ___. CXR,
UA, history, and exam unrevealing. Awaiting blood cultures. He
was drowsy but easily awakened, and cognition similar to recent
baseline when he was awake and alert. No neck pain or HA, so
suspicion for CNS infection was low. Possible transient viral
illness.
#HTN/labile BPs/likely dysautonomia/age related baroreceptor
dysfunction:
Reviewing prior data, seems to have pattern of nocturnal
hypertension with afternoon lows, a typical pattern for age
related baroreceptor dysfunction/dysautonomia. On ___ had BPs
to 200s overnight, but otherwise was not as severe. Started
trial of amlodipine 5 mg QPM. Elevated head of bed at night.
#Eye discharge, recent bilateraly acute conjunctivitis
Per patient's daughter had been ok until few days before
admission, then increasing discharge from L eye, started on
topical abx at admission, with some persistent discharge from L
eye on exam ___. No erythema or vision change. Informal
evaluation by ophtho - felt to be likely mild nonspecific
irritation. Completed 5 days of erythromycin and continued
artificial tears. Not fully resolved, but still low suspcicion
for active infection.
#mild volume depletion/fluctuating renal function:
Creatinine fluctuating in 1.1-1.5 range. Likely related to
POs/volume status, although no appreciable changes in exam.
Intermittently received fluids, particularly if low PO intake
suspected.
#Afib/CAD, severe AS s/p TAVR
Continued on coumadin, statin, ASA< amio
#Lymphoma
On brentuxumab, s/p 6 cycles. Will most likely be on hold while
in rehab. CT ___ showed stable disease burden, suggesting that
this would be reasonable delay in order to improve his
functional status. This was discussed extensively with his
family who was ultimately agreeable.
#Urinary retention
Had intermittent need for straight catheterization for bladder
volume over 500. He has prostate issues, and we started him on
tamsulosin 0.4mg at bedtime. He did require extra encouragement
to void. Should be followed up with PCP and his urologist as an
outpatient.
====================
Transitional issues:
- onc follow-up, likely restarting chemo after rehab
- can consider EMG/nerve conduction studies as outpatient if
appropriate
- check vitamin D level, if replete then would consider
osteoporosis treatment
- continue titrating BP regimen
- recommend elevation of head of bed ___ degrees to reduce
nocturnal supine hyeprtension
====================
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Falls
#T1 compression fracture of indeterminate age
#Generalized weakness
#Lymphoma
#Afib
#CKD
#Mild left eye irritation
#Labile blood pressures
#Mild leukocytosis
#Fever
#Suspected metabolic encephalopathy
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:
You were admitted to the hospital because of a fall. Fortunately
you did not suffer a major injury, although we did discover a
compression fracture in your spine that may have been unrelated
to your fall. because of your repeated falls and deconditioning
noted by our physical therapist, we have recommended a rehab
stay to help improve your strength so that you can return home
and continue with your chemotherapy.
You also had some trouble with retaining urine. We started you
on a medication to make it easier to urinate. Please see your
urologist or primary care doctor about managing this issue as an
outpatient.
Followup Instructions:
___
|
19664531-DS-22
| 19,664,531 | 28,174,917 |
DS
| 22 |
2140-10-01 00:00:00
|
2140-10-01 18:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Foley catheter exchange ___
History of Present Illness:
___ M s/p left hip hemiarthroplasty taking oxycodone for pain,
presenting w/ AMS from local nursing home (___).
40 minutes prior to arrival at ED, pt had episode of vomiting
and a ?unresponsiveness. Brought to ED by EMS. Per EMS, patient
was alert and oriented in the field but lethargic and without
complaints. Staff at ___ were not able to add
additional detail, however, there is possibly report of a fever.
On arrival to ED, patient does not remember vomiting and
continues to deny any complaints. He denies any cough,
congestion, chest pain, shortness of breath. He has had 3 days
of diarrhea. He also has had a Foley in place in ___ clinic
___ for urinary retention.
In the ED, initial vital signs were notable for: T100.7, HR80,
BP
125/56, RR 16, 99% RA, 355
Exam notable for:
Rectal temp 102.8; Constricted pupils; Dry mucous membranes;
Diffusely tender in the lower abdomen most notably over the left
and right suprapubic areas
Foley with murky and bloody urine in bag; Surgical site on left
hip w/CDI steri strips, no erythema/drainage.
Labs were notable for:
-WBC 14.2 (N90.4), H/H 8.8/29.1, PLT 186
-BUN 23, Are 1.5
-Lactate 2.2
-Trop 0.04
-Alb 3.3
-UA hazy, specGr 1.01, pH 7.0, Leuk trace, Old mod, nitrate pos,
protein trace, RBC 34, WBC 15, Bact few
Studies:
___. No acute intracranial abnormality.
2. Chronic sinus disease, including unchanged hyperdense
opacification of the sphenoid sinus, which can be seen in the
setting of fungal infection or inspissated secretions.
___ CXR
Minimal linear lateral left base atelectasis is seen. There is
no focal consolidation. No large pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are stable. Patient is status post aortic valve repair.
Evidence of DISH is seen along the thoracic spine.
IMPRESSION: No definite focal consolidation.
___ EKG- R66 QTC 490/504
___ Bcx x2- pending
___ Ucx- pending
Patient was given:
-1.5L NS
-IV Tylenol ___ mg x1
-Ceftriaxone 1g x1
-home synthroid ___ mcg
-home amlodipine 5 mg
Consults: Orthopedics- no acute orthopedic concerns
Vitals on transfer: 98.7 BP132 / 63 HR 59 RR 18 97%RA
Upon arrival to the floor, the patient is lethargic and does not
engage in interview. A&Ox3 (First Name, ___,"
___.
Unable to do attention tasks per nursing.
REVIEW OF SYSTEMS:
==================
(+) Per HPI, otherwise 10-point ROS is negative
Past Medical History:
- Atrial Fibrillation secondary to Severe AS
- Aortic Stenosis s/p TAVR in ___
- Hypertension
- CAD
- Hypothyroidism s/p thyroidectomy in ___ and I-131
- Thyroid Cancer (papillary carcinoma) in ___
- Asthma
- Nasal Polyps
- Colon Polyps
- Dyslipidemia
- Left Putamen Infarct without Residual Deficit
- BPH s/p prostate surgery x ___
- s/p ORIF left hip ___
- seudoanuerysm of the arterial femoral artery with basses
formation
- s/p bilateral cataract surgery in ___
- s/p hernia repair
Social History:
___
Family History:
Mother deceased at ___ from esophageal cancer.
Father deceased at ___ from natural causes. Daughter with
metastatic breast cancer.
Physical Exam:
Admission exam:
VITALS: 98.7 BP132 / 63 HR 59RR 1897%RA
GENERAL: Lethargic. A&O x3 (first name, ___," ___
___: Normocephalic. 3cm well-healed laceration on left brow.
Pinpoint pupils. Patient unable to participate in assessment of
extra ocular movements. Sclera anicteric. Dry mucous membranes.
Ulcer on right tongue border.
NECK: No cervical lymphadenopathy. No JVD appreciated.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Holosystolic murmur that radiates to clavicles.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds in the apices. Patient unable to turn for exam. No
increased work of breathing.
BACK: Patient unable to turn for exam.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants.
EXTREMITIES: 1+ bilateral lower extremity edema to ankles. Skin
tenting appreciated above ankles. Pulses DP/Radial 2+
bilaterally.
GU: Foley in place draining dark yellow, transparent urine
SKIN: Diffuse skin tenting, Warm. Well-healed abrasion on L
thigh.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Discharge exam:
VITALS:
Temp: 98.1 (Tm 98.1), BP: 146/73 (146-173/73-85), HR: 66
(64-73), RR: 18, O2 sat: 99% (95-99), O2 delivery: Ra
GENERAL: Sleeping. Oriented to name only.
___: Normocephalic. Pupils round and equal in size. Patient
unable to participate in assessment of extra ocular movements.
Sclera anicteric.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic ejection murmur.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds in the anterior lung fields. Patient unable to turn for
exam. No increased work of breathing.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants.
EXTREMITIES: Warm. 1+ bilateral lower extremity edema to ankles.
Skin tenting appreciated above ankles.
GU: Foley in place draining yellow non-cloudy urine. No
suprapubic tenderness.
NEUROLOGIC: AAOx1 as above. Moving all extremities
symmetrically. Speech normal.
Pertinent Results:
Admission and notable labs
___ 02:32PM BLOOD WBC-14.2* RBC-3.40* Hgb-8.8* Hct-29.1*
MCV-86 MCH-25.9* MCHC-30.2* RDW-19.3* RDWSD-60.0* Plt ___
___ 06:00AM BLOOD ___ PTT-32.1 ___
___ 02:32PM BLOOD Glucose-188* UreaN-23* Creat-1.5* Na-138
K-4.6 Cl-98 HCO3-25 AnGap-15
___ 02:32PM BLOOD ALT-10 AST-22 AlkPhos-143* TotBili-1.5
___ 06:00AM BLOOD ALT-8 AST-27 LD(LDH)-697* AlkPhos-113
TotBili-1.2
___ 02:32PM BLOOD cTropnT-0.04*
___ 02:32PM BLOOD CK-MB-<1
___ 02:32PM BLOOD Lipase-18
___ 06:00AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.3
___ 02:32PM BLOOD Albumin-3.3*
___ 02:43PM BLOOD Lactate-2.2*
___ 02:42PM URINE Blood-MOD* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 02:42PM URINE RBC-34* WBC-15* Bacteri-FEW* Yeast-NONE
Epi-0
___ 09:00AM URINE RBC-108* WBC->182* Bacteri-MANY*
Yeast-NONE Epi-0
___ 09:00AM URINE Blood-MOD* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*
___ 09:00AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 05:46AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
MICROBIOLOGY:
___ 2:42 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
FOSFOMYCIN REQUESTED BY ___ ON
___, 11:45AM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 9:00 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Susceptibility testing performed on culture # ___
ON ___.
Blood cultures pending at discharge
Discharge labs:
___ 06:00AM BLOOD WBC-7.0 RBC-3.55* Hgb-9.1* Hct-30.8*
MCV-87 MCH-25.6* MCHC-29.5* RDW-18.8* RDWSD-60.1* Plt ___
___ 06:00AM BLOOD Glucose-73 UreaN-25* Creat-1.1 Na-139
K-4.9 Cl-101 HCO3-23 AnGap-15
___ 06:00AM BLOOD ALT-8 AST-27 LD(LDH)-697* AlkPhos-113
TotBili-1.2
___ 06:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2
___ 07:46AM BLOOD Lactate-2.0
Imaging:
___ CT head IMPRESSION:
1. No acute intracranial abnormality.
2. Chronic sinus disease, including unchanged hyperdense
opacification of the sphenoid sinus, which can be seen in the
setting of fungal infection or inspissated secretions.
CXR ___
IMPRESSION: No definite focal consolidation.
Brief Hospital Course:
___ man with Hodgkin's lymphoma on treatment, BPH complicated
by urinary retention, and recently s/p left hip hemiarthroplasty
(taking oxycodone for pain) admitted with lethargy and altered
mental status, likely secondary to E.coli UTI.
--------------
ACTIVE ISSUES:
--------------
# Toxic metabolic encephalopathy:
# Urinary tract infection, catheter-associated:
Patient presented with AMS, leukocytosis, fever to 102, and
nitrates on UA most consistent with urosepsis. Patient with
recurrent UTIs with proteus, enterococcus, aerococcus, and
corynebacterium in the last 3 months, most recently with pyuria
in clinic on ___. His Foley catheter was exchanged this
admission. Given risk factors for resistant organisms, patient
was initially broadened to vancomycin and cefepime, but
subsequently narrowed to ceftriaxone following clinical
improvement. Urine cultures grew E. coli, sensitive only to
meropenem and ciprofloxacin. The patient was switched to
ciprofloxacin for a 7-day treatment course for complicated UTI
(day 1 = ___ with meropenem; Day ___ = ___ with cipro). He will
follow up with ID for consideration of suppressive antibiotics
given multiple UTIs and will follow up with urology for
consideration of BPH management given need possible need for
indwelling foley due to BPH
# Urinary retention
# BPH:
Presented to outpatient clinic on ___ with urinary retention
requiring Foley catheter placement. Catheter was replaced on
admission given concern for UTI as above. Continued to drain
adequate urine well through catheter. Patient will need
outpatient follow-up with urology in ___ weeks for consideration
of a voiding trial. This was arranged.
STABLE / CHRONIC ISSUES
# Hemiarthroplasy:
Incision clean/dry/intact. Orthopedics was consulted in ED, no
further recommendations. Patient not currently endorsing pain.
Pain was well controlled with Tylenol. Home oxycodone was
discontinued, especially given concern for possible contribution
to altered mental status on presentation as above.
# Atrial fibrillation: Continued home amiodarone, metoprolol,
Coumadin (dosed daily per INR).
# ___ on CKD: presented with Creatinine peaked at 1.5 from
baseline of 1.2. Likely secondary to volume losses in the
setting of 3 days of diarrhea and acute vomiting given dry
mucous membranes and skin tenting on exam. Resolved with fluid
resuscitation. Discharge creatinine=1.1.
# Aortic Stenosis: Moderate to severe AS s/p TAVR with
bioprosthesis. Stable.
# Hodgkin's Lymphoma: Status post 7 cycles bretuximab. Closely
followed in outpatient ___ clinic. Last CT torso ___ no
evidence of progression.
# Gout: Continued home allopurinol.
# Hypothyroidism: Continued home synthroid.
# CAD: Continued home ASA.
# Chronic health issues: Continued home erythromycin eye
ointment and home vitamins.
-------------------
TRANSITIONAL ISSUES
-------------------
[] Completing 7-day treatment course with ciprofloxacin for
catheter-associated UTI (day 1 = ___ day 7 = ___
[] Patient will need outpatient follow-up with urology for
consideration of a voiding trial and possible surgical
management of BPH
[] Please follow up with ID for consideration of suppressive Abx
for recurrent UTI
[] Discontinued oxycodone given that pain was well controlled
and given concern for possible contribution to altered mental
status on admission.
[] Discharge creatinine = 1.1.
==============
CORE MEASURES:
==============
# CODE: Full (presumed)
# ___
___: Wife Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID hip surgery
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
7. Tamsulosin 0.4 mg PO QHS
8. Warfarin 3 mg PO Q24H
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Vitamin D 200 UNIT PO BID
12. Artificial Tears ___ DROP BOTH EYES 5X/DAY
13. Docusate Sodium 100 mg PO BID
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Mirtazapine 15 mg PO QHS:PRN insomnia
16. Ferrous Sulfate 325 mg PO DAILY
17. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
end ___. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Allopurinol ___ mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Artificial Tears ___ DROP BOTH EYES 5X/DAY
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 500 mg PO BID hip surgery
8. Docusate Sodium 100 mg PO BID
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Mirtazapine 15 mg PO QHS:PRN insomnia
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D 200 UNIT PO BID
16. Warfarin 3 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
- Complicated urinary tract infection
SECONDARY DIAGNOSES:
====================
- Confusion/Acute on chronic encephalopathy
- anemia
- urinary retention
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with some confusion and you
were found to have a urinary tract infection. We were able to
grow the bacteria causing the infection so that we could
determine the best antibiotic to use.
While you were in the hospital, you were started on this
antibiotic and you improved. In addition, we gave you what
medicines to treat your pain and we were able to do that without
making you sleepy or confused.
You will need to continue to use the Foley catheter to pass
urine because your bladder was not able to squeeze urine out
properly. This is probably a result of an enlarged prostate and
urinary tract infection. We stopped your medicine tamsulosin
because it was not helping you to urinate. He will need to keep
the Foley catheter in for another ___ weeks, and then you will
have to follow-up with urology if you are still not able to
urinate. When the Foley catheter is removed, you can try
starting tamsulosin again.
After leaving the hospital, please continue to take the
antibiotics until they finish on ___. Please take the
antibiotics through ___. If you have worsening abdominal
pain, confusion, fevers, chills, or other concerning symptoms
you should call your doctor or go to the ICU.
Thank you for letting us participate in your care!
Your ___ Care team
Followup Instructions:
___
|
19664783-DS-10
| 19,664,783 | 24,747,368 |
DS
| 10 |
2122-01-22 00:00:00
|
2122-01-30 06:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain/Back Pain/RUQ Abd Pain
Major Surgical or Invasive Procedure:
___: open cholecystectomy
History of Present Illness:
___ female with history of afib, CKD, and
tachybradycardia syndrome, s/p pacer placement 3 weeks ago, who
presented with chest pain. Pt. reports gradual onset of
substernal chest pain. Initially there was some concern of pain
radiating to the back with cutting/tearing sensation, but on
reevaluation seems that it was more mild chest pain. Some
associated nausea, vomiting, and epigastric pain. Denied fevers,
dyspnea.
In the ED, initial vitals were: 98.3, 75, 219/79, 18, 100%
Labs notable for leukocytosis with neutrophil predominance, INR
2.9, Cr 2.7 (baseline), trop<0.01.
She was placed on an esmolol drip given that there was
initially some concern for dissection. Unfortunately, due to CKD
and recent pacer, she was unable to undergo CTA or MRA. She had
a non-con CT of the chest that was negative. Her blood pressure
was equal bilaterally, and her pain resolved with her blood
pressure control. She was taken off the esmolol gtt and did
well. She was admitted to ___ for further monitoring.
VS prior to transfer: 97.6, 75, 118/55, 21, 91% on RA. This
morning on the floor, Ms ___ says that chest pain and back
pain have resolved. She complains of abdominal pain in RUQ and
RLQ. She also complains of a cough, but denies dyspnea. No
headaches, fever, n/v, dysuria.
Past Medical History:
-Diastolic Congestive Heart Failure (LVEF>55%)
-Atrial Fibrillation (s/p cardioversion ___, back in AFib
at ___
-Chronic Kidney Disease (baseline Cr 2.0-2.6, eGFR<30)
-Type II Diabetes Mellitus (on oral medications only)
-Peripheral Artery Disease
-Right Renal Artery Stenosis (90% on ___ by
arteriography)
-Hypertension
-Hyperthyroidism
-External Hemorrhoids
-Gallbladder Stent in ___ at ___
-History of falls and syncope
Social History:
___
Family History:
non-contributory
Physical Exam:
ON ADMISSION:
Vitals - T: 98.3 BP: 102/44 HR: 75 RR: 18 02 sat: 96% RA
bilateral BP: left arm: 116/52; right arm: 114/50
WEIGHT: 70.9 kg
GENERAL: NAD
NECK: Nontender supple neck, no LAD, no JVD
CARDIAC: RRR, no murmurs
LUNG: CTAB, no wheezes, ronchi, crackles, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, nondistended,nontender in all quadrants, pain on
palpation in RUQ (Positive ___ Sign), Mild tenderness on
palpation of RLQ, negative Rovign's Sign
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose.
SKIN: warm and well perfused, no rashes, blister on her right
later aspect of leg with no active bleeding, edema, or purulent
discharge.
ON DISCHARGE:
Pertinent Results:
ADMISSION LABS:
___ 07:45PM BLOOD WBC-15.7*# RBC-3.29* Hgb-9.9* Hct-29.3*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.7* Plt ___
___ 07:45PM BLOOD Neuts-86.0* Lymphs-8.2* Monos-4.1 Eos-1.4
Baso-0.3
___ 07:45PM BLOOD ___ PTT-45.3* ___
DISCHARGE LABS:
IMAGING:
CHEST (PA & LAT) ___:
IMPRESSION:
No acute cardiopulmonary process. Mediastinal contour unchanged
compared to ___.
CT CHEST W/O CONTRAST ___:
IMPRESSION:
1. No evidence of intramural hematoma on this noncontrast study.
No
mediastinal hematoma.
2. Cardiomegaly.
3. Distended gallbladder with multiple calcified stones as well
as a 3.7 cm rounded hyperdense region within the gallbladder
neck which could represent a polypoid mass lesion, recommend
right upper quadrant ultrasound for further evaluation.
4. Pneumobilia, correlate with history of prior sphincterotomy.
5. Enlarged multinodular thyroid, further evaluation with
thyroid ultrasound
can be obtained if clinically indicated.
ANKLE (AP, MORTISE & LA) ___:
IMPRESSION:
No evidence of fracture.
LIVER OR GALLBLADDER US ___:
IMPRESSION:
Distended gallbladder with multiple gallstones and large sludge
ball at neck with gallbladder wall edema and pericholecystic
fluid. Patient also had a positive sonographic ___ sign.
Overall findings are compatible with acute cholecystitis.
MICROBIOLOGY:
___ 10:30 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
___ 3:26 pm URINE Source: ___.
URINE CULTURE (Pending):
Brief Hospital Course:
___ y.o. ___ woman with HTN, DM, CKD, Afib,
tachybrady syndrome s/p pacer 3 weeks ago presenting with chest
and back pain.
# Chest/Back Pain: Patient presenting with gradual onset
substernal chest pain radiating to back. EKG unremarkable for
ischemic changes, trop/CK-MB negative x2. BP Left arm 116/52;
Right arm: 114/50. Noncontrast chest CT unremarkable for aortic
dissection. Patient reported chest and back pain resolved by the
time she was admitted to the medical floor. The patient's
presentation was likely from hypertensive urgency vs gallbladder
disease as detailed below.
# Hypertensive urgency: BP significantly elevated on admission
at 219/79. While patient reported chest pain, no evidence of end
organ damage on exam and labs with baseline Cr, normal trop, and
lack of neuro symptoms. Unclear trigger for hypertensive
crisis. Patient reportedly compliant with anti-hypertensive
medications. The patient was briefly on esmolol gtt in the ED
but later discontinued after BP improved. On the floor, BP were
Left arm 116/52; Right arm: 114/50. The patient was continued on
her home Losartan 100 mg PO QDaily and Torsemide as below.
# Acute Cholecystitis: Patient presented with two days of RUQ
pain with associated nausea or vomiting. On admission, WBC was
15.7 and later rose to 25.8. AP was elevated at 177. TBili was
initially normal but rose to 2.2 (DBili 0.9). Exam was notable
for positive ___ sign. Lipase wnl at 29. Right upper
quadrant ultrasound was notable distended gallbladder with
multiple gallstones and large sludge ball at the neck with
gallbladder wall edema and pericholecystic fluid. CBD was 9 mm.
The patient underwent a laparoscopic cholecystectomy...She also
had an ECRP which revealed...
CHRONIC ISSUES:
# Diastolic Congestive Heart Failure (LVEF>55%): Dry weight per
prior d/c summary is around 70.4 kg. Weight on admission was
70.9 kg. On admission, the patient did not appear volume
overloaded.
-Continued home Torsemide 20 mg PO QOD/Torsemide 30 mg PO QOD
# Atrial Fibrillation (s/p cardioversion ___, back in AFib
at ___. On admission, the patient was in normal sinus
rhythm. The patient's home Amiodarone 200 mg PO QDaily and
Metoprolol Succinate 25 mg PO QDaily were continued. The
patient's home coumadin was initially held in anticipation of
surgery as above, but resumed prior to discharge.
# Chronic Kidney Disease (baseline Cr 2.0-2.6, eGFR<30): Cr at
baseline. No indication for HD.
-Avoided nephrotoxic agents, renally dosed medications
# Type II Diabetes Mellitus: Diet-controlled.
- The patient was managed on an insulin sliding scale.
# Hyperthyroidism:
- Continued home Methimazole 2.5 mg PO QDaily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Torsemide 20 mg PO QOD
6. Senna 8.6 mg PO BID:PRN Constipation
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Methimazole 2.5 mg PO DAILY
9. Ferrous Sulfate 325 mg PO HS
10. Losartan Potassium 50 mg PO DAILY
11. Warfarin 1 mg PO DAILY16
12. Calcitriol 0.25 mcg PO 3X/WEEK (___)
13. Nystatin Cream 1 Appl TP TID
14. Torsemide 30 mg PO EVERY OTHER DAY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Docusate Sodium 100 mg PO DAILY
5. Ferrous Sulfate 325 mg PO HS
6. Methimazole 2.5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
9. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
10. Cephalexin 500 mg PO Q8H Duration: 5 Days
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth three times
a day Disp #*5 Capsule Refills:*0
11. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth Before Bed
Disp #*30 Capsule Refills:*0
12. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg ___ tablet(s) by mouth every four
hours Disp #*50 Tablet Refills:*0
13. Acetaminophen 650 mg PO Q6H
14. Bisacodyl ___ID:PRN Constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally twice a day Disp
#*40 Suppository Refills:*0
15. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
16. Losartan Potassium 50 mg PO DAILY
17. Senna 8.6 mg PO BID:PRN Constipation
18. Torsemide 20 mg PO QOD
19. wheelchair miscellaneous all Mobilization
RX *wheelchair Use for mobilization As needed Disp #*1 Each
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitlization at
the ___. As you know, you were
admitted with chest and back pain. We did tests which did not
show you were having a heart attack or problems with your blood
vessel called the aorta. We did tests which showed you had
inflammation of your gallbladder. We had a procedure to remove
your gallbladder called a cholecystectomy.
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:
___
|
19664783-DS-6
| 19,664,783 | 22,987,477 |
DS
| 6 |
2121-04-10 00:00:00
|
2121-04-12 22:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ year old woman with PMHx of ___ with
preserved EF, atrial fibrillation on coumadin, CKD with
creatinine of 2.0-2.6 who presents with recently worsening lower
extremity edema. She was at her PCP's office and was seen today
and and there per the PCP she reported worsening lower extemrity
edema and shortness of breath and there was concern for volume
overload on exam. In the ED per report she said that she had no
significant shortness of breath or chest pain. SHe does report
that she has difficulty with walking long distances secondary to
shortness of breath. Also of note the patient reports that she
has had a small amount of BRBPR on the day prior to admission
and feels that it is likely from her hemorrhoid. She reports
that it has stopped.
In the ED, initial vitals were: 97.6 101 130/78 18 97%.
She recieved 20mg IV lasix. She had a rectal exam that per
report was notable for dried blood around rectum, small
hemorrhoid @ 6 o'clock and guaiac+ scant brown stool. She was
admitted to ___ for further work up and care.
Vitals on transfer: 98.0, 79, 113/71, 18, 97% RA.
Past Medical History:
-DM
-___ with preserved EF
-PAD
-HYPERTHYROIDISM
-HTN
-CKD (2.0-2.6)
-PAF
Social History:
___
Family History:
No early CAD or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=================================
VS: T=98.2 BP=136/71 HR=76 RR=20 O2 sat=99%RA
General: NAD, Laying in bed, ___: MMM, EOMI, PERRL
Neck: Supple, JVP elevated at 90degrees.
CV: Irregularly irregular.
Lungs: Bibasilar crackles
Abdomen: +BS, soft, NT, ND
Ext: 2+ pitting edema up to the level of the thigh on the left
and mid shin on the right.
Neuro: CN ___ grossly intact
Skin: Warm and dry
DISCHARGE PHYSICAL EXAMINATION:
=================================
VS: 98.1, 72, 130/65, 18, 98% on RA
Discharge Weight: 70kg (estimated dry weight 69.5kg)
General: NAD
___: MMM, EOMI, PERRL
Neck: Supple, JVP 10cm
CV: Irregularly irregular. No M/R/G/C
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: +BS, soft, NT, ND
Ext: trace to 1+ ___ edema (right > left)
Neuro: CN ___ grossly intact. A/O x3
Pertinent Results:
ADMISSION LABS
===============
___ 02:11PM BLOOD WBC-8.0 RBC-3.58* Hgb-10.2* Hct-32.8*
MCV-92 MCH-28.4 MCHC-31.0 RDW-16.7* Plt ___
___ 02:11PM BLOOD Neuts-74.3* Lymphs-15.5* Monos-6.1
Eos-3.2 Baso-0.8
___ 02:11PM BLOOD ___ PTT-44.0* ___
___ 02:11PM BLOOD Glucose-126* UreaN-55* Creat-2.4* Na-140
K-3.9 Cl-99 HCO3-29 AnGap-16
NOTABLE LABS
==================
___ 07:49AM BLOOD ___ PTT-39.3* ___
___ 07:35AM BLOOD ___ PTT-39.0* ___
___ 10:40AM BLOOD ___ PTT-40.6* ___
___ 07:49AM BLOOD Glucose-123* UreaN-57* Creat-2.5* Na-137
K-3.6 Cl-95* HCO3-31 AnGap-15
___ 07:35AM BLOOD Glucose-128* UreaN-68* Creat-2.6* Na-139
K-3.8 Cl-96 HCO3-29 AnGap-18
___ 03:25PM BLOOD Glucose-171* UreaN-78* Creat-2.9* Na-138
K-4.4 Cl-95* HCO3-27 AnGap-20
___ 02:11PM BLOOD cTropnT-<0.01
___ 02:11PM BLOOD ___
DISCHARGE LABS
================
___ 07:00AM BLOOD WBC-9.7 RBC-3.69* Hgb-10.9* Hct-32.3*
MCV-88 MCH-29.6 MCHC-33.7 RDW-16.2* Plt ___
___ 07:00AM BLOOD ___ PTT-38.8* ___
___ 07:00AM BLOOD Glucose-122* UreaN-87* Creat-3.0* Na-137
K-4.0 Cl-95* HCO3-30 AnGap-16
___ 07:00AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3
STUDIES
==========
ECG (___): Atrial fibrillation with a mean rate of 83.
Non-specific repolarization abnormalities. Compared to the
previous tracing of ___ the rhythm is now atrial
fibrillation.
ECG (___): Atrial fibrillation. Premature ventricular
complexes. Non-specific repolarization abnormalities. Compared
to the previous tracing the ventricular rate has increased.
Ventricular ectopy is new. Otherwise, findings are similar.
LEFT LOWER EXTREMITY ULTRASOUND (___): IMPRESSION: No
evidence of DVT in the left lower extremity.
CXR (___): IMPRESSION: Questionable medial right upper lobe
opacity versus mediastinal widening. When clinically feasible,
repeat radiographs are suggested with PA and lateral technique
to better assess. The main concern is a possible right
perihilar consolidation which might indicate pneumonia in the
appropriate setting. There is no generalized convincing
evidence for fluid overload although the finding may
alternatively indicate mild perihilar congestion change.
CXR (___): IMPRESSION: 1. Stable cardiac enlargement and
stable unfolded tortuous aorta. A faint opacity is seen in the
right medial lung adjacent to the paratracheal soft tissues.
This is not felt to likely correspond to vascular structures and
either could represent an area of pneumonia, post-inflammatory
scarring, or possibly a mass. Further imaging evaluation with
CT may be helpful. No evidence of pulmonary edema. No pleural
effusions. No pneumothorax. Degenerative changes in the mid to
lower thoracic spine with no acute bony abnormality appreciated.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is an ___ year old woman with
PMHx of dCHF with preserved EF, atrial fibrillation on coumadin,
CKD with creatinine of 2.0-2.6 who presented with worsening
lower extremity edema, shortness of breath, and weight gain
consistent with acute on chronic dCFH exacerbation. Pt. was
diuresed with IV lasix with success. Her volume status improved.
She was discharged at a weight of 70kg, with estimated dry
weight being around 69.5kg (153 lbs). Her home regimen was
changed from lasix 40mg to torsemide 20mg.
ACTIVE ISSUES
===============
# Acute on Chronic dCHF with preserved EF: Patient presented
with increased ___ edema, DOE, and weight gain consistent with
exacerbation of CHF. Likely trigger was thought to be ___ to
rapid ventricular rates in the setting of poorly rate controlled
afib. Her home metoprolol was uptitrated with resolution of
RVR. Her infectious cultures were revealing only for a urine
culture with nearly pan-sensitive ecoli. Pt. was without
symptoms consistent of a UTI (including no frequency, urgency,
incontinence, dysuria) and as such was not treated with
antibiotics. Pt. was initially diuresed with IV lasix. She was
later transitioned to and discharged on torsemide 20mg PO daily.
# ___ on CKD: Pt. presented with creatinine at 2.4 within her
baseline 2.0-2.6.. In the setting of diuresis, pt's creatinine
increased to 3.0. Pt. was discharged with the plan to recheck
her renal function and electrolytes within 1 week of discharge.
She was continued on her losartan.
Left Leg Swelling: Pt. was noted to have asymmetric left lower
extremity edema great than right. She had ___ which returned
negative for DVT.
CHRONIC ISSUES
=================
# Paroxysmal Afib: Pt continued on coumadin. Metoprolol was
uptitrated as detailed above.
# HTN: Continue home losartan and metoporol.
# Hyperthyroidism : Continue home methimazole.
# DM: Pt. continued on ISS while inpatient. She was restarted
on glipizide at discharge.
# Iron Deficiency: Pt. continued on ferrous sulfate.
# Vitamin D Deficiency: Pt. continued on vitamin D.
TRANSITIONAL ISSUES
=====================
# Discharge Weight: 70kg (estimated dry weight 69.5kg)
# Right Lung Opacity: Pt. found to have opacity at right medial
lung adjacent to the paratracheal soft tissues. Radiology
recommended further assessment with CT scan.
# CHF: discharged on torsemide 20mg. ___ to follow daily weights
and discuss further necessary adjustments with PCP. Dry weight
estimated at 69.5 kg (153 lbs). For increased HRs, pt. d/c'ed on
Metoprolol XL 50mg PO Daily.
# Positive urine culture: Urine Culture grew E Coli. Pt. was
asymptomatic. As such, pt. was not treated with antibiotics.
# ___: Cr up to 3.0 on discharge likely from aggressive
diuresis, will draw repeat chem panel ___. Results
should be faxed to PCP.
# Anticoagulation: repeat INR ___, coumadin managed by
PCP
# Code: DNR/DNI, confirmed with patient.
# Contact: ___ (Granddaughter Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Methimazole 5 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Warfarin 2 mg PO DAYS (___)
7. Warfarin 1 mg PO DAYS (___)
8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. GlipiZIDE 5 mg PO DAILY:PRN FSBS>150
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Methimazole 5 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 2 mg PO DAYS (___)
7. Warfarin 1 mg PO DAYS (___)
8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
9. GlipiZIDE 5 mg PO DAILY:PRN FSBS>150
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 25 mg 2 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
11. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Outpatient Lab Work
___ Chronic kidney disease, unspecified
Please check chem 10 and communicate results to PCP ___.
___ at Phone: ___ Fax: ___
13. Outpatient Lab Work
___.31 : Atrial fibrillation
Please draw INR and communicate results to PCP ___
at Phone: ___ Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
# Acute on Chronic Diastolic Heart Failure
SECONDARY DIAGNOSES
=====================
# Paroxysmal Atrial Fibrillation
# Hypertension
# Chronic Kidney Disease
# Hyperthyroidism
# Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was as pleasure meeting and caring for you during your most
recent hospitalization. You were admitted with shortness of
breath, increased weight gain, and swelling of your ankles. We
gave you medication to help remove extra fluid. Your symptoms
improved quickly and you were able to leave the hospital after a
few days.
We would like you to go get your labs checked on ___ and
you will see your PCP ___ ___ (see below)
Please check your weight every day at home. If your weight
increases more than 3 lbs, call your doctor immediately. We
wish you a speedy recovery.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
19664876-DS-3
| 19,664,876 | 24,524,866 |
DS
| 3 |
2151-03-08 00:00:00
|
2151-03-08 15:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Aneurysmal SAH, right PCOM aneurysm
Major Surgical or Invasive Procedure:
___ - Cerebral angiogram for coil embolization of right
PCOM aneurysm
___ - Right EVD placement
___ - Right VP shunt placement - ___ Strata Valve
set at 1.5
History of Present Illness:
___ is a ___ year old male who presented to the ED on
___ as a transfer from an outside facility with
complaints of the worst headache of his life. Imaging at the
outside facility was concerning for aneurysmal SAH. The patient
was transferred to ___ for escalation of care. Neurosurgery
was consulted for evaluation and management recommendations.
Past Medical History:
- Gout
Social History:
___
Family History:
No known family history of aneurysms.
Physical Exam:
On Admission:
-------------
Physical Exam:
Date and Time of Neurosurgical Evaluation: ___ 13:00
Hunt and ___ Scale:
[x]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurologic deficit other than cranial nerve palsy
[ ]Grade III: Drowsiness, confusion, mild focal neurologic
deficit
[ ]Grade IV: Stupor, moderate to severe hemiparesis
[ ]Grade V: Coma, decerebrate posturing
Fisher Grade:
[ ]1 No SAH evident
[ ]2 SAH less than 1mm thick
[x]3 SAH more than 1mm thick
[ ]4 SAH of any thickness with IVH or parenchymal extension
___ Grading Scale:
[x]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[ ]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
GCS:
Airway:
[ ]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
Total: 15
ICH Score:
GCS:
[ ]2 GCS ___
[ ]1 GCS ___
[x]0 GCS ___
ICH Volume:
[ ]1 30 mL or greater
[x]0 Less than 30 mL
IVH:
[ ]1 Present
[x]0 Absent
Infratentorial ICH:
[ ___ Yes
[x]0 No
Age:
[ ]1 ___ years old or greater
[x]0 Less than ___ years old
Total: 0
VS: T 97.4F, HR 45, BP 131/86, RR 18, O2Sat 99% on room air
General: Well nourished. Vomiting.
HEENT: PERRL. EOMs intact.
Neck: Supple.
Extremities: Warm and well-perfused.
Neurologic:
Mental Status: Awake and alert. Cooperative with exam. Normal
affect.
Orientation: Oriented to person, place, and time.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: PERRL, 3-2mm, bilaterally. VFF to confrontation.
III, IV, VI: EOMs intact bilaterally without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength ___ throughout. No drift.
Sensation: Grossly intact to light touch.
Coordination: Normal on finger-nose-finger, rapid alternating
movement, and heel-shin testing.
Handedness: Right
On Discharge:
-------------
General:
VS: T ___, HR 56, BP 110/75, RR 16, O2Sat 100% on room air
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOMs: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trap Deltoid Biceps Triceps Grip
Right 5 5 5 5 5
Left 5 5 5 5 5
IP Quad Ham AT ___ ___
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
Sensation: Grossly intact to light touch.
EVD Sites:
- Clean, dry, intact
VP Shunt Sites:
- Clean, dry, intact
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Brief Hospital Course:
___ year old male found to have aneurysmal SAH and ruptured right
PCOM aneurysm.
#Aneurysmal SAH, ruptured right PCOM aneurysm
The patient presented to the ED on ___ as a transfer from
an outside facility with complaints of the worst headache of his
life. Imaging at the outside facility was concerning for
aneurysmal SAH. The patient was transferred to ___ for
escalation of care. Neurosurgery was consulted for evaluation
and management recommendations. Additional imaging in the ED was
concerning for a ruptured right PCOM aneurysm. The patient was
taken to the Angiography Suite on ___ for a cerebral
angiogram for coil embolization of the right PCOM aneurysm. The
procedure was uncomplicated. Please see OMR for further
intraprocedural details. He was extubated in the OR and
transferred to the Neuro ICU postprocedurally for close
neurologic monitoring. Postprocedurally, he was started on
Keppra for seizure prophylaxis and nimodipine to prevent
cerebral vasospasm. He was also started on IV fluids for goal
euvolemia. Postprocedurally, the patient developed increasingly
worsened headache. CT of the head at this time showed a slight
interval increase in ventricular size, but was otherwise
unremarkable. On ___, the patient because acutely
confused and agitated. A repeat CT of the head was concerning
for worsened hydrocephalus. As a result, the patient was
intubated and sedated, and a right EVD was placed. The procedure
was uncomplicated. Please see OMR for further intraprocedural
details. Postprocedural CT of the head was stable, and showed
adequate positioning of the EVD. The patient remained intubated
and sedated postprocedurally. The patient was extubated on
___ without incident. TCDs on ___, and
___ were negative for definitive cerebral vasospasm, but
were limited by poor bone windows. CTA of the head on ___
showed possible cerebral vasospasm within the right MCA and its
distal branches. His EVD was adjusted and he continued to
receive IV fluids for goal euvolemia to combat this. He was
unable to be weaned from the EVD, so a right VP shunt was placed
on ___. The VP shunt is a ___ Strata Valve
programmed to 1.5. The operation was uncomplicated. Please see
OMR for further intraoperative details. The patient was
extubated in the OR and returned to the Neuro ICU
postoperatively. Postoperative CTA of the head showed adequate
positioning of the VP shunt, and was concerning for cerebral
vasospasm within the right MCA. Postoperative shunt series was
within expected limits. An additional CTA of the head on
___ showed an interval decrease in ventricular size as
well as mildly increased narrowing of the bilateral A1 segments,
P2 segments, P3 segments, and left M2 segment as well as
persistent narrowing of the right M1 segment and basilar artery.
Despite this, the patient remained neurologically stable and he
was transferred to the floor. On ___, he was afebrile
with stable vital signs, mobilizing independently, tolerating a
diet, voiding and stooling without difficulty, and his pain was
well controlled with oral pain medications. He was discharged
home on ___ in stable condition.
#Disposition
___ and OT were consulted and recommended discharge home with
outpatient ___. The patient was discharged home on ___ in
stable condition.
1. DVT prophylaxis administered? [x]Yes [ ]No
2. Dysphagia screening before any PO intake? [x]Yes [ ]No
3. Assessment for rehabilitation? [x]Yes [ ]No
4. Stroke Education given in written form? [x]Yes [ ]No
5. Smoking cessation counseling given? [ ]Yes [x]No - Nonsmoker
Stroke Measures:
1. Was a Hunt and ___ Scale performed within 6 hours of arrival
[x]Yes [ ]No
2. Was nimodipine given? [x]Yes [ ]No
3. Was a procoagulant reversal agent given? [ ]Yes [x]No - Not
anticoagulated
Medications on Admission:
- indomethacin PO PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 3000mg in 24 hours.
2. NiMODipine 60 mg PO Q4H Duration: 6 Days
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not drive while taking.
4.Outpatient Physical Therapy
Evaluation and treatment
Discharge Disposition:
Home
Discharge Diagnosis:
Aneurysmal SAH, right PCOM aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, independent.
Discharge Instructions:
Procedure/Surgery:
- You had a angiogram to coil the aneurysm. You may experience
some mild tenderness and bruising at the puncture site.
- You also had surgery to have a VP shunt placed for
hydrocephalus. Your VP shunt is a ___ Strata Valve, which
is programmable. This will need to be readjusted after all MRIs
or other exposure to large magnets. Your VP shunt is currently
programmed to 1.5.
- You may shower at this time.
- Do not rub, scrub, scratch, or pick at any scabs along the
surgical incision.
Activity:
- You may take leisurely walks and slowly increase your activity
at your once pace once you are symptom free at rest. Don't try
to do too much all at once.
- We recommend that you avoid heavy lifting, running, climbing,
and other strenuous exercise until your follow-up.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for at least 6 months.
- No driving while taking narcotics or any other sedating
medications.
- If you experienced a seizure, you are not allowed to drive by
law.
Medications:
- Resume your normal medications and begin new medications as
directed.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- Please do not take any other blood thinning medications such
as aspirin, clopidogrel (Plavix), ibuprofen, warfarin
(Coumadin), etc. until cleared by your neurosurgeon.
- You have been discharged on a medication called nimodipine.
This medication is used to help prevent cerebral vasospasm,
which is narrowing of the blood vessels in the brain.
What You ___ Experience:
- Mild to moderate headaches that last several days to a few
weeks.
- Fatigue is very normal.
- Difficulty with short-term memory.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try an over-the-counter
stool softener if needed.
Please Call Your Neurosurgeon At ___ For:
- Fever greater than 101.4 degrees Fahrenheit.
- Severe pain, redness, swelling, or drainage from the puncture
site or surgical incision.
- Severe headaches not adequately relieved with prescribed pain
medications.
- Extreme sleepiness or not being able to stay awake.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
- Nausea or vomiting.
- Seizures.
- Blood in your urine or stool.
- Constipation.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden severe headaches with no known reason.
- Sudden dizziness, trouble walking, or loss of balance or
coordination.
- Sudden confusion or trouble speaking or understanding.
- Sudden weakness or numbness in the face, arms, or legs.
Followup Instructions:
___
|
19665025-DS-6
| 19,665,025 | 27,898,058 |
DS
| 6 |
2129-01-07 00:00:00
|
2129-01-09 22:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain x2 days. Her first episode
of pancreatitis occured in ___. It was thought that her
pancreatitis may be ___ gallstones (although no gallstones were
identified on imaging), and she had a laparascopic
cholecystectomy shortly after. Her pancreatitis was complicated
by pseudocyst formation. Between ___ and ___ she had ___
episodes of mild pancreatitis which she managed at home with a
liquid diet. In ___ her pancreatic pseudocyst ruptured
and she underwent exploratory laparotomy with external drainage
of the pseudocyst. She was then well until 2 days PTA when she
developed epigastric pain that radiated to her mid upper back,
c/w her previous episodes of pancreatitis. Has also had nausea
but has not vomited. She managed at home for 48 hours on liquid
diet, but when her sx did not improve she presented to the ED.
In the ED, initial VS were 98.4 83 162/93 17 100%. Labs were
notable for HCO3 19, AG 22, glucose 265, AP 110, lipase 151.
She had a CT abdomen/pelvis which showed minimal inflammatory
stranding, improved from prior images in ___. She received IV
dilaudid for pain and zofran for nausea. Surgery was consulted
and felt there was indication for surgery. She was admitted to
the floor for management of acute pancreatitis.
.
Upon transfer to the floor, she is pleasant, c/o mild pain and
nausea but states it is tolerable with zofran/dilaudid. Pain is
worst in her mid back, c/w her previous episodes of
pancreatitis. She has no other complaints.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Exploratory laparotomy (___)
External drainage of pancreatic pseudocyst (___)
Gallstone pancreatitis (first attack ___ w/ mult recurrences)
Obesity
Splenic vein thrombus
Laparoscopy ccy (___)
C-section x2 (remote past)
Social History:
___
Family History:
Notable for PBC and Sjogren's in mother.
Physical Exam:
GENERAL - Pleasant, morbidly obese middle-aged female in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no LAD, unable to appreciate JVP due to habitus
LUNGS - respiration unlabored, CTAB, no r/rh/wh
HEART - quiet heart sounds, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, no focal deficits
Pertinent Results:
Admission Labs:
___ 12:35PM BLOOD WBC-8.3# RBC-5.95*# Hgb-17.0*# Hct-48.2*#
MCV-81* MCH-28.6 MCHC-35.3* RDW-13.1 Plt ___
___ 12:35PM BLOOD Glucose-265* UreaN-13 Creat-0.7 Na-136
K-4.6 Cl-100 HCO3-19* AnGap-22*
___ 09:50PM BLOOD ALT-24 AST-20 LD(LDH)-180 AlkPhos-90
TotBili-0.7
___ 12:35PM BLOOD Lipase-151*
___ 12:35PM BLOOD Calcium-9.8 Phos-2.8 Mg-1.8
___ 09:50PM BLOOD Acetone-SMALL
___ 05:19PM BLOOD Glucose-217* Lactate-1.1
A1c: ___ 09:50PM BLOOD %HbA1c-12.2* eAG-303*
Lipid panel: ___ 06:30AM BLOOD Triglyc-116 HDL-31
CHOL/HD-5.0 LDLcalc-101
CT ABDOMEN/PELVIS ___:
CT OF THE ABDOMEN: The visualized lung bases appear clear with
no focal
consolidation or pleural effusion. The visualized heart and
pericardium are
unremarkable.
The liver and bilateral adrenal glands appear unremarkable. The
patient is
status post cholecystectomy. Both kidneys enhance and excrete
contrast
symmetrically without evidence of hydronephrosis. A small
hypodensity within the left kidney is too small to characterize
but statistically likely represents a renal cyst. The spleen
measures 14.5 cm, consistent with splenomegaly, similar to the
prior examination. Splenic vein is not well visualized,
consistent with splenic vein thrombosis, unchanged from ___. There are no masses noted within the pancreas. No
pancreatic cysts are visualized. Minimal stranding in the lesser
sac, along the spleen, pancreas, and stomach is much improved
since the most recent prior examination. Retroperitoneal and
mesenteric lymph nodes do not meet CT size criteria for
pathologic enlargement. There are prominent gastric collaterals
noted. There is no free air or free fluid within the abdomen.
CT OF THE PELVIS: The bladder, distal ureters, rectum and
sigmoid colon
appear unremarkable.
The visualized osseous structures show no focal lytic or
sclerotic lesion
suspicious for malignancy. There is minimal loss of height of
the L5
vertebral body, similar in appearance to the prior examination.
IMPRESSION:
1. No evidence of pancreatic cyst with minimal residual
inflammatory
stranding adjacent to the pancreas, significantly improved since
___.
2. Stable splenomegaly with splenic vein thrombosis.
Brief Hospital Course:
Primary Reason for Hospitalization:
___ y/o female with history of pancreatitis and ruptured
pancreatic pseudocysts presents with mild acute pancreatitis and
found to have new diabetes mellitus.
.
Active issues:
#Acute pancreatitis: Pt's symptoms were consistent with her
previous episodes of pancreatitis (abdominal pain that radiates
to her back, associated with nausea) and lab data was notable
for elevated lipase (150). She was evaluated by the surgery
service in the ED, who felt no acute surgical indication but
recommended an MRCP as outpatient to evaluate the pancreatic
duct. She was made NPO and her pain was managed with tylenol and
IV dilaudid. On HD#2 her diet was advanced to low fat clears
and then to regular diet. She was switched to PO dilaudid for
pain management. Since the etiology of her pancreatitis is
still not clear and she now presents with evidence of pancreatic
endocrine dysfunction (new diabetes), she was scheduled to
follow up in the GI clinic with a ___ pancreatologist.
.
#New Onset Diabetes: Noted to have high blood glucose levels
during hospitalization and HbA1C was 12.2% (of note, per pt A1c
___ year ago was <6%). She was evaluated by the ___ service who
recommended starting metformin and insulin glargine. Lipid
panel was HDL at 30, LDL at 101, and total cholesterol at 155.
She was started on ASA 81mg PO daily. She was scheduled to
follow up in ___ clinic after discharge. She will likely
benefit from rechecking fasting lipid panel and possibly
starting oral statin therapy as outpatient.
.
#Anion gap metabolic acidosis: She presented with mild AG
metabolic acidosis, likely ___ ketosis (small amount of serum
ketones) in setting of new diabetes. Her AG resolved by HD#2.
.
Transitional Issues:
- New medications: lantus 15 units QHS, metformin 500mg PO BID,
and aspirin (81mg) daily.
- She is scheduled for follow up with her PCP, ___ diabetes
specialist, and pancreatology.
- She is scheduled for outpatient MRCP and follow-up in surgery
clinic.
- Would recommend repeat fasting lipid panel and consider
starting statin.
Medications on Admission:
None
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. One Touch Ultra System Kit Kit Sig: One (1) glucometer
Miscellaneous once a day.
Disp:*1 glucometer* Refills:*0*
4. One Touch Ultra Test Strip Sig: One (1) strip
Miscellaneous twice a day.
Disp:*60 strips* Refills:*0*
5. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Fifteen
(15) units Subcutaneous at bedtime.
Disp:*QS * Refills:*0*
6. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous twice a day.
Disp:*60 lancets* Refills:*0*
7. Alcohol Prep Swabs Pads, Medicated Sig: One (1) swab
Topical twice a day.
Disp:*qs * Refills:*2*
8. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every ___ hours:
Avoid taking this medication while driving.
Disp:*24 Tablet(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue taking while taking pain medication.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute pancreatitis
Diabetes mellitus
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 had mild pancreatitis.
You were treated with IV fluids and a clear liquid diet, and
your symptoms improved. While you were here, your labwork
showed that your Hemoglobin A1c is 12.2%, which means that you
have diabetes. We started you on nighttime insulin and an oral
diabetes medication called metformin.
We made the following changes to your medications while you were
in the hospital:
-START lantus 15 units by injection at bedtime
-START metformin 500mg by mouth twice daily
-START a baby aspirin (81mg) by mouth once daily
Regarding monitoring of your sugars be sure to check your
fingersticks twice daily (breakfast and before dinner) with goal
sugars: 100-120; if sugar levels are consistently >250 please
call your doctor, conversely if sugar levels are low (<80)
please inform your doctors.
___ of high sugars include increased thirst, hunger, and
urination.
Symptoms of low sugars include dizziness, feeling faint and
sweating.
.
We made appointments for you to follow up with your primary care
provider, ___ diabetes specialist, and a pancreas
specialist. Please see below for your appointment times. If
you are unable to make an appointment, please call and
reschedule.
It has been a pleasure taking care of you at ___ and we wish
you a speedy recovery.
Followup Instructions:
___
|
19665025-DS-7
| 19,665,025 | 22,751,409 |
DS
| 7 |
2130-06-07 00:00:00
|
2130-06-07 17:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain. The patient reports that
her pain began 2 days prior to admission while placing A/C units
in the window. She noticed ___ back pain as if someone put a
fist through her back. She thought is was muscular in etiology,
but when she got home from her daughters, she developed nausea
and mid/epigastric abdominal pain consistent with her
pancreatitis flares. SHe went to bed that night and the next
morning tried to eat some toast with some tea and her pain
became ___ and she had increased nausea without vomiting. She
took some tylenol and advil without benefit and she made herself
NPO. On the morning of admission, she tried to work from home
hoping the pain would improve, but it was persistent so she came
to the ED for further evaluation. She also reports some mild
loose BM the day of admission. Not watery or bloody, just
loose.
In addition over the last few days, she has had increased
vaginal itching and whitish discharge.
In the ED, initial vs were: 97.3 71 162/87 16 98% RA. Labs were
remarkable for lipase 362, Hgb 16, UA w/ large leuk (12 WBC) few
bacteria. Patient was given ceftriaxone 1gm for possible UTI
and morphine 5mg x3 for pain control. Also given zofran 4mg IV
x2 and metoclopramide 10mg IV x1 for nausea. CT abdomen/pelvis
was performed which showed Stranding along the second and third
portions of the duodenum may be duodenitis, however, given
elevated lipase inflammation may be secondary to pancreatitis.
Patient was given 2L NS. Vitals on Transfer: 98.2 70 128/70 16
97%
On the floor, patient pain is better controlled, but with nausea
and vomiting.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies constipation. Denies
arthralgias or myalgias.
Past Medical History:
Exploratory laparotomy (___)
External drainage of pancreatic pseudocyst (___)
? Gallstone pancreatitis in ___ although recurrent episodes
after cholecystectomy and no evidence of stones on imaging.
Chronic pancreatitis of the tail of the pancreas evident on
imaging
Obesity
Splenic vein thrombus
Laparoscopy ccy (___)
C-section x2 (remote past)
Diabetes Mellitus
Social History:
___
Family History:
Notable for PBC and Sjogren's in mother.
Sister with multiple sclerosis
Father with CAD and DM
Physical Exam:
admission
Vitals: T: 97.7 BP: 127/78 P: 77 R: 12 O2: 94% RA, FSG: 282
General: Alert, oriented, in moderate distress ___ nasuea
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, tender in epigastric area with no gaurding with
mid/deep palpation, non-distended, bowel sounds present,
Organomegaly difficult to assess given body habitus
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, varicosities of the lower extremity
Neuro: CN II-XII intact, strenght and sensation intact on
extremities, gait deferred
.
discharge
VS: 97.4 74 106/59 18 96%RA
I/O: NPO 150 IVF | 550 UOP BMx1
General: Alert, oriented, in moderate distress ___ nasuea
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds, no m/r/g
Abdomen: soft, minimally tender in epigastric area with no
gaurding with mid/deep palpation, non-distended, bowel sounds
present
Ext: Warm, well perfused
Neuro: A&Ox3
Pertinent Results:
admission
___ 03:11PM BLOOD WBC-10.6# RBC-5.38 Hgb-16.3* Hct-46.8
MCV-87 MCH-30.3 MCHC-34.7 RDW-13.5 Plt ___
___ 03:11PM BLOOD Glucose-174* UreaN-11 Creat-0.8 Na-140
K-4.1 Cl-101 HCO3-28 AnGap-15
___ 03:11PM BLOOD ALT-33 AST-26 AlkPhos-110* TotBili-1.2
___ 03:11PM BLOOD Albumin-4.8
___ 07:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
STUDIES:
CT ABD/PELVIS ___
1. Stranding along the second and third portions of the duodenum
may be duodenitis, however, given elevated lipase inflammation
may be secondary to pancreatitis.
2. Chronic splenic vein thrombosis.
3. Splenomegaly.
.
discharge
___ 07:20AM BLOOD WBC-5.5 RBC-4.09* Hgb-12.7 Hct-36.4
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.4 Plt ___
___ 07:20AM BLOOD Glucose-133* UreaN-8 Creat-0.7 Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
___ 07:20AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain and recurrent pancreatitis.
.
# Acute on Chronic Pancreatitis: Patient with recurrent flare
of her pancreatitis over the last 2 days. Her last flare
requiring hospitalization was ___. There continues to
be no clear etiology of her symptoms. She last had her MRCP 4
months ago and given her acute symptoms, and is not due for
repeat MRCP so we did not perform. Patient maintained on pain
control, IVF, and NPO status initially with gradual advancing of
diet. Patient did well and was discharged home with plan to
follow up in primary care.
.
# Chronic Splenic Vein Thrombosis: Patient with known chronic
splenic vein thrombosis. Likely secondary to recurrent
inflammation from pancreatitis flares. Monitored patient for
signs/symptoms of bleeding from gastric varices.
.
# Diabetes: Held metformin while in house given poor PO intake
and risk for ___ and possible need for further contrast studies.
Maintained on ISS. Discharged back on home metformin.
.
# Yeast infection: Patient noted to have UA with 12 WBC but
asymptomatic. Thereafter on history/physical noted to have
signs/symptoms of vulvovaginal candidiasis. It is likely this
may have contributed to WBC in urine. Treated patient with
fluconazole IV (given NPO status).
.
TRANSITIONAL ISSUES:
- Patient should continue to be followed with periodic MRCPs as
delineated by her GI and primary care providers
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Spironolactone 25 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Spironolactone 25 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
Q4H:PRN Disp #*10 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Acute on chronic pancreatitis
Secondary diagnoses:
Chronic splenic vein thrombosis
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure to take care of you. You were admitted to
___ because of belly and back pain likely to be due to a flare
of pancreatitis. We treated you with intravenous fluids and pain
medications. As you are tolerating oral intake, we are able to
discharge you today.
Please follow up with your doctors as below.
Please review your medication list closely.
Followup Instructions:
___
|
19665270-DS-4
| 19,665,270 | 21,907,947 |
DS
| 4 |
2153-06-16 00:00:00
|
2153-06-16 21:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Oxycodone
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Liver biopsy ___
History of Present Illness:
___ woman with a remote cholecystectomy and ERCP ___ years ago
admitted with 2 week of diffuse abdominal pain. It feels like
"pins and needles" across her abdomen. It radiates to her R back
and R scapula. She has had three episodes of nonbilious
nonbloody emesis in the past few days. No dark or bloody stools.
Her stools are soft, and have been lighter in color (yellow).
She has felt intermittently febrile over the past few days,
documented at home to ___ F today. She saw her PCP regarding her
symptoms yesterday, and was sent for a RUQ ultrasound today. She
presented to the ED with ongoing pain, nausea, and an
abnormality on her ultrasound (? FNH).
In the ED, initial VS: 98.1 96 132/78 18 100%. Labs notable for
alk phos 413, no leukocytosis. The patient underwent CT
abdomen/pelvis that showed a 7.8 cm hyopdense mass in right lobe
of the liver, concerning for abscess vs. malignancy, with
associated right portal vein clot. She recieved toradol for pain
control. She was admitted to medicine for further evaluation. VS
prior to transfer: 98.3 75 114/73 18 99% RA.
On the floor, the patient states that pain is markedly improved
after toradol. She denies nausea. She does endorse 2 days of
abdominal bloating. She is quite anxious about being in the
hospital. On pertinent review of systems, the patient denies
chest pain or dyspnea. Of note, she is originally from ___,
and last travelled there ___. She never uses travel
prophyalxis when she goes, and eats and drinks local food and
water. She did get a BCG vaccine as a child, and denies known TB
exposure.
Review of Systems:
(+) per HPI
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-s/p cholecystectomy
-iron deficiency anemia
-headaches (head imaging reportedly unremarkable)
-irregular menstruation on OCP for ___ yrs (last ___ yrs ago)
Social History:
___
Family History:
Father with alcoholic cirrhosis. Died of metastatic liver cancer
(presumed HCC?)
Physical Exam:
ADMISSION PHYSICAL EXAM
T: 98.2 BP: 135/87 HR: 72 RR: 20 02 sat: 99%RA
GENERAL: pleasant woman in NAD, appears mildly anxious
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, mildly distended, patient mildly tender to
palpation across abdomen, with moderat tenderness to palpation
RUQ; right lobe of liver feels normal in size, palpable left
lobe, +BS, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals: 98.6 98/55 84 18 99% RA
Tmax 98.6 SBP 94-110 HR ___
General: Alert, oriented, no acute distress
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, no m/g/r
Abdomen: +BS, soft, no guarding, no apparent tenderness to
palpation, liver edge palpable. Bandage c/d/i with no apparent
tenderness and no surrounding erythema.
Rectal: No gross blood. No gross stool. Guaiac of glove
negative though there was minimal sample.
Ext: Warm, well perfused, no edema
Skin: No abnormalities noted.
Pertinent Results:
ADMISSION LABS
___ 02:55PM PLT COUNT-285
___ 02:55PM NEUTS-75.4* LYMPHS-16.2* MONOS-7.1 EOS-0.4
BASOS-0.9
___ 02:55PM WBC-9.5 RBC-4.47 HGB-12.1 HCT-38.4 MCV-86
MCH-27.2 MCHC-31.7 RDW-12.7
___ 02:55PM ALBUMIN-4.2
___ 02:55PM LIPASE-29
___ 02:55PM ALT(SGPT)-24 AST(SGOT)-36 ALK PHOS-413* TOT
BILI-0.4
___ 02:55PM GLUCOSE-108* UREA N-12 CREAT-0.6 SODIUM-136
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-13
___ 07:34PM LACTATE-0.8
OTHER LABS
___ 06:10AM BLOOD AFP-1.6
___ 06:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:10AM BLOOD HCV Ab-NEGATIVE
Echinococcus antibody: Pending
Histoplasma antigen: Pending
MICROBIOLOGY
Blood cultures ___: Pending
DISCHARGE LABS
___ 05:55AM BLOOD WBC-8.1 RBC-3.78* Hgb-10.5* Hct-33.3*
MCV-88 MCH-27.7 MCHC-31.4 RDW-12.7 Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD ___ PTT-34.1 ___
___ 05:55AM BLOOD Glucose-84 UreaN-15 Creat-0.6 Na-138
K-4.0 Cl-99 HCO3-27 AnGap-16
___ 05:55AM BLOOD ALT-19 AST-28 AlkPhos-381* TotBili-0.4
___ 05:55AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.___bdomen/pelvis with contrast ___
1. 7.8 cm hypodense lesion in the right lobe of the liver for
which ddx
includes abscess or malignancy. Biopsy is recommended.
2. Associated thrombosis of the right portal vein and small
branches of the
right hepatic vein. Asymmetric perfusion of the liver may
reflect venous
thrombosis.
CT head w/o contrast ___
No evidence of acute intracranial process.
Brief Hospital Course:
___ F h/o anemia, headaches (head imaging reportedly
unremarkable), irregular menstruation on OCP for ___ yrs (last ___
yrs ago), and cholecystectomy who presents with two weeks of b/l
upper quadrant abdominal pain, found to have mass in right liver
lobe as well as thromboses in right portal vein and branches of
right hepatic vein.
ACTIVE ISSUES
# Liver mass: Differential diagnosis includes infection vs
malignancy. Patient underwent liver biopsy. Ultrasound
radiologist's impression pre-procedure was more likely abscess
than malignancy, though cytopathology technologist's impression
of gross appearance during the procedure was neoplasm.
Pathology was still pending at the time of discharge. AFP was
within normal limits at 1.6. Hepatitis serologies included
positive HBsAb (negative HBsAg and HBcAb), positive HAV Ab
(negative HAV IgM), and negative HCV Ab. Echinococcus serology,
histoplasma antigen, and blood cultures were pending at the time
of discharge.
# Abdominal pain and back pain: Likely due to liver mass.
Patient received ketorolac in the ED as well as on the floor,
and by the morning after admission she was pain-free. On the
second hospital night, she awoke with pain at the right upper
flank near the site of the biopsy, and she received
acetaminophen with improvement of symptoms. She was advised to
take acetaminophen after discharge as needed for pain.
# Portal vein and hepatic vein branch thromboses: Differential
diagnosis includes mass effect due to liver mass,
hypercoagulability in the setting of malignancy, or
metastases/vegetations within vessels. Head CT was negative for
contraindication to anticoagulation, and guaiac from rectal exam
glove was negative though there was no visible stool to test.
Patient was started on enoxaparin 70mg SC q 12hrs (waited >12
hours after liver biopsy as per ___ recs) and discharged with
enoxaparin 100mg SC daily.
CHRONIC ISSUES
# Anemia: Pt has a history of anemia. H/H was 12.1/38.4 on
admission, which decreased on the second hospital and again
after liver biopsy but then remained stable. H/H on discharge
was 10.5/33.3.
TRANSITIONAL ISSUES
-Follow up liver pathology results.
-Follow up Echinococcus serology, Histoplasma antigen, and blood
cultures.
-Follow up with PCP and obtain referral for further work-up and
management of liver mass, depending on pathology.
-If mass is not cancer, consider transitioning to coumadin. If
malignant, recommend continuation of Lovenox.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Glucosamine (glucosamine sulfate) 500 mg oral daily
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Glucosamine (glucosamine sulfate) 500 mg oral daily
3. Simethicone 40-80 mg PO QID:PRN bloating, gas
RX *simethicone 80 mg 0.5 to 1 tab by mouth four times a day
Disp #*100 Tablet Refills:*0
4. Enoxaparin Sodium 100 mg SC DAILY
Start: ___ - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC daily Disp #*30 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Liver mass
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 part in your care at ___
___ ___. As you know, you came to the hospital
due to abdominal pain, nausea and vomiting. You had a CT scan
which revealed a mass in the liver, and you underwent a biopsy
of the mass. The pathology results are still pending at the
time of discharge. You also have blood clots in some of the
veins in your abdomen, so you were started on enoxaparin to thin
the blood.
You can continue to Take Tylenol ___ Every 8 hours) to help
with your abdominal and back pain.
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.